human resources for health · human resources for health policy reference to community level hrh in...

Maternal, neonatal &

reproductive health

www.hrhhub.unsw.edu.au

Angela Dawson, Tara Howes, Natalie Gray and Elissa Kennedy

HUMAN RESOURCES

FOR HEALTH

HUMAN RESOURCES FORHEALTH KNOWLEDGE HUB

Bangladesh

in maternal, neonatal and reproductive health at community level

A profile of Bangladesh

© 2011 Human Resources for Health Hub and Burnet Institute

on behalf of the Women’s and Children’s Health Knowledge Hub

Suggested citation:

Dawson et al. 2011, Human resources for health in maternal, neonatal and reproductive health at community level: A profile of Bangladesh, Human

Resources for Health Knowledge Hub UNSW and Burnet Institute, Sydney.

National Library of Australia Cataloguing-in-Publication entry

Dawson, Angela

Human resources for health in maternal, neonatal and reproductive health

at community level: A profile of Bangladesh / Angela Dawson ... [et al.]

9780733429736 (pbk.)

Maternal health services--Bangladesh--Personnel management.

Community health services--Bangladesh--Personnel management.

Howes, Tara.

University of New South Wales. Human Resources for Health.

Gray, Natalie.

Kennedy, Elissa.

Burnet Institute. Women and Children’s Health Knowledge Hub.

362.19820095492

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of the School of Public Health and Community Medicine at the University

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The Human Resources for Health Knowledge HubThis technical report series has been produced by the Human Resources for Health Knowledge Hub of the School of Public Health and Community Medicine at the University of New South Wales.

Hub publications report on a number of significant issues in human resources for health (HRH), currently under the following themes:

� leadership and management issues, especially at district level

� maternal, neonatal and reproductive health workforce at the community level

� intranational and international mobility of health workers

� HRH issues in public health emergencies.

The HRH Hub welcomes your feedback and any questions you may have for its research staff. For further information on these topics as well as a list of the latest reports, summaries and contact details of our researchers, please visit www.hrhhub.unsw.edu.au or email [email protected]

1MNRH at community level: A profile of Bangladesh Dawson et al.

CoNTENTS

2 Acronyms

3 Executive summary

4 Bangladesh: selected HRH and MNRH indicators

5 Key background information

6 Overview of maternal, neonatal and reproductive health

7 Services and cadres at community level

9 Coverage and distribution

10 Supervision and scope of practice

10 Competency

10 Team work

10 Education and training

11 Country registration

11 Human resource for health policy and plans

12 Maternal, neonatal and reproductive health policy and plans

13 Remuneration and incentives

13 Key issues or barriers

14 Key initiatives

15 Critique of data sources

16 References

18 Appendix 1: Pre-service education and training in Bangladesh

19 Appendix 2: In-service training in Bangladesh

20 Appendix 3: Country registration in Bangladesh

21 Appendix 4: Country human resource for health policies in Bangladesh

22 Appendix 5: Maternal, neonatal and reproductive health policy in Bangladesh

LiST of TABLES

5 Table 1. Key statistics

8 Table 2. Cadres involved in maternal, neonatal and reproductive health at community level in Bangladesh

9 Table 3. Health worker density in Bangladesh

9 Table 4. Health worker distribution in Bangladesh


ACRoNyMS

A note about the use of acronyms in this publication

Acronyms are used in both the singular and the plural, e.g. MDG (singular) and MDGs (plural). Acronyms are also used throughout the references and citations to shorten some organisations with long names.

AAAH Asia and Pacific Action Alliance for Human Resources for Health

ANMC Australian Nursing and Midwifery Council

BAVS Association for Voluntary Sterilization

BRAC non-government organisation, formally known as the Bangladesh Rehabilitation Assistance Committee

GDP gross domestic product

HR human resources

HRH human resources for health

iCM International Confederation of Midwives

MDG Millennium Development Goal

MNRH maternal, neonatal and reproductive health

MoHfW Ministry of Health and Family Welfare

NGo non-government organisation

NSDP Non-government Organisation Service Delivery Program

SAMCo sub-assistant community medical officer

SEARo World Health Organization Regional Office for South-East Asia

UNDESA United Nations Department of Economic and Social Affairs

UNfPA United Nations Population Fund

US United States

USD$ United States dollars

WHo World Health Organization


Accurate and accessible information about the providers of maternal, neonatal and reproductive health (MNRH) services at the community level (how they are performing, managed, trained and supported) is central to workforce planning, personnel administration, performance management and policy making.

Data on human resources for health (HRH) is also essential to ensure and monitor quality service delivery. Yet, despite the importance of such information, there is a paucity of available knowledge for decision making. This highlights a particular challenge to determining the workforce required to deliver evidence based interventions at community level to achieve Millennium Development Goal (MDG) 5 targets. This profile summarises the available information on the cadres working at community level in Bangladesh; their diversity, distribution, supervisory structures, education and training, as well as the policy and regulations that govern their practice.

The profile provides baseline information that can inform policy and program planning by donors, multilateral agencies, non-government organisations (NGOs) and international health practitioners. Ministry of health staff may also find the information from other countries useful in planning their own HRH initiatives.

The information was collected through a desk review and strengthened by input from key experts and practitioners in the country. Selected findings are summarised in the diagram on page 4. There are key gaps in the collated information which may point to the need for consensus regarding what HRH indicators should be routinely collected and how such collection should take place at community level.

EXECUTiVE SUMMARy

This profile provides baseline information that can inform policy and program planning bydonors, multilateral agencies, non-government organisations and international health practitioners.


BANGLADESH: SELECTED HRH AND MNRH iNDiCAToRS

Maternal, neonatal and reproductive health policy reference to community

level HRH in MNRH

yES

Human resources for health policy reference

to community level HRH in MNRH

yES

Maternal mortality ratio in 2008

370 deaths per 100,000 live births

3 nurses and midwivesper 10,000 people

3 doctors per 10,000 people

33.6% Government spending on health as a percentage of

total expenditure on health (2007)

Skilled birth attendance:

24% of births attended by a skilled

birth attendant (2005-2009)

Key to acronyms

HRH human resources for healthMNRH maternal, neonatal and reproductive health

(Adapted from Bangladesh Health Watch 2008; MoHFW Bangladesh 2004; MoHFW Bangladesh 2008; UNICEF 2010; WHO 2009; WHO 2010b)

Neonatal mortality ratio in 2009

30 deaths per 1,000 live births


Key to acronyms

GDP gross domestic productMDG Millennium Development Goal

A note on health expenditureThe government’s expenditure on health as a percentage of the total gross domestic product (GDP) remained relatively constant between 1995 and 2004 (3% and 3.3% respectively) but dropped to 2.8% in 2005 (as seen in Table 1). The health workforce takes up approximately 75% of the health budget (Bangladesh Health Watch 2008).

KEy BACKGRoUND iNfoRMATioN

TABLE 1. KEy STATiSTiCS

(Adapted from Hogan et al. 2010; UNDESA 2005; UNICEF 2010; WHO 2010b)

PoPULATioN

Total thousands (2008) 160,000

Annual growth rate (1998–2008) 1.6%

HEALTH EXPENDiTURE (2007)

Total expenditure on health as a percentage of GDP 2.4%

General government expenditure on health as a percentage of total expenditure on health 33.6%

Private expenditure on health as a percentage of total expenditure on health 66.4%

MDG 5 STATUS Possible to achieve

MoRTALiTy RATio

Number of maternal deaths for every 100,000 live births:

UNICEF 2010

Hogan et al. 2010

340

338 (195–546)

Number of neonatal deaths for every 1,000 live births (in the first 28 days of life; 2009) 30

SKiLLED BiRTH ATTENDANCE (2005–2009)

Percentage of births attended by a skilled birth attendant 18%


There are approximately 3.5 million births in Bangladesh each year, 90% of which take place at home (Bangladesh Health Watch 2008). Each year, 12,000 mothers die in childbirth. Women face a 1 in 21 lifetime risk of dying from pregnancy and childbirth related causes (Ahmed and Jakaira 2009; MoHFW Bangladesh 2003).

Mortality rates are highest amongst adolescent mothers, possibly attributable to high levels of malnutrition amongst this group (SEARO).

Despite some progress, the maternal mortality ratio remains high although there are considerable variations within regions of the country and inconsistencies between WHO and government estimates, leading to uncertainty as to whether the country is on track to reach its MDG targets.

One of the considerable achievements in Bangladesh has been the increase in the contraceptive prevalence rate and the decrease in fertility rate. The contraceptive prevalence rate rose from 8% in 1975 to 53% in 2000 (MoHFW Bangladesh 2003). The fertility rate dropped from 6.3% in 1975 to 3% in 2004 (SEARO 2004). This was due to the Maternal Child Health Family Planning Program which started in the 1970s. However, pregnancy care remains sub-optimal.

Two thirds of women do not receive antenatal care; in rural areas only 28% of women have any antenatal visits (MoHFW Bangladesh 2003). Fifteen percent of births took place in health facilities in 2007, an increase from 9% in 2004 (Ahmed and Jakaira 2009). Doctors, nurses and midwives assist in 13% of births with other midwifery-trained health providers assisting in another 14%.

The government is aiming to increase the skilled birth attendance rate to 50% by 2010, particularly for women in the lower wealth quartiles, focusing on improved skilled attendance at home births (Anwar et al. 2007). Only 18% of mothers receive postnatal care from a trained provider (SEARO, 2004). Among women who give birth at home, only 7% receive postnatal care (MoHFW Bangladesh 2003).

There is an increasing challenge in reaching urban poor communities with health care. There have been large increases in the number of urban poor, from 7 million in 1985 to 12 million in 1999. There is a low coverage of health services in these areas and often a poor attitude of staff towards people of lower socio-economic status (SEARO 2004).

oVERViEW of MATERNAL, NEoNATAL AND REPRoDUCTiVE HEALTH

Two thirds of women do not receive antenatal care. In rural areas only 28% of women have any antenatal visits.


This section outlines the structure of health service from sub-district to village level as well as the cadres working in these settings and the roles they perform.

Note, the symbol # in the descriptions below refers to the number of subjects in question (e.g., number of staff, services, etc.).

Upazila (sub-district) level

` Upazila health complex (#407)

� Health-care hub with in-patient care support, 31–50 beds and emergency obstetric care

� Staff: gynaecologist, anaesthetist, medical doctors and skilled support nurses on 24 hour duty

� Capacity: provide both inpatient and outpatient care, have basic laboratory facilities, serve a population of about 200,000 (Bangladesh Health Watch 2008; Baqui et al. 2008b)

` Maternal and child health and family planning unit

� Staff: family welfare visitors, graduate medical officer, sometimes gynaecologist and midwives (SEARO 2004)

� Services: antenatal care, normal delivery, postnatal care, expanded program of immunisation, health education, childcare, contraceptives and sterilisation (MoHFW Bangladesh 2006)

` Maternal and child welfare centre (#12)

� Staff: medical officer, anaesthetist, family welfare visitor and dai (nurses)

� Services: antenatal care, normal delivery, emergency obstetric care, postnatal care, expanded program of Immunisation, contraceptives and sterilisation (MoHFW Bangladesh 2006)

` NGo clinics (#68) (MoHfW Bangladesh 2006)

Union level

` Union health and family welfare centre (#3,500)

� Provides only outpatient care (Bangladesh Health Watch 2008)

� Staff: medical officers, family welfare visitor, pharmacist, family welfare assistant (outreach only) and medical assistants (not all staff is available in all centres)

� Services: antenatal care, screening of at-risk pregnancies, safe delivery (domiciliary care), postnatal

care, child care, health education and contraceptives (MoHFW Bangladesh 2006).

` Rural dispensary (#1,275) (MoHfW Bangladesh, 2006)

� Staff: doctors, village doctors, sales people, traditional healers and homeopaths (Bangladesh Health Watch 2008)

` Mother and child welfare centre (#23) (MoHfW Bangladesh 2006)

Village level

` Satellite clinic (30,000 provided per month)

� Services: maternal care and family planning (MoHFW Bangladesh 2006)

` Domiciliary service (#23,500) (MoHfW Bangladesh 2006)

SERViCES AND CADRES AT CoMMUNiTy LEVEL


TABLE 2. CADRES iNVoLVED iN MATERNAL, NEoNATAL AND REPRoDUCTiVE HEALTH AT CoMMUNiTy LEVEL iN BANGLADESH

(Adapted from Baqui et al. 2008a; Ahmed and Jakaira 2009; Bangladesh Health Watch 2008; SEARO 2004)

BASE oR

PLACE

STAff iNVoLVED

(NAME of CADRE)PoSSiBLE SERViCE iN THE CoMMUNiTy

Home Female community health worker1 Identifies pregnant women

Makes two antenatal home visits to promote birth and newborn-care preparedness

Makes postnatal home visits to assess newborns on the first, third, and seventh

days of birth

Refers or treats sick neonates, community education on postnatal care

Promotes breast feeding, family planning and distributes contraception

Dai (traditional birth attendant) Assists births

In some instances, makes referrals for complicated cases

Outreach

centre

Family welfare assistant Supplies condoms and contraceptives pills during home visits

Family planning

Family welfare visitor Supplies condoms and contraceptive pills

Family planning and counselling

Maternal health

Newborn care

Basic delivery

Posted at Union Health Centres, Mother and Child

Welfare Centres and Upazila health facilities

Health assistant Makes home visits every two months for preventive health care services

Community-based skilled birth

attendant

Antenatal care

Conducts normal home births, postnatal care,

Identifies and refers obstetric complications

Distributes contraception

Performs on average 3 to 4 births each month

Community health worker Works for a number of non-government organisations

Collects information on newlyweds and mothers

Family planning education

Distributes contraception and medicine

Aid post or

basic clinic

Nurse Antenatal care

Birth attendance

Postnatal care

Village doctor Cares for general health needs in rural villages

Medical assistant Works at Upazila health complexes, in private clinics and in Union Health

and Family Welfare Centres

Antenatal care, delivery and postnatal care

This cadre was originally designed to make up for a shortfall in doctors.

The government has stopped hiring medical assistants and employment

is now mainly in the private sector

Notes 1. Only in selected areas, especially where non-government organisations are working


CoVERAGE AND DiSTRiBUTioN

This section provides an overview of the numbers of health workers who may be engaged in MNRH at community level. Table 4 describes the distribution of this workforce according to age, gender and employment in the public and private sectors.

There is a significant difference between health care services offered in rural and urban areas. The majority of the health workforce, when all health providers are taken into account, is located in rural areas.

The majority of qualified providers, however, are located in urban areas. This means that the majority of the rural population is relying on the informal sector for health care services. The private sector provides 60% of health care services in rural areas (Bangladesh Health Watch 2008).

Further, 95% of all traditional birth attendants and 97% of traditional healers are located in rural areas, compared to 17% of doctors and 25% of nurses (Bangladesh Health Watch 2008). There is little formal knowledge of these

providers; however, it has been estimated that 85% of the population turn to them as a first resort (Bangladesh Health Watch 2008). The majority of elderly people (aged over 60) providing health care services are working in the informal sector, usually in traditional medicines. Younger providers are mainly in the cadres of nursing and community health workers (Bangladesh Health Watch 2008).

TABLE 4. HEALTH WoRKER DiSTRiBUTioN iN BANGLADESH

(Adapted from Bangladesh Health Watch 2008; MoHFW Bangladesh 2009a; AAAH 2008; MoHFW Bangladesh 2009b; WHO 2009; WHO 2010a)

CADRE NUMBER PUBLiC PRiVATE MEAN AGE fEMALE MALERATio (foR EVERy

1,000 PEoPLE)

Family planning officer 546 0.004

Community-based skilled

birth attendant3,000 0.019

Assistant family

planning officer

1,440 0.009

Health assistant 21,016 0.135

Family welfare visitor 5,705 0.036

Family welfare assistant 23,500 0.151

Community health worker 48,692 34.5 83.8% 16.3% 0.312

Village doctor 39.6 5.5% 94.5%

Traditional birth attendant 51.5 98.8% 1.2%

Traditional healer 21,000 52.9 24.4% 75.6% 0.135

Trained dai 1 per village

Registered nurse 27,732 14,686 41 96.6% 3.4% 0.178

Midwife 18,516 4,110 22,350 0.119

Medical assistant 5,598 5,598 720 0.036

Doctor 50,004 19,002 31,002 43 10.6% 89.4% 0.321

TABLE 3. HEALTH WoRKER DENSiTy iN BANGLADESH

(Adapted from WHO 2009; Bangladesh Health Watch 2008)

Number of health workers 0.58 for every 1,000 people

Number of nurses

and midwives0.3 for every 1,000 people

Ratio of nurses and

midwives to doctors1:1


Lines of supervision exist but are considered to be quite weak. There is also confusion about the supervisory structure of community-based skilled birth attendants with some reporting to the Directorate General of Family Planning and others reporting to the Directorate General of Health Services (MoHFW Bangladesh and UNFPA 2004).

Health assistants and family welfare assistants are supervised by the health inspector (male) and family planning inspector (male) at the union level (WHO Bangladesh 2009). Family welfare visitors have been trained since 2008 to supervise the newly created cadre of community-based skilled birth attendants (Ahmed and Jakaira 2009).

CoMPETENCy

A study of skilled birth attendants trained by two different NGOs (The Bangladesh Association of Voluntary Sterilization and the NGO Service Delivery Program or NSDP) found that, while most attendants were competent in antenatal care, postnatal care and normal delivery, skill levels were low in emergency cases.

Overall, knowledge scores were 41% (BAVS) and 68% (NSDP), and skill test results were 56% (BAVS) and 65% (NSDP) (Anwar et al. 2007).

TEAM WoRK

While there is information available on the cadres working in different settings, it is difficult to ascertain how well these cadres work together. In health facilities the main cadres found working together are doctors, nurses and paraprofessionals.

Village doctors often also work in NGO health facilities and community health workers in government clinics. Two community-based workers, one family welfare assistant and one medical assistant generally work in a team to serve communities of around 6,000 to 7,000 people (Baqui et al. 2008b).

There are a large number of vacant teaching posts and overcrowding in teaching facilities with a teacher to student ratio of 1:57 in some settings (Bangladesh Health Watch 2008).

DoctorsThe Bangabandhu Sheikh Mujib Medical University offers graduate degrees and diplomas in medicine and the Bangladesh College of Physicians and Surgeons offers specialised degrees (Bangladesh Health Watch 2008).

NursesThere are 70 training institutes across the country, 51 of these are government run and 19 are private. Each year approximately 2,280 students are admitted (1,790 in public institutes and 490 in private institutes) and around 1200 qualify for a Diploma in Nursing. The fourth year of this course is devoted to midwifery,family planning, obstetrics and neonatal nursing. There is a focus on community nursing throughout the course. All colleges follow the same curriculum for the four-year Nursing Diploma.

The College of Nursing offers a Bachelor Degree in Nursing (Bangladesh Health Watch, 2008). Educational standards, teacher qualifications, training courses and examinations are overseen by the Bangladesh Nursing Council (Ministry of Law Justice and Parliament Affairs Bangladesh 1983).

The International University of Agriculture, Business and Technology (Dhaka), with assistance from educators from Vancouver, has started a Bachelor of Science in Nursing with a strong focus on primary health care. There are 65 students currently enrolled in this four-year course (Bangladesh Health Watch 2008).

Medical Assistants (also known as SAMCo – Sub-assistant community medical officer)There are five medical assistant training schools run by the government which offer a four-year course. The course covers antenatal care, postnatal care and delivery care (SEARO 2004).

There are 900 students currently enrolled with a yearly intake of 300 (predominantly male) students. This course has been considered too technical for the skill level of the students involved (Bangladesh Health Watch 2008).

family welfare visitors There are 12 training institutes for Family Welfare Visitors which are managed by the National Institute of Population Research and Training (Bangladesh Health Watch 2008).

SUPERViSioN AND SCoPE of PRACTiCE

EDUCATioN AND TRAiNiNG


Community-based skilled birth attendantsThe Obstetrical and Gynaecological Society of Bangladesh runs six-month training courses for community-based skilled birth attendants. This course includes 4 weeks of lectures, 13 weeks clinical practice in a hospital, 8 weeks practice at the community level and 1 week of final evaluation. Students must carry out 20 deliveries during training.

Training is conducted through Family Welfare Training Institutes, Nursing Institutes and Mother and Child Welfare Centres. There are 480 students trained annually in antenatal care, normal home delivery, postnatal care, newborn care, identifying and referring complications, clinical midwifery practices and community midwifery practice.

Following assessment at the end of the course graduates are registered. There have been plans within the Ministry of Health and Family Welfare (MoHFW) to scale up this training (Bangladesh Health Watch 2008; SEARO 2004; UNFPA and ICM 2006).

In the NGO sector, the Bangladesh Red Crescent Society provides a one-year midwifery program to young women with no nursing qualifications (SEARO 2004).

Twenty-two percent of traditional birth attendants have received training, with 56.5% of trained traditional birth attendants receiving their training from the government (MoHFW Bangladesh 2008).

Community health workersCommunity health workers receive minimal training. This can involve 14 to 20 days training which is provided by the program that has hired them, for example, BRAC2, the NGO Service Delivery Program or the Urban Primary Healthcare Project (Bangladesh Health Watch 2008). The majority (90.8%) of Community health workers have received training of some kind, with 46.5% receiving training from NGOs (MoHFW Bangladesh 2008).

Village doctorsVillage doctors have a low level (three to six months) of formal training from private providers (Bangladesh Health Watch 2008).

For more information on pre-service and in-service training please refer to Appendices 1 and 2.

The Bangladesh Nursing Council is responsible for registration of all nurses and midwives as outlined in the Bangladesh Nursing Council Ordinance 1983 (Ministry of Law Justice and Parliament Affairs Bangladesh 1983).

Applicants are eligible for registration following the successful completion of the four-year Nursing and Midwifery Certificate. Registration is renewed every five years (ANMC 2009).

HUMAN RESoURCE foR HEALTH PoLiCy AND PLANS

Bangladesh Health Workforce Strategy 2008The aim of this strategy is to enable all people to have equitable access to effective health services by placing an optimum number of competent and motivated health personnel at all levels.

There is a focus on integrating the system of managing human resources across the public, private and NGO sectors. This includes developing an accreditation system which will span all of these sectors.

The strategy includes measures to improve health workforce planning including the development of a human resource master plan, improve incentives to work in rural and remote areas, integrate more community-focused aspects into training programs and improve the quality of health workforce education and planning, which includes improving the capacity of teaching and training institutions with a shift from a more knowledge-based to a skills-based approach. The plan also focuses on stewardship (regulation of health human resources), recruitment and career development and retention, performance management processes, leadership and coordination of human resource (HR) functions, public-private partnerships, effective financing and an integrated human resource management information system.

HRH is also included in the Bangladesh Health Master Plan (2010–2040). For more information refer to Appendix 3.

2 Non-government organisation, formally known as the Bangladesh Rehabilitation Assistance Committee

CoUNTRy REGiSTRATioN


Two policies are used to direct maternal, neonatal and reproductive health – the Population Policy (MoHFW Bangladesh 2004) and the National Strategy for Maternal Health (MoHFW Bangladesh 2001).

Population policy (2004)The goal of this policy is to improve the health and living conditions of the population and reduce the population growth rate. It focuses specifically on vulnerable groups and under serviced areas.

Included in this policy are aims to make reproductive health and family welfare services available to all sections of society, reduce maternal mortality by providing antenatal care, safe delivery practices, emergency obstetric care and postnatal care, delay first pregnancy for adolescent women, increase the number of deliveries attended by a skilled birth attendant (with the aim of 100% by 2010) and include reproductive health education in school curricula.

Human resource development is included in point 4.5 of this policy. It has a strong focus on improving training for HRH, with measures to incorporate population, family planning, maternal, child and reproductive health into medical education curriculums to strengthen training in policy and management (MoHFW Bangladesh 2004).

National Strategy for Maternal Health 2001The aims of the Maternal Health Strategy are to strengthen the provision of essential (including emergency) obstetric care and improve referral and utilisation of facilities, improve the nutritional status of women and adolescent girls, ensure the right people with the right skills are trained to provide quality maternal health services at all levels of the health system, promote women-friendly health services and to bring about positive changes in the perception and behaviour of individuals, families, service providers and the community to support women in their realisation to their right to safe motherhood and a life free from violence and discrimination.

Included are plans to provide one community midwife for every 18,000 community clinics and ensure the capacity and quality of training institutes through accreditation (MoHFW Bangladesh and UNFPA 2004).

The aims of the Maternal Health Strategy are to... ensure the right people with the right skills are trained to provide quality maternal health services at all levels of the health system.

MATERNAL, NEoNATAL AND REPRoDUCTiVE HEALTH PoLiCy AND PLANS


A number of cadres have reported earning over 10,000 Taka (USD$147) a month. Eighty percent of paraprofessionals, 36% of nurses, 35% of Community health workers, 14% of traditional healers and 9% of traditional birth attendants report earning over this amount (Bangladesh Health Watch 2008).

Community-based skilled birth attendants earn an average monthly income of 7,000 Taka. Most receive extra incentives as gifts from clients including money and clothing (Bangladesh Health Watch 2008). The majority (74%) expressed satisfaction with the financial benefits. Community health workers receive different remuneration depending on which program they are working with.

BRAC community health workers earn approximately USD$4.70 a month from sales. NGO Service Delivery Program community health workers earn approximately USD$6.27 a month from sales and earn a 50% commission for referring clients to health centres. Community Health Workers working with Urban Primary Health Care Project receive salaries that range from USD$31 to $62 a month (Bangladesh Health Watch 2008).

Traditional birth attendants are often motivated by a sense of obligation to help their community, especially neighbours and relatives. They are often compensated with small items such as a meal or soap from poorer families and a sari from wealthier households (BRAC 2001).

Lack of incentives and supervision has contributed to doctors spending more time in private practice at the expense of services at public posts (MoHFW Bangladesh 2008).

� There is a high doctor to nurse ratio across the country which is more pronounced in some areas. In some areas this is more pronounced. For example, in Sylhet there is one nurse to 10 doctors (Bangladesh Health Watch 2008).

� Rapid population growth means that even if doctor training rates increase at the current rate, the doctor to population ratio will remain the same (Bangladesh Health Watch 2008).

� Low income and lack of career prospects have been cited as reasons for dissatisfaction with health occupations (Bangladesh Health Watch 2008).

� Family welfare visitors have sometimes been noted to be hesitant to offer services to the poor (Chaudhury and Hammer 2004).

� Lack of opportunity for promotion means that many health care professionals are seeking employment with NGOs or private sector employees (MoHFW Bangladesh 2008).

� Two key workforce issues are vacant posts and absenteeism. Twenty six percent of public heath positions are vacant nationwide. Although the overall doctor density rate is thought to be 20 to 100,000, 41% of posts are vacant and a study found that in 42% of posts the doctor was found to be absent, bringing the density down to 8.4 for every 100,000. Absenteeism was found to be roughly 40% in upazila3 and 74% in upgraded union family welfare centres. Many public doctors use the afternoons to see private patients and are therefore not available to see public patients (Chaudhury and Hammer 2004).

� There is a high number of vacant teaching posts leading to overcrowding in teaching facilities (Bangladesh Health Watch 2008).

Lack of incentives and supervision has contributed to doctors spending more time in private practice at the expense of services at public posts.

REMUNERATioN AND iNCENTiVES

KEy iSSUES oR BARRiERS

3 Upazila: sub-district health complex


Community-based skilled birth attendantsIn March 2003, WHO, UNFPA and the Obstetrical and Gynaecological Society of Bangladesh started the Community-Based Skilled Birth Attendant and Services Program. This is a six-month program to up-skill family welfare assistants and family health assistants to carry out safe delivery at home. By the end of 2000, 4,000 skilled birth attendants and 40 supervisors had been trained across 56 districts (of the total 64 districts).

The program started with a train-the-trainers course run by senior professors of medical or nursing schools. Trainers were from district hospitals, maternal and child welfare centres and from the health department. They went on to train family welfare assistants and family health assistants in 74 skills covering the antenatal, birth and postpartum periods. At the end of each course the Bangladeshi Nursing Council examined and certified trainees as skilled birth attendants.

Between 2006 and 2008, 1,739 community based skilled birth attendants delivered 65,000 babies and referred 21,000 complicated cases amongst women who had previously only been assisted by a relative or traditional birth attendant. However, 13,500 community-based skilled birth attendants are needed by 2010 to cover the whole population; a number that is unlikely to be achieved (Ahmed and Jakaira 2009).

Maternal and Child Health-family Planning ProgramThe Maternal Child Health Family Planning Program started in the 1970s. It aims to decrease rapid population growth by taking information about family planning and contraception into women’s homes (as women were often confined to their homes and unable to access health care). A large number of employees were hired, with 23,000 government field workers and 12,000 NGO workers hired to go from household to household in communities targeting married women aged between 15 and 49.

The Maternal Child Health Family Planning Program is dependent on donor funding, with 37% of funds provided by the government. As the population grows and future funding is uncertain a strain will be put on this service (Routh et al. 2001). A study in urban areas in 2001 found that removing the doorstop service and encouraging mothers to obtain their contraception from clinics led to an increase in social marketing campaigns carried out in the private sector.

Drug stores and supermarkets increased their contraceptive sales, and there was an increase in utilisation of maternal health services at clinics without a decline in the use of contraception (Routh et al. 2001). There was also the challenge to integrate the services that had been offered into a more comprehensive health package (Ahsan and Thwin 1998).

Perinatal care projectThis project was run by Women and Children First (UK), the Diabetic Association of Bangladesh and the London Centre for International Health and Development. The program ran in three districts from 2002 to 2008. It facilitated women’s groups to identify health problems associated with pregnancy and child birth and develop possible solutions to these problems.

Some of the outcomes were measures to develop community awareness, increase communication, support and education amongst the women in the villages and improve communication with health care staff located at clinics. In response to feedback from the women’s groups, training was held with health care staff to improve their skills, their level of cultural appropriateness and their ability to relate to the women from the villages (Khan et al. 2007; Women and Children First (UK) 2009).

KEy iNiTiATiVES

13,500 community-based skilled birth attendants are needed by 2010 to cover the whole population – a number that is unlikely to be achieved.


DocumentationA significant amount of information was available on the health workforce and MNRH in Bangladesh. Most sources of information could be quickly retrieved from the internet. Some government documents, however, were more difficult to access such as the National Strategy for Maternal Health (2001).

The main source of information on the health workforce for MNRH was the Bangladesh Health Watch report, Health Workforce in Bangladesh (Bangladesh Health Watch 2008). This report explores the density and profile of health care providers with a special focus on providers servicing the rural community. It provided more in-depth information on issues of training, recruitment, incentives, job satisfaction and job performance. This information was based on inventory lists of health workers derived from informal discussions with community members and surveys and interviews conducted with health care staff and key informants (Bangladesh Health Watch 2008).

A number of different sources were used to obtain numbers of workers in each cadre (AAAH 2008; Bangladesh Health Watch 2008; MoHFW Bangladesh 2009b, MoHFW Bangladesh 2009c; WHO, 2009). Where there were conflicting numbers the Ministry of Health and Family Welfare human resource development data set was used (MoHFW Bangladesh 2009b).

The information for this data set came mainly from the Human Resource Department in the Ministry of Health; other sources were various government offices such as the Nursing Council. It was not possible to obtain consistent information about the disaggregation of the workforce in different cadres, with certain information being available for some cadres but not others. It was also not possible to locate information outlining the geographic distribution of health workers.

ReviewersThis profile was reviewed by the program leader for a key NGO working in the field. They did not include written feedback on the document but commented that some of the figures were outdated. It was also reviewed by a key academic working in the field who provided short comments and feedback about the accuracy of certain aspects of the profile. They commented on the accuracy of the maternal mortality ratio and provided additional information on the current state of health care centres.

CRiTiQUE of DATA SoURCES

The Bangladesh Health Watch report provided more in-depth information on issues of training, recruitment, incentives, job satisfaction and job performance.


AAAH 2008, Annual Review of HRH Situation in Asia-Pacific Region 2006–2007, Asia-Pacific Action Alliance for Human Resources for Health.

Ahmed, T and Jakaria, SM 2009, ‘Community-Based Skilled Birth Attendants in Bangladesh: Attending deliveries at home’, Reproductive Health Matters, vol. 17, no. 33, pp.45–50.

Ahsan, S and Thwin, A 1998, Bangladesh’s Experiences with Human Resource Development Strategies in Family Planning Service Delivery: A Critical Look at the Past and Directions for the Future Dhaka, International Centre for Diarrhoeal Disease Research.

ANMC 2009, Country profile – Bangladesh, accessed 26 October 2009, <http://www.anmc.org.au/bangladesh>.

Anwar, I, Fedous, J, Akhtar, N, Kalim, N, Elahi, M, Hoque, E and Koblinsky, M 2007, Evaluation of Two Home-Based Skilled Birth Attendant Programmes in Bangladesh, paper presented at the Annual Scientific Conference (ASCON).

Bangladesh Health Watch 2008, Health Workforce in Bangladesh: Who constitutes the healthcare system?, James P. Grant School of Public Health, Centre for Health System Studies, BRAC University, Dhaka, Bangladesh.

Baqui, A, Williams, E, Rosecrans, A, Agrawal, P, Ahmed, S, Darmstadt, G, Kumar, V, Kirar, U, Panwar, D, Ahuja, R, Srivastava, V, Black, R and Santo-sham, M 2008a, ‘Impact of an Integrated Nutrition and Health Programme on Neonatal Mortality in Rural Northern India’, Bulletin of the World Health Organization, vol. 86, no. 10, pp. 796–804.

Baqui, AH, El-Arifeen, S, Darmstadt, GL, Ahmed, S, Williams, EK, Seraji, HR, Mannan, I, Rahman, SM, Shah, R, Saha, SK, Syed, U, Winch, PJ, Lefevre, A, Santosham, M and Black, RE 2008b, ‘Effect of Community-Based Newborn-Care Intervention Package Implemented Through Two Service-Delivery Strategies in Sylhet district, Bangladesh: A cluster-randomised controlled trial’, The Lancet, vol. 371, no. 9628, pp. 1936–1944.

Bangladesh Nursing Council Ordinance 1983, Ordinance LXI of 1983, 5 October 1983.

BRAC 2001, Skilled Attendance at Delivery in Bangladesh: An ethnographic study, BRAC Research and Evaluation Division and the University of Aberdeen, Dhaka.

Chaudhury, N and Hammer, J 2004, ‘Ghost Doctors: Absenteeism in Rural Bangladesh Health Facilities’, The World Bank Economic Review, vol. 18, no.3, pp. 423–441.

Hogan, MC, Foreman, KJ, Naghavi, M, Ahn, SY, Wang, M, Makela, SM, Lopez, AD, Lozano, R and Murray, CJL 2010, ‘Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5’, Lancet, vol. 375, no. 9726, pp. 1609–1623.

Khan, K, Costello, A, Barnett, S, Barua, S, Roselyn Rego, A, Flatman, D, Azad, K and Azad Khan, A 2007, Towards Millennium Development Goal 4 and 5: Experience with Women’s Groups in Community Mobilization in Bangladesh, paper presented at the Annual Scientific Conference (ASCON), <http://www.icddrb.org/pub/publication.jsp?pubID=7976&classificationID=0&typeClassificationID=0>.

MoHFW Bangladesh 2001, National Ministry of Health Strategy 2001, Ministry of Health and Family Welfare, Government of the People, Republic of Bangladesh.

MoHFW Bangladesh 2003, Maternal Health Review Bangladesh, Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh and DFID, Dhaka.

MoHFW Bangladesh 2004, Bangladesh Population Policy, Ministry of Health and Family Welfare, Government of the People’s Republic Of Bangladesh, Dhaka.

MoHFW Bangladesh 2006, Maternal, Child and Reproductive Health Unit, accessed 15 October 2009, <http://www.dgfp.gov.bd/unit%20function/unit_9.htm>.

MoHFW Bangladesh 2008, Bangladesh Health Workforce Strategy 2008, Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh, Dhaka.

MoHFW Bangladesh 2009a, Directorate of Nursing Services, accessed 15 October 2009, <http://www.mohfw.gov.bd/index.php/directorates-and-other-offices/dns>.

MoHFW Bangladesh 2009b, HRD Data Sheet, Ministry of Health and Family Welfare Government of the People’s Republic of Bangladesh, Dhaka.

MoHFW Bangladesh 2009c, Ministry of Health and Family Welfare: Government of the People’s Republic of Bangladesh, accessed 14 December 2009, <http://www.mohfw.gov.bd/>.

MoHFW Bangladesh and UNFPA 2004, Thematic Review of Safe Motherhood in Bangladesh, Ministry of Health Bangladesh and the United Nations Population Fund, Dhaka.

Routh, S, El Arifeen, S, Jahan, S, Begum, A, Thwin, A and Hel

REfERENCES


Baqui, A 2001, ‘Coping with changing conditions: alternative strategies for the delivery of maternal and child health and family planning services in Dhaka, Bangladesh’, Bulletin of the World Health Organization, no. 79, pp. 142–149.

SEARO 2004, Improving Maternal, Newborn and Child Health in the South-East Asia Region: Bangladesh, World Health Organisation, South-East Asia Regional Office.

SEARO 2009, Bangladesh Goal Five: Improve Maternal Health, accessed 15 October 2009, <http://www.searo.who.int/LinkFiles/Publications_NUR-458.pdf>.

UNDESA 2005, The Millennium Development Goals Report, United Nations Department of Economic and Social Affairs, New York.

UNFPA and ICM 2006, Investing in Midwives and Others with Midwifery Skills to Save the Lives of Mothers and Newborns and Improve their Health, United Nations Population Fund and International Confederation of Midwives, New York.

UNICEF 2010, Bangladesh: Statistics, accessed 5 May 2011, <http://www.unicef.org/infobycountry/bangladesh_bangladesh_statistics.html>.

WHO 2009, World Health Statistics 2009, <http://apps.who.int/whosis/data/Search.jsp>.

WHO 2010a, Global Atlas of Health Workers, accessed 5 February 2010, <http://apps.who.int/globalatlas/default.asp>.

WHO 2010b, World Health Statistics 2010, World Health Organization, Geneva.

WHO Bangladesh 2009, Health System in Bangladesh, <http://www.whoban.org/health_system_bangladesh.html>.

Women and Children First (UK) 2009, Bangladesh, Perinatal Care Programme (2002–2008), accessed 26 October 2009, <http://www.wcf-uk.org/northsouth/extra3.nsf/2/Bangladesh-Maternal-Child-Health?OpenDocument>.


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ion

Pol

icy

The

goal

of t

his

polic

y is

to im

prov

e th

e he

alth

and

livi

ng c

ondi

tions

of t

he p

opul

atio

n an

d re

duce

the

popu

latio

n gr

owth

rat

e w

hich

has

been

iden

tified

as

the

natio

n’s

grea

test

pro

blem

. It f

ocus

es s

peci

fical

ly o

n vu

lner

able

gro

ups

and

unde

rser

vice

d ar

eas.

Incl

uded

in th

is p

olic

y ar

e ai

ms

to p

rovi

de r

epro

duct

ive

heal

th a

nd fa

mily

wel

fare

ser

vice

s to

all

sect

ions

of s

ocie

ty, r

educ

e m

ater

nal

mor

talit

y ra

tio b

y pr

ovid

ing

ante

nata

l car

e, s

afe

deliv

ery

prac

tices

, em

erge

ncy

obst

etric

car

e an

d po

stna

tal c

are,

del

ay fi

rst p

regn

ancy

for

adol

esce

nt w

omen

, inc

reas

e th

e nu

mbe

r of

del

iver

ies

atte

nded

by

a sk

illed

birt

h at

tend

ant w

ith th

e ai

m o

f 100

% b

y 20

10 a

nd in

clud

e

repr

oduc

tive

heal

th e

duca

tion

in s

choo

l cur

ricul

ums.

Hum

an r

esou

rce

deve

lopm

ent i

s in

clud

ed in

poi

nt 4

.5 o

f thi

s po

licy.

It h

as a

str

ong

focu

s on

impr

ovin

g tr

aini

ng fo

r hu

man

res

ourc

es fo

r

heal

th, w

ith m

easu

res

to in

corp

orat

e po

pula

tion,

fam

ily p

lann

ing,

mat

erna

l chi

ld h

ealth

, rep

rodu

ctiv

e he

alth

med

ical

edu

catio

n cu

rric

ula,

to s

tren

gthe

n tr

aini

ng in

pol

icy

and

man

agem

ent (

MoH

FW B

angl

ades

h 20

04).

Nat

iona

l Str

ateg

y fo

r M

ater

nal H

ealth

200

1

The

aim

s of

the

Mat

erna

l Hea

lth S

trat

egy

are

to s

tren

gthe

n th

e pr

ovis

ion

of e

ssen

tial (

incl

udin

g em

erge

ncy)

obs

tetr

ic c

are

and

impr

ove

refe

rral

and

util

isat

ion

of fa

cilit

ies,

impr

ove

the

nutr

ition

al s

tatu

s of

wom

en a

nd a

dole

scen

t girl

s, e

nsur

e th

e rig

ht p

eopl

e w

ith th

e rig

ht

skill

s ar

e tr

aine

d to

pro

vide

qua

lity

mat

erna

l hea

lth s

ervi

ces

at a

ll le

vels

of t

he h

ealth

sys

tem

, pro

mot

e w

omen

-frie

ndly

hea

lth s

ervi

ces

and

to b

ring

abou

t pos

itive

cha

nges

in th

e pe

rcep

tion

and

beha

viou

r of

indi

vidu

als,

fam

ilies

, ser

vice

pro

vide

rs a

nd th

e co

mm

unity

to

supp

ort w

omen

in th

eir

real

isat

ion

to th

eir

right

to s

afe

mot

herh

ood

and

a lif

e fr

ee fr

om v

iole

nce

and

disc

rimin

atio

n.

Incl

uded

are

pla

ns to

pro

vide

one

com

mun

ity m

idw

ife fo

r ev

ery

18 0

00 c

omm

unity

clin

ics

and

ensu

re th

e ca

paci

ty a

nd q

ualit

y of

trai

ning

inst

itute

s th

roug

h ac

cred

itatio

n (M

oHFW

Ban

glad

esh

and

UN

FPA

, 200

4).

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health policy.

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Aims to facilitate the development and integration of health information systems in the broader health system strengthening agenda as well as increase local capacity to ensure that cost-effective, timely, reliable and relevant information is available, and used, to better inform health development policies. www.uq.edu.au/hishub

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Aims to support regional, national and international partners to develop effective evidence-informed national policy-making, particularly in the field of health finance and health systems. Key thematic areas for this Hub include comparative analysis of health finance interventions and health system outcomes; the role of non-state providers of health care; and health policy development in the Pacific. www.ni.unimelb.edu.au

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