bangladesh - ICS Integrare

Transcription

BANGLADESH
RMNH
WORKFORCE
ASSESSMENT
MARCH 2014
Human Resources Management Unit
Ministry of Health and Family Welfare
of the Government of Bangladesh
Supported by the H4+ High
Burden Countries Initiative
Acknowledgements
This report was produced under the leadership and the coordination
of the Directorate of Human Resources of the Ministry of Health and
Family Welfare of Bangladesh (Ms. Farzana Mamtaz, Ms. Feroza Sarker,
Dr. Sayed Abu Jafar Md. Musa, Dr. Pabitra Kumar Sikder, Dr. Gias Uddin, Dr.
Reza Ul Karim, Ms. Taslima Begum, Ms. Suraiya Begum) with the collaboration
of several people including individuals from the H4+ agencies: UNFPA in New York
(Laura Laski, Luc de Bernis), the UNFPA Office in Bangladesh (Ms. Yuki Suehiro, Dr.
Prasanna Gunasekera, Dr. Hashina Begum, Dr. Zaman Ara, Dr. Sanchoy Kumar Chanda,
Dr. Rama Das, Ms. Anna af Ugglas, Ms. Michaela Michel-Schuldt, Dr. Loshan Moonesinghe),
the WHO Office in Bangladesh (Dr. Khaled Hassan, Dr. Rabeya Khatoon, Ms. Monica Driu
Fong, Dr. Tekendra Karki), UNICEF Office in Bangladesh (Dr. Lianne Kuppens, Dr. Indrani
Chakma) and the World Bank Office in Bangladesh (Dr. Bushra Binte Alam, Karar Zunaid Ahsan).
The Bangladesh RMNH Workforce Steering Committee consisted of the Government of Bangladesh, the
H4+ Country Offices (UNFPA, UNICEF, WHO and The World Bank), the Jhpiego/Save the Children Office
of Bangladesh, the Bangladesh Midwifery Society, the Bangladesh Nursing and Midwifery Council and the
Obstetrical and Gynaecological Society of Bangladesh. This committee was responsible for the overall lead of
the project.
Thanks also to the many in-country RMNH partners and stakeholders who participated in the process and enriched
it with their contributions or comments.
The writing team was led by ICS Integrare of Barcelona, Spain with Rupa Chilvers and Paul Van Look. Quality control
by Petra ten Hoope-Bender and Jim Campbell (ICS Integrare). This report was edited by Elizabeth Coleman and Ward
Rinehart of Jura Editorial Services SARL. Design and layout was done by Prographics, Annapolis. Special thanks also to Zoe
Matthews and Andy Tatem (University of Southampton), Luc de Bernis, UNFPA, Jim Campbell, Maria Guerra-Arias, and
Sally Stansfield, ICS Integrare, and Allysin Moran, USAID, for their valuable contributions.
The production of this report was funded by the H4+ Canada grant of UNFPA, while primary data collection and
analysis were funded by the Bangladesh UNFPA Country Office and conducted by Research, Training and Management
International (RTMI) based in Bangladesh (Ms. Farhtheeba Rahat Khan, Mr.Nazmul Huq).
The HBCI Secretariat
Design and Printing
ICS Integrare
Prographics, Inc.
Email: [email protected]
Email: [email protected]
www.integrare.es
www.prographic.com
Recommended citation: Chilvers R, Van Look P, ten Hoope-Bender P. RMNH Workforce Assessment 2014. MOHFW Bangladesh, UNFPA,
ICS Integrare. Barcelona, Spain, 2014
© United Nations Population Fund (UNFPA), 2014. All rights reserved.
The designations employed and the presentation of material in the present document do not imply the expression of any opinion on the
part of the Bangladesh RMNH Workforce Steering Committee and the RMNH Workforce Assessment partners concerning the legal or
other status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
The present volume has been consolidated and edited in accordance with United Nations Population Fund practice and
requirements. All reasonable precautions have been taken by the United Nations Population Fund and the RMNH
Workforce Assessment partners to verify the information contained in this publication. However, the published material
is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation
and use of the material lies with the reader. In no event shall the Bangladesh RMNH Workforce Steering Committee
members and the RMNH Workforce Assessment partners be liable for damages arising from its use.
Printed on recycled paper. In an effort to reduce environmental impact, provide increased access to
publications and keep printing costs down, almost all United Nations Population Fund publications are
made available online in electronic format, as PDF and Word documents, for free.
BANGLADESH
RMNH
WORKFORCE
ASSESSMENT
MARCH 2014
Contents
Foreword ............................................................................................. ii-iii
Executive Summary ..................................................................................1
Background and Methods ........................................................................6
Country Assessment: Context ..................................................................8
Domain A: Essential RMNH Interventions and their Utilization ...........10
Domain B: The RMNH Workforce......................................................15
Domain C: The Work Environment.....................................................20
Domain D: Management and Policies .................................................23
Domain E: Financing..........................................................................27
Options, Costs and Impact .....................................................................32
Annex 1: Mapping of MNH interventions: PMNCH guidelines and
the Bangladesh health system .................................................................41
Annex 2: Abbreviations ..........................................................................43
Foreword
Access to family planning, emergency obstetric
care and skilled attendance at birth are
internationally acknowledged to reduce the
number of maternal deaths. Not only do skilled
attendants play a central role in averting maternal
deaths during childbirth, they also provide
antenatal care for pregnant women and postnatal
care for mothers and the newborn. Counselling of
modern family planning methods, good nutrition
and promoting exclusive breastfeeding of infants
is an integral part of their core responsibilities
To further strengthen reproductive, maternal and neonatal healthcare
(RMNH) and move towards universal coverage, the Government of Bangladesh
has taken the initiative to assess health workforce requirements up to 2021.
This RMNH workforce assessment report analyzed across five domains will
enable evidence based workforce development strategies.
According to recommendations in the RMNH workforce assessment, these
strategies will provide impetus to emergency obstetric care and RMNH skills
in the workforce in the short term and development of a dedicated cadre with
full competencies in the longer term.
M M Neazuddin
Secretary Ministry of Health and Family Welfare.
ii
B A N G L A D E S H: NAT IONAL ASSE SSME NT OF R MNH WOR K FORC E
Argentina Matavel Piccin, Dr Pascal Villeneuve,
UNFPA Representative,
UNICEF Representative,
Bangladesh
Bangladesh
In 2010, the United Nations
Secretary-General launched the
Global Strategy for Women’s and
Children’s Health. In response,
the “Health 4+” (H4+) agencies
(UNFPA, UNICEF, WHO,
UNAIDS, UN Women, World
Bank), under the High Burden
Countries Initiative, supports
countries confronting the most
intense reproductive, maternal
and newborn health (RMNH)
challenges by strengthening
evidence-based policy and its
implementation.
Without a doubt, human resources
are an integral part of health
systems and service delivery,
especially for maternal and
newborn health. This comprehensive report highlights human resource
issues related to RMNH in Bangladesh and will contribute to develop a
costed National RMNH Workforce Strategy by the Ministry of Health and
Family Welfare, which will in turn improve the health and well-being of
women and children.
Dr Thushara Fernando,
WHO Representative,
Bangladesh
Johannes Zutt. Country
Director, World Bank
FOREWOR D
iii
iv
B A N G L ADE SH : NAT IONAL ASSE SSME NT OF R MNH WOR K FORC E
Executive Summary
Overview
Despite decades of steady improvement in Bangladesh’s
healthcare system, an unacceptable number of mothers and
newborns continue to die. The country’s newborn mortality
rate (NMR) is 31 neonatal deaths per 1,000 live births and its
maternal mortality ratio (MMR) is 194 maternal deaths per
100,000 live births. However, building on recent advances, the
policies outlined in this assessment could, by 2021, nearly halve
the NMR to an estimated 19 and reduce the MMR to 142.
What’s more, these measures to expand and
train the reproductive, maternal and newborn health (RMNH) workforce require an
investment as low as US$3.67 per expected
pregnancy between 2013 and 2021. During that
same period, they would avert an estimated
172,270 neonatal deaths, 11,062 maternal
deaths, and 314,421 intrapartum deaths.
This report details findings that are the
results of a national assessment of the RMNH
workforce in Bangladesh, undertaken from
March 2012 to October 2013. The central
question was:
What is the appropriate RMNH workforce,
and how is it best deployed, to equitably deliver
essential maternal and newborn health interventions at scale and quality, and what (including
costs) needs to be put into place to achieve
universal access?
The assessment framework considered five
domains of investigation: essential interventions for RMNH and their utilization, the
maternal and newborn health workforce, the
work environment, management and policies,
and financing.
EX ECUTIV E SUMMA RY
1
Main findings
Utilization of RMNH essential interventions.
Bangladesh is expected to reach, by 2015, MDG
5 (a three-quarter reduction in the maternal
mortality ratio from the 1990 baseline) and
MDG 4 (a two-third reduction in the under-5
mortality rate). The rate of newborn deaths
is declining significantly, although stillbirths
remain too common. However, the national
figures hide marked inequities between the rich
and the poor in antenatal care, skilled attendance at delivery, postnatal care and caesarean
delivery rates.
The overall level of skilled attendance at birth
remains low, at 32%, and varies from 54% in
urban areas to 25% in rural areas. Analysis of
the RMNH essential interventions found that
those either not practised or
practised only to a limited
extent included corticosteroids for respiratory distress
in newborns, magnesium
sulphate for eclampsia, and
Active Management of the
Third Stage of Labour for
prevention of postpartum
haemorrhage. Given that
postpartum haemorrhage
and eclampsia account for
more than half of maternal
deaths in Bangladesh, special attention to training staff in the essential interventions could
save many lives.
The Dhaka district
has 31% of the
country’s nursemidwives and 37%
of its doctors and
yet only 8% of its
pregnancies.
The RMNH workforce. Among the 10 cadres of public-sector healthcare personnel who
provide RMNH care, education and training
vary greatly, from six months of training for
community-based skilled birth attendants
(CSBAs) to three years for nurse-midwives
and seven years for obstetrician/gynaecologists. An estimated 107,000 health workers
(cadre and non-cadre) provide RMNH care,
but a substantial number of sanctioned posts
are vacant, especially in poor rural divisions;
absenteeism is pervasive among full-time
public-sector healthcare personnel; and all cadres perform other duties besides RMNH care.
(Nurse-midwives perform midwifery services
2
an estimated 20% of their time.) Significantly,
the distribution of RMNH staff is inequitable,
particularly with regard to doctors and nursemidwives. The district of Dhaka has 31% of the
country’s nurse-midwives and 37% of its doctors and yet only 8% of its pregnancies.
The work environment. The plans and strategies of the Government of Bangladesh (GOB)
have recognized the need to build new facilities
and upgrade existing facilities for emergency
obstetric care (EmOC). However, the numbers
of facilities providing such care fall short of
World Health Organization (WHO) standards.
The majority (91%) of the 110 healthcare providers interviewed for this assessment said their
training had prepared them adequately to give
maternal and newborn care; nearly four fifths
(79%) said that they could perform all tasks for
which they were trained, but 20% expressed
disappointment that they were not permitted to
carry out all of these tasks.
Management and policies. National policies
over the years have sought to: (1) achieve greater professionalism among healthcare personnel
caring for pregnant women and their newborn,
including increasing the proportion of births
attended by a skilled birth attendant and promoting institutional delivery; and (2) increase
the number and quality of facilities able to provide EmOC and essential newborn care (ENC).
However, progress towards these goals has been
slow. Management issues affecting the workforce included the absence of a comprehensive
plan on human resources for health (HRH);
complex procedures for creating new positions
and recruiting staff into sanctioned posts; the
difficulties of retaining staff in rural areas;
and lack of a centralized Human Resources
Information System (HRIS).
Financing. Per capita national health expenditure in Bangladesh is among the world’s lowest,
at US$27 in 2011, or about 3.8% of gross domestic product (GDP). While the amount that the
public sector actually spends on RMNH cannot
be determined, a rough estimate puts the figure at US$480 million per year. As this falls far
short of the amount needed to reach the three
health-related Millennium Development Goals
(MDGs) 4, 5 and 6, the GOB has set the following 2016 targets at 50%: deliveries attended by
a skilled birth attendant; antenatal coverage
(at least four visits); and postnatal care within
48 hours (at least one visit). Since sector-wide
approaches (SWAps) provide some flexibility for
re-allocating funds in line with government priorities, annual and mid-term SWAp assessments
should provide the GOB with regular opportunities to adjust its policies and programmes,
including funding allocations, in response to
changing needs.
and Nutrition Sector Development Program
(HPNSDP), to enable quality care, including
the implementation of regulatory standards
with supportive supervision and enhancement
of existing training capacity, leading to care by
midwifery-skilled cadres with access to basic
EmOC-equipped facilities without the need for
referral. Depending on the numbers of providers graduating from educational institutes, and
if capacity increases to 2,400 graduates per
year as of 2019, which is equivalent to nursemidwives admissions, this strategy will have
produced some 20,000 diploma midwives by
2024, thus reaching universal coverage.
Options, costs and impact
In consultation with national stakeholders,
the evidence generated by the assessment was
used to develop, model and cost options for
the future RMNH workforce. These options
address: (1) the need to increase EmOC and
MNH (maternal and newborn health) skills in
the short term to ensure capacity for planned
coverage, and (2) the development of a dedicated cadre with the full set of competencies for
managing births and complications, providing
24/7 service and reaching universal coverage in
the longer term.
Key area 1: short-term “skill-up”
This focuses on the development of skilled
healthcare personnel within the existing government-sanctioned posts to meet the needs of
the population through 2016. If 70% of nursemidwives and family welfare visitors (FWVs)
received “skill-up” training and the contributions of the CSBAs and midwives are included,
by 2021 an estimated 22,074 nurse-midwives,
FWVs, CSBAs and midwives would be in the
workforce to deliver RMNH care with up-to-date
essential skills. However, given these cadres’
other roles, this equates to just 4,415 full-time
equivalents—far short of estimated requirements. Thus, this scenario offers only a partial
and short-term solution to be implemented
along with other options.
Estimated costs. The estimated costs of implementing the policies outlined above are US$160
million over eight years (2013-2021), with relevant RMNH cadres included in the skill-up, a
new dedicated cadre developed to achieve universal coverage in the long term, and associated
costs for support mechanisms and regulatory
systems. This amounts to an investment of about
US$3.67 per expected pregnancy between 2013
and 2021.
Impact. Gradual scaling up and skilling up
in line with current targets through 2016 and
to universal coverage (including 85% facility births) by 2021 would avert an estimated
172,270 neonatal deaths, 11,062 maternal deaths,
and 314,421 intrapartum deaths in the period
2013 to 2021. In contrast to the current NMR
of 31 neonatal deaths per 1,000 live births and
the current MMR of 194 maternal deaths per
100,000 live births, this would equate to an
estimated NMR of 19 and an MMR of 142.
Key area 2: long-term development of a dedicated RMNH cadre and system strengthening
This focuses on system strengthening and scaleup, as envisioned in the Health, Population
EX ECUTIV E SUMMA RY
3
BANGLADESH
POPULATION IN 2010: 151,125,000
Estimated pregnancies in 2015: 4,890,863
A national assessment of the reproductive, maternal and newborn health (RMNH) workforce in Bangladesh took
place in 2012/2013. It asked the key question: “In Bangladesh, what is the appropriate RMNH workforce,
and how is it best deployed, to equitably deliver essential RMNH interventions at scale and
quality, and what (including costs) needs to be put into place to achieve universal access?”
NEED
In 2010, Bangladesh’s newborn
mortality rate (NMR) is 31
neonatal deaths per 1,000 live
births and its maternal mortality
ratio (MMR) is 194 maternal
deaths per 100,000 live births;
however, millions of women
and newborns are still at risk.
SUPPLY
Recent initiatives are expanding
the competencies of the existing
workforce and developing new
posts dedicated to maternal and
newborn care. However, the need
continues for better workforce
distribution, improved skills and
better-equipped facilities.
DISPARITY/GAP
Currently, Bangladesh is
lacking an estimated 22,000
(2013) skilled birth attendants
for all expected pregnancies,
67% of which should be
available in rural areas.
STRATEGY
Bangladesh has the
opportunity to both meet
future needs and deliver
universal coverage (to 75%)
by 2021 by scaling up the
dedicated workforce for
maternal and newborn health.
• The decline of both maternal and neonatal mortality is uneven across districts due to
factors such as urban vs. rural and the education of the mother. Some districts have
already achieved the 2015 NMR target of 21, whilst others are at nearly double this and
unlikely to reach it.
• Though the total fertility rate is decreasing in Bangladesh, the two most populous
divisions of Dhaka and Chittagong still expect large numbers of pregnancies but have
few healthcare professionals in their rural areas.
• Haemorrhage and eclampsia account for more than half of maternal deaths. Prevention
and treatment of these complications could save many mothers’ lives.
• In urban areas skilled healthcare providers attend over half of all births. In contrast, in
rural areas skilled providers attend just one quarter of births.
• Among deliveries with a skilled health worker present, about 70% were attended by
doctors, who are located mostly in urban facilities.
• Various types of health personnel provide RMNH care, but their roles and responsibilities
vary widely and most do not cover the full spectrum of essential MNH Interventions.
• Several cadres spend relatively little time in RMNH and training them all is costly
compared to training a few dedicated cadres.
• Skilled providers of delivery care are mainly nurse-midwives, medical doctors, family
welfare visitors (FWVs), community -based skilled birth attendants (CSBAs) and,
increasingly, a new dedicated cadre of midwives.
• The district of Dhaka has nearly one-third of the country’s nurse-midwives (31%) and
some 37% of its doctors, yet only 8% of its pregnancies.
• The GOB intends to implement immediate skill-up of the existing workforce and scale-up
of a dedicated workforce in order to achieve universal coverage (to 75%) by 2021.
• Follow-up training for CSBAs and skilling up of 70% of the nurse-midwives and FWVs
can result in a significant short-term impact for both urban and rural areas.
Short term:
the development of a
percentage of the skilled
cadres within the existing
government-sanctioned posts to meet the
needs of the population through 2016.
• Improve the skills of some 15,000 nursemidwives, CSBAs and FWVs in the short
term and train 4,400 fully competent
midwives by 2021.
Long term:
system strengthening and
workforce scale-up to make
quality care available through
increased pre-service education capacity,
regulatory standards and guidelines, and
supportive supervision.
• Strengthen health governance systems for scaleup, including programme costs, supervision and
leadership for a new health cadre and regulatory
mechanism scale-up.
• Provide quality care for some 44 million expected
pregnancies from 2013 to 2021.
4
NEED
SUPPLY
DISPARITY/GAP
STRATEGY
Half of all
maternal deaths
are due to either
haemorrhage (31%) or
eclampsia (20%) —
conditions that are
easily prevented with
skilled care.
The level of skilled
attendance at birth
remains low at 32%,
and varies from 54%
in urban areas to 25%
in rural areas.
Marked regional
differences exist
in the MMR: from 158
in Dhaka district to
782 in the northern
coastal regions.
Increase
emergency obstetric
care and RMNH skills
in the short term; develop
a dedicated cadre with
full competencies in
the longer term.
Number of pregnancies by upazila by 2021
<5,000
5,000-7,500
10,000-12,500
4
7,500-10,000
>12,500
6
3
ADMINISTRATIVE
DIVISIONS
Reaching an equitable
distribution of
healthcare providers
across populations
and regions remains
a priority for maternal
and newborn health
in Bangladesh.
1
1 Dhaka
2 Chittagong
3 Rajshahi
4 Rangpur
5
2
5
Khulna
7
6 Sylhet
7 Barisal
Projected supply by 2021:
Projected average supply by
headcount (at the
start of the year) of
skilled birth attendants
(2013-2021).
2013
2014
2015
2016
2017
2018
2019
2020
2021
Diploma
midwives
0
0
0
428
842
1,202
1,548
1,883
2,206
Certified
midwives
621
1,180
1,925
2,644
2,551
2,462
2,376
2,293
2,213
Nursemidwives
15,649
15,415
15,022
14,955
15,349
15,581
15,813
16,045
16,278
CSBAs
7,305
8,416
9,570
11,489
13,341
13,855
14,352
14,831
15,294
FWVs
3,583
3,345
3,623
3,894
4,168
4,435
4,694
4,945
5,189
Average cost of implementing the strategy per pregnancy between
2013 and 2021: US$3.67
Impact
From 2013 to 2021, the recommended
strategic option will avert:
11,062
maternal deaths,
172,270 neonatal deaths, and
314,421 intrapartum stillbirths
5
BACKGROUND AND METHODS
In response to the United Nations SecretaryGeneral’s Global Strategy for Women’s and
Children’s Health, the “H4+1” (UNFPA, UNICEF,
WHO, The World Bank, UNAIDS and UN
Women) are collectively supporting a number of
countries, including Bangladesh, to strengthen
key maternal and neonatal health interventions,
with a focus on the human resource requirements
for healthcare professionals with midwifery skills.
the costed policy options for strengthening the
RMNH workforce. The HBCI Secretariat provided technical inputs to the review of existing
data, primary data collection methods, data
analysis and report writing and participated in
the Scoping Mission and a national stakeholders’ consultation held on 1 September 2012.
The National Assessment of the reproductive, maternal and newborn health (RMNH)
workforce2 in Bangladesh took place from
March 2012 to October 2013. It followed the
HBCI Operational Guidance and Assessment
Framework3 and was planned and initiated during a Scoping Mission (18–22 March 2012). This
mission met with a wide range of stakeholders
and in-country partners active in the field of
human resources for RMNH and conducted
field visits to Savar and Munsiganj. Focal persons
were identified for consultation and interviews
in relevant government ministries and among
the H4+ and other development partners. A
Steering Committee4 supported and oversaw
the process, including the work of Research,
Training and Management International (RTMI),
the in-country partner engaged to contribute
to the assessment, data collection and analysis,
writing-up of the results and development of
What is the appropriate RMNH workforce, and
how is it best deployed, to equitably deliver essential maternal and newborn health interventions
at scale and quality, and what (including costs)
needs to be put into place to achieve universal
access?
1
2
3
4
6
The main question of the assessment was:
To answer this question, and in line with
the Operational Guidance and Assessment
Framework, ICS Integrare reviewed existing
data and RTMI collected and analysed primary
data in five domains of interest: (1) essential
interventions for RMNH and their utilization,
(2) the RMNH workforce, (3) the work environment, (4) management and policies, and
(5) financing.
The initial analysis involved a comprehensive
review of published and grey literature, including governmental and international statistics
H4+: The four original “Health 4” partners (UNFPA, UNICEF, WHO, The World Bank), later joined by UNAIDS and UN
Women.
For the purpose of the assessment the RMNH workforce was defined as those cadres of health workers who look after the
health of women during pregnancy, labour and the postpartum period, the health and survival of the fetus during delivery,
and the health and survival of the newborn during the first few hours and days after birth. An alternative term would be
“midwifery workforce”.
H4+ High Burden Countries Initiative National Assessment — midwifery workforce. Operational Guidance and Assessment
Framework. Prepared by the HBCI Secretariat and Technical Working Group. April 2012. Available at http://integrare.es/
wp-content/uploads/2012/09/HBCI-OG-REVISED-19Apr12_EN.pdf
Members of the Steering Committee: the Government of Bangladesh (Ministry of Health and Family Welfare), H4+
members (UNFPA, UNICEF, WHO, The World Bank), Jhpiego/Save the Children, the Bangladesh Midwifery Society, the
Bangladesh Nursing and Midwifery Council, and the Obstetrical and Gynaecological Society of Bangladesh.
and data sets; policies, strategies and reports
from the GOB, its development partners and
non-governmental organizations (NGOs); and
papers published in the scientific literature. As
much as possible, searches of existing data filled
information gaps identified during the review
and Scoping Mission. Primary data were collected using a set of existing and validated data
collection tools adapted as required to the country context.5
In-depth interviews using structured
questionnaires6 were carried out with a total
of 110 service providers and 10 managers
from the public, private and NGO sectors in
three districts: a high- (Rajshahi), a medium(Madaripur) and a low-performing district
(Habiganj).7 Approval for the study was
obtained from the Ministry of Health and
Family Welfare (MOHFW).
The Steering Committee appraised the assessment findings and their analysis. The findings
and analysis were consolidated in a draft
report, which was reviewed by the MOHFW, the
Steering Committee, the HBCI Secretariat and
HBCI Technical Working Group (TWG). The
final report incorporates comments from the
stakeholders’ consultation8 and from the H4+
country offices.
5
6
7
8
Primary data collection tools are available at http://integrare.es/peoples-republic-of-bangladesh.
The questionnaires are available at http://integrare.es/peoples-republic-of-bangladesh.
For the purpose of this study, “performance” was assessed by considering the proportion of deliveries assisted by skilled health
personnel at the district level. In selecting the districts, the poverty headcount ratio of the districts and geographical distribution
also were considered. The sampled districts were selected in such a way that they were not concentrated in any particular region.
A longer version of this report is available at http://integrare.es/peoples-republic-of-bangladesh.
C OUNTRY A SS ES S MENT
7
CONTEXT
Bangladesh covers an area of 147,570 km2 and
in 2010 had a population of about 151 million
people, the majority (some 72%) living in rural
areas.9 Some 31% of the population is under
the age of 15 years, reflecting the country’s
high fertility rates of the 1980s and 1990s. The
country is divided into seven administrative
divisions: in order of population size, Dhaka,
Chittagong, Rajshahi, Rangpur,10 Khulna, Sylhet
and Barisal.11 Each division is divided into zilas
(districts), and each zila into upazilas. Each
rural area in the upazila is divided into union
parishads (UP) and then mouzas within a UP; an
urban area in an upazila is divided into wards,
and then into mohallas within a ward. These
divisions allow the country as a whole to be easily separated into rural and urban areas.12
This report focuses on the need and demand
for healthcare services during pregnancy,
childbirth and the immediate postnatal period.
Understanding these issues is imperative for
planning the production and deployment of the
relevant workforce cadres. The emphasis is on
rural areas because the needs are greatest there.
In fact, 70% of pregnant women lived in rural
9
10
11
12
13
14
15
16
17
8
areas in 2011.12 Future expansion and upgrading
of the RMNH workforce will need to focus on
the rural areas.
The workforce needed to care for women during pregnancy, childbirth and the immediate
postnatal period, and for their newborns, was
assessed using information found in existing
reports but also new analysis, including disaggregated data on the number and distribution
of pregnancies in 2010 (Figure 1) and projected
through 2025 (Figure 2).
Estimates of the distribution of live births in
2010 were calculated from detailed population
distribution maps of women of reproductive
age (15–49) by 5-year age groupings.14 Agespecific fertility rates broken down by urban
and rural areas and by division came from the
2011 Bangladesh Demographic and Health
Survey (BDHS).12 These rates were applied
to the corresponding age group and urban/
rural assigned populations of reproductive-age
women.16 National statistics on the proportion of
stillbirths in 2009 (36.4 per 1,000 total births)17
and the South-east Asia regional estimate for
United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2010
Revision, Volume II: Demographic Profiles. New York: United Nations, 2011. (ST/ESA/SER.A/317).
The division of Rangpur was created in January 2010 by separating eight northern districts from the Rajshahi division.
Thus, pre-2010 data for Rangpur districts are part of the Rajshahi division data. In this report, data for Rangpur and
Rajshahi are reported separately, including pre-2010 data, when district-level data were available.
Bangladesh Population and Housing Census 2011. National Report, Volume-4. Socio-Economic and Demographic Report,
2012. Available at http://www.bbs.gov.bd/WebTestApplication/userfiles/Image/BBS/Socio_Economic.pdf (accessed on 14
April 2013).
National Institute of Population Research and Training (NIPORT), Mitra and Associates and ICF International. Bangladesh
Demographic and Health Survey 2011. Dhaka, Bangladesh and Calverton, Maryland, USA: NIPORT, Mitra and Associates,
and ICF International, 2013. Available at http://www.measuredhs.com/publications/publication-FR265-DHS-Final-Reports.cfm
(accessed on 23 March 2013).
Ibid., ref. 12.
AsiaPop (2012). Available at www.asiapop.org (accessed on 22 March 2013).
Ibid., ref. 12.
United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2012
Revision, Volume I: Demographic Profiles. New York: United Nations, 2013. (ST/ESA/SER.A/336).
World Health Organization and Save the Children. Country stillbirth rates per 1000 total births for 2009. Available at
http://www.who.int/pmnch/media/news/2011/stillbirths_countryrates.pdf (accessed on 10 September 2012).
FIGURE 1
PROJECTED PREGNANCIES
IN BANGLADESH
Number of pregnancies per administrative division
4
<5,000
5,000-7,500
7,500-10,000
6
3
10,000-12,500
>12,500
1
Source: HBCI Bangladesh original
data analysis. Geographic analysis
of pregnancies 2010.
FIGURE 2
PROJECTED TOTAL PREGNANCIES AND
PREGNANCIES IN RURAL AREAS IN 2025,
BY ADMINISTRATIVE DIVISION
2
5
7
1,800,000
1,500,000
1,504,592
ADMINISTRATIVE DIVISIONS
1 Dhaka
2 Chittagong
5 Khulna 6 Sylhet
1,200,000
3 Rajshahi 4 Rangpur
7 Barisal
997,201
900,000
1,006,987
Total pregnancies
766,979
600,000
Rural pregnancies
561,177
477,547
470,484
300,000
415,198
447,306
378,647
369,221
345,091
254,940
232,234
0
1
2
3
abortions (36 abortions per 1,000 women ages
15–44 years)18 were then used to adjust the birth
map, converting it to the estimated distribution
of pregnancies in 2010 (Figure 1), with data projected to 2015, 2020 and 2025 (Figure 2) using
UN urban- and rural-specific growth rates.19
The results indicate that the overall annual
number of pregnancies in Bangladesh is
4
5
6
7
expected to decrease between 2010 and 2025
by about 339,000, or 7% of the 2010 number.
Due to urbanization the decrease will be particularly pronounced in the rural areas (some
315,000, or 8% fewer pregnancies in 2025 than
in 2010), whereas in urban areas the number
will decrease by about 24,000, or 2% of the 2010
figure. Rural pregnancies will continue to outnumber urban pregnancies, but the difference,
18 Sedgh G, Singh S, Shah IH, Åhman E, Henshaw SK, Bankole A. Induced abortion: incidence and trends worldwide from
1995 to 2008. The Lancet 2012; 379:625-632.
19 United Nations, Department of Economic and Social Affairs, Population Division. World Urbanization Prospects: The 2011
Revision. New York: United Nations, 2012. (ST/ESA/SER.A/322).
9
a rural:urban ratio of about 3.8:1 in 2010, will
diminish gradually to 3.6:1 in 2025. As is to be
expected, the largest and most populous divisions, Dhaka and Chittagong, with some 52%
of the population in 2010, will continue to have
the largest numbers of both rural and urban
pregnancies. Together these two divisions had
some 54% of all pregnancies in 2010.
Understanding these key demographic
dynamics offers an important context for considering options for the future and the costs
of strengthening the workforce to enhance the
availability, appropriate deployment and quality of RMNH care and its impact on maternal
and neonatal mortality.
DOMAIN A:
Essential RMNH
Interventions and
their Utilization
Maternal mortality:
trend, causes and challenges
During the last few decades, Bangladesh has
achieved marked improvements in the survival
of its pregnant women. Specifically, between
1990 and 2010 the maternal mortality ratio
(MMR; the number of maternal deaths per
100,000 live births) fell by 70%, from 800 to 240,
according to international estimates.20 National
estimates confirm this rapid downward trend,
with a 40% reduction from an MMR of 322 in
200121 to 194 in 2010.22 This accomplishment has
put the country on track to achieve its maternal
health target of MDG 5, which is to reduce the
MMR to 143 by 2015. The main reasons for the
marked decline include the reduction in the fertility rate (and associated drop in the proportion
of higher-risk, high-parity pregnancies) and the
increased use of facilities for deliveries (from 9%
to 23% of all deliveries between 2001 and 2010
and from 16% to 29% in cases of maternal complications during the same period). Better access
to care, substantially higher levels of female
education, improved awareness and healthcareseeking behaviour and better economic conditions have contributed to these positive
developments.23 But much remains to be done.
First, sub-national analysis indicates marked
differences in MMR among different regions
of the country, ranging from 158 in Dhaka
district to 782 in the northern coastal regions,
a more than five-fold difference.24 Second,
deaths due to maternal causes continue to be
prevalent among women of reproductive age in
Bangladesh, accounting for 5.7% of all deaths
in this age group.25,26 Third, half of all maternal
deaths are due to either haemorrhage (31%) or
eclampsia (20%).27,28 These complications can be
prevented or treated. Thus, there is clear scope
for lowering maternal mortality (and morbidity) further by expanding access to healthcare
personnel skilled in life-saving interventions for
eclampsia and haemorrhage.
20 World Health Organization, UNICEF, UNFPA, The World Bank. Trends in Maternal Mortality: 1990 to 2010. WHO, UNICEF,
UNFPA and The World Bank estimates. Geneva: World Health Organization, 2012.
21 National Institute of Population Research and Training (NIPORT), ORC Macro, Johns Hopkins University, ICDDR,B.
Bangladesh Maternal Health Services and Maternal Mortality Survey 2001. Dhaka, Bangladesh and Calverton, Maryland,
USA: NIPORT, ORC Macro, Johns Hopkins University, and ICDDR,B, 2003.
22 Streatfield PK, El Arifeen S with contributions from Al-Sabir A and Jamil K. Bangladesh Maternal Mortality and Health Care
Survey 2010. Summary of Key Findings and Implications. Available at http://www.cpc.unc.edu/measure/our-work/programareas/family-planning/BMMS%202010%20summary%20-%20implications.pdf/view (accessed on 9 August 2012).
23 Ibid., ref. 22.
24 Ahmed S, Hill K. Maternal mortality estimation at the subnational level: a model-based method with an application to
Bangladesh. Bulletin of the World Health Organization 2011; 89:12-21.
25 The corresponding percentages in other emerging economies in Asia are 5.5% (Indonesia), 2.4% (Malaysia), 2.4% (Sri
Lanka), 1.0% (Thailand) and 2.6% (Viet Nam). Myanmar also has a lower rate (4.3%), but rates are higher in India (7.4%),
Maldives (6.1%), Nepal (7.9%) and Pakistan (11.4%).
26 WHO, UNICEF, UNFPA, The World Bank and UN Population Division Maternal Mortality Estimation Inter-Agency Group.
Maternal Mortality in 1990-2010. Available at http://www.who.int/gho/maternal_health/countries/en (accessed on 6
September 2012).
27 The other half of maternal deaths are due to indirect causes of death (35%), obstructed or prolonged labour (7%), abortion
(1%), other direct causes (5%) and undetermined causes (1%).
28 Ibid., ref. 22.
10
Finally, although all maternal healthcare indicators show improvements in coverage over the last
decade, progress has been uneven both between
and within indicators.29 In particular, levels of
antenatal care (1+ visit with skilled provider: 31%
to 84%; 4+ visits with any provider: 8% to 47%),
skilled attendant at delivery (5% to 51%), and use
of caesarean section (2% to 26%) show marked
inequities in relation to wealth quintile (Figure
A.1), as well as by maternal education (not shown),
administrative division and rural/urban residence.30
Neonatal mortality: trend, causes and
challenges
Progress in neonatal mortality reduction has
closely paralleled the decrease in maternal
mortality. For instance, between 1990 and
2010, the neonatal mortality rate (NMR)
declined from 65 to 31 deaths per 1,000 live
births (a 52% reduction).31 Based on this trend,
Bangladesh is expecting to achieve, in 2015, its
NMR target of 21. In contrast to the declining
neonatal mortality, stillbirths remain common,
with reported rates of 36.9 per 1,000 births in
200832 and 36.4 in 2009.33 Nearly two-thirds of
these stillbirths (21 per 1,000 births) occur at
delivery, illustrating the potential of substantially lowering this rate by expanding access to
healthcare personnel skilled in providing quality intrapartum care.
Although neonatal mortality is declining,
much remains to be done. First, the decline
is very uneven among districts; some have
already achieved the 2015 NMR target of 21,34
whereas others have NMRs of 40 or more35 and
seem unlikely to reach the target.36 Second,
the main causes of neonatal deaths in the
country are prematurity (44.5%),
intrapartum-related
complications
(23.1%) and severe
infection (sepsis/meningitis/
tetanus/pneumonia) (20.1%).37,38.39
Some three-quarters of neonatal
deaths happen in
the first week of
life, and between
one quarter and
half, in the first 24 hours after birth.40 Thus,
important gains in neonatal survival could be
made through better care of women at delivery
and of newborn babies in the first few hours
and days after birth.41 Third, inequities in relation to wealth, education of the mother, place of
residence (urban versus rural), and administrative division continue to exist for some of the
Important gains in
neonatal survival could
be made through
better care of women
at delivery and of
newborn babies in the
first few hours and
days after birth.
29 Countdown to 2015. Countdown equity analyses by country – June 2012. Available at http://www.countdown2015mnch.org/
documents/2012Report/2012Equity/full_equity_profiles_2012.pdf (accessed on 22 March 2013).
30 Ibid., ref. 12.
31 Knoll Rajaratnam J, Marcus JR, Flaxman AD, Wang H, Levin-Rector A, Dwyer L, Costa M, Lopez AD, Murray CJL. Neonatal,
postneonatal, childhood and under-5 mortality for 187 countries, 1970-2010: a systematic analysis of progress towards
Millennium Development Goal 4. The Lancet 2010; 375:1988-2008.
32 Lawn JE, Blencowe H, Pattinson R, Cousens S, Kumar R, Ibiebele I, Gardosi J, Day LT, Stanton C for The Lancet’s Stillbirths
Series steering committee. Stillbirths: Where? When? Why? How to make the data count? The Lancet 2011; 377:1448-1463.
33 Ibid., ref. 17.
34 Natore, Pabna, Rangamati, Barguna, Chandpur, Satkhira, Shariatpur
35 Khagrachhari, Sylhet, Kurigram, Rajbari, Sirajganj, Habiganj, Sherpur, Maulvibazar, Joypurhat, Sunamganj, Madaripur
36 National Institute of Population Research and Training (NIPORT), Dhaka, Bangladesh & MEASURE Evaluation, UNC-CH,
USA & ICDDR,B. Bangladesh District Level Socio-demographic and Health Care Utilization Indicators, 2011.Available at
http://www.cpc.unc.edu/measure/publications/tr-11-84 (accessed on 31 August 2012).
37 The remaining causes of neonatal death include congenital abnormalities (7.6%), other disorders (4.0%) and diarrhoea
(0.6%).
38 Black RE, Cousens S, Johnson HL, Lawn JE, Rudan I, Bassani DG, Jha P, Campbell H, Walker CF, Cibulskis R, Eisele T, Liu L,
Mathers C, for the Child Health Epidemiology Reference Group of WHO and UNICEF. Global, regional, and national causes
of child mortality in 2008: a systematic analysis. The Lancet 2012; 375: 1969-1987. Webappendix.
39 Rubayet S, Shahidullah M, Hossain A, Corbett E, Moran AC, Mannan I, Matin Z, Wall SN, Pfitzer A, Mannan I, Syed U for
the Bangladesh Newborn Change and Future Analysis Group. Newborn survival in Bangladesh: a decade of change and
future implications. Health Policy and Planning 2012; 27 (Suppl. 3): iii40-iii56.
40 Lawn JE, Cousens S, Zupan J for the Lancet Neonatal Survival Steering Team. 4 million neonatal deaths. When? Where?
Why? The Lancet 2005; 365:891-900.
41 Kusiako T, Ronsmans C, Van der Paal L. Perinatal mortality attributable to complications of childbirth in Matlab,
Bangladesh. Bulletin of the World Health Organization 2000; 78:621-627.
11
TOTAL FERTILITY RATE IN URBAN AND RURAL AREAS AND BY ADMINISTRATIVE
DIVISION; COVERAGE OF CORE MNH INDICATORS AGAINST SOCIO-ECONOMIC
CHARACTERISTICS; MAJOR CAUSES OF MATERNAL AND NEONATAL MORTALITY
FIGURE A.1
Fertility
Causes of Maternal Mortality
Rural
Urban
TFR (15-49)
Eclampsia
Obstructed/
prolonged labour
20%
Abortion
2.0 2.5
0
.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
7%
1%
5.0
Other direct
causes
5%
Total Fertility Rate by Administrative Division
4
TFR
3
2
2.8
2.3
2.2
1
0
l
risa
Ba
g
on
a
uln
aka
Dh
g
itta
Ch
1.9
2.1
2.1
i
ah
r
pu
jsh
Kh
Ra
Indirect causes
31%
35%
t
lhe
ng
Ra
Haemorrhage
Undetermined
Sy
1%
Highest Wealth Quintile (%)
Lowest Wealth Quintile (%)
Family planning
needs satisfied
89.1 95.5
Contraceptive prevalence
rate (15-49 years)
Antenatal care, 1+ visits,
skilled provider
Skilled attendant
at delivery
30.7
Congenital
Sepsis and other
severe infections abnormalities
83.6
20.1%
47.3
4.9
1.8
0.6%
25.7
Intrapartumrelated
complications
4.0 10.5
8.9
0
Diarrhoea
4.0%
40.4 43.3
Postnatal care
for all babies
7.6%
Other disorders
50.6
Early initiation
of breastfeeding
Postnatal care for
babies born at home
Causes of Neonatal Mortality
54.8 59.9
Antenatal care, 4+ visits,
8.3
any provider
Caesarean
delivery rate
3.1
10
51.2
20
30
40
50
23.1%
60
70
80
90 100
Prematurity
44.5%
Source: Bangladesh Population and Housing Census 2011. National Report, Volume 4. Socio-Economic and Demographic Report, 2012. Available at
http://www.bbs.gov.bd/WebTestApplication/userfiles/Image/BBS/Socio_Economic.pdf (accessed on 14 April 2013).
services indicators, particularly those concerned
with postnatal care (Figure A.1).42
systematic focus on the quality of care in facilities, especially for vulnerable populations.
Much of the progress in neonatal survival has
been attributed to extensive changes in health
policy relating to neonatal care, including the
development of the National Neonatal Health
Strategy,43 with its initial focus on communitybased initiatives. But greater consistency is
needed between the many implementing
partners at the community level, as is a more
The essential interventions for maternal
and newborn health
Achieving universal coverage for all the service
indicators shown in Figure A.1 is not enough
to ensure that women and their newborns
receive optimal care. The healthcare system
needs to deliver the comprehensive package
of Essential Interventions44 for maternal and
42 Ibid., ref. 29.
43 Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh. National Neonatal Health
Strategy and Guidelines for Bangladesh, 2009.
44 The Partnership for Maternal, Newborn and Child Health (PMNCH). A Global Review of the Key Interventions Related to
Reproductive, Maternal, Newborn and Child Health. Geneva: PMNCH, 2011.
12
TABLE A.2
HEALTH CADRES PROVIDING THE ESSENTIAL MNH INTERVENTIONS IN BANGLADESH
Family
Planning/
Sexual
Health
PostAbortion
Care
Antenatal
Care
Obstetrics and Gynaecology Consultant
Y
Y
Doctor (with training in Obstetrics and
Gynaecology)
Y
Paediatrics Consultant
Safe Birth
Postnatal
Care
Family
Planning
(postnatal)
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
N
N
N
Y
Y
Nurse-midwives
N
N
Y
Y
Y
Y
Medical Officer, Medical Officer (Maternal &
Child Health – Family Planning), Medical Officer
(Obs&Gyn)
Y
Y
Y
Y
Y
Y
Others: Assistant Director Clinical Contraception
(ADCC), Medical Officer Clinical Contraception
(MOCC), Expanded Programme on Immunization
(EPI) technician, Medical Assistant
Y
Y
N
N
N
Y
Family Welfare Visitor (FWV)
Y
Y
Y
Y
Y
Y
Medical Officer
Y
Y
Y
Y
Y
Y
Sub-Assistant Community Medical Officer (SACMO)
Y
N
Y
N
Y
Y
Family Welfare Visitor (FWV)
Y
Y
Y
Y
Y
Y
Doctors (Outreach)
Y
Intervention type
REFERRAL
1ST LEVEL
COMMUNITY LEVEL
Family Welfare Visitor (FWV) (satellite clinics)
Y
Y
Y
Y
Y
Y
Family Welfare Assistant/Health Assistant
(not-CSBA qualified)
Y
N
Y
N
Y
Y
Community Health Care Provider (CHCP) (new)
Y
N
Y
N
Y
Y
Y = Yes, N=No
newborn health to all who need them and with
the highest possible standard of care. Table A.2
summarizes the main categories of Essential
Interventions delivered at the community,
primary and referral levels of the healthcare
system and the types of healthcare workers
providing these services. (A full list of all 42
Essential Interventions for maternal and newborn health, the recommended level of care as
per guidelines of the Partnership for Maternal,
Newborn and Child Health and the current situation in Bangladesh can be found in Annex 1.)
As Table A.2 and Annex 1 indicate, even
when pregnant women and their newborns
are able to access healthcare, several gaps
exist in the provision of evidence-based interventions. For instance, a major assessment45
45 Mridha MK, Koblinsky MA, Moran AC, Ashraf A, Campbell O, Anwar I, Islam N, Islam KS, Johnson FA, Chandra H,
Matthews Z, Alam B, Sarker BK, Wahed T, Ahmed A, Safi S, Matin A, Dasgupta SK, Khan MA, Chowdhury ME on behalf of
the Study Team. Assessment of Maternal, Neonatal and Child Health and Family Planning Facilities in Bangladesh. Dhaka,
Bangladesh: Center for Reproductive Health, ICDDR,B, 2011.
13
carried out in 2011/2012 under the auspices
of the International Centre for Diarrhoeal
Disease Research, Bangladesh (ICDDR,B) in
7,680 public, private and for-profit NGO facilities providing maternal and newborn health
services found that many of the essential
interventions were not being
practiced. Procedures such
as the use of corticosteroids
to prevent respiratory distress syndrome in preterm
newborns, administration
of magnesium sulphate
(MgSO ) for the treatment
of eclampsia, and oxytocin
injection after the delivery of the baby for the
prevention of postpartum
haemorrhage (PPH) were
not available in many facilities, even at the tertiary
level of care. Similarly, a
study published in 200846 found that only 50%
of the district, sub-district (upazila) and medical college hospitals used Active Management
of the Third Stage of Labour (AMTSL) to
prevent PPH, even though evidence for the
effectiveness of this intervention has been
available for more than 20 years.47
Special attention will
also need to be given
to the training of
staff—both existing
and new—in the use
of evidence-based
essential interventions,
particularly
life-saving skills.
4
Clearly, many facets of healthcare delivery
for women and their newborns at the level of
both communities and facilities require quality
improvement. Thus, in addition to the modalities adopted to expand the RMNH workforce,
special attention will also need to be given to
the training of staff—both existing and new—in
the use of evidence-based essential interventions, particularly life-saving skills.
Types of healthcare staff providing
RMNH care
As Table A.2 shows, a variety of healthcare personnel and support staff provide RMNH care.
The roles and responsibilities of these types of
health workers vary widely, and few, if any, cover
the full spectrum of essential interventions. This
report addresses the subset of healthcare personnel and support staff that are most involved with
providing RMNH services. Also, the proportion
of working time that these health workers devote
to RMNH care varies markedly. For instance, in
2001 the Bangladesh Maternal Health Strategy48
recommended the creation of a new cadre
of RMNH staff, the community-based skilled
birth attendant (CSBA),49 in order to reach the
Strategy’s target of 50% of all births attended by
skilled health personnel by 2010. However, the
CSBAs’ contribution to increasing the percentage of births attended by a skilled healthcare
worker has so far been minimal. For example,
in the three years before the 2010 Utilization of
Essential Service Delivery (UESD) survey, CSBAs
attended only 0.1% of live births, compared with
17.3% by doctors and 8.6% by nurse-midwives
and paramedics.50 Thus, in 2008–2010, the rate
of use of a skilled attendant at birth continued to
be low, at 26%. The 2011 BDHS51 put the current
level at 32%,52 still well below the 2015 target of
50%. In 2011, 53% of births were still attended
46 Koblinsky M, Anwar I, Mridha MK, Chowdhury ME, Botlero R. Reducing maternal mortality and improving maternal health:
Bangladesh and MDG 5. Journal of Health, Population and Nutrition 2008; 26:280-294.
47 Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage trial: active versus physiological management
of the third stage of labour. British Medical Journal 1988; 297:1295–1300.
48 Ministry of Health and Family Welfare. Bangladesh National Strategy for Maternal Health. Dhaka, Bangladesh: Ministry of
Health and Family Welfare, 2001.
49 Community-based skilled birth attendants (CSBAs) are family welfare assistants (FWAs), female health assistants (HA)
and like cadres with six months of additional training in basic maternal and newborn care. They do not have the full
complement of midwifery competencies as defined by the International Confederation of Midwives (see http://www.
internationalmidwives.org/Portals/5/2011/DB%202011/Essential%20Competencies%20ENG.pdf), nor are they skilled birth
attendants as defined by WHO in 2004 (see http://whqlibdoc.who.int/publications/2004/9241591692.pdf).
50 National Institute of Population Research and Training (NIPORT) and Associates for Community and Population Research
(ACPR). Utilization of Essential Service Delivery (UESD) Survey 2010. Provisional findings, 2011. Available at http://www.
niport.gov.bd/UESD-Survey-2010-provisional-findings.pdf (accessed on 22 August 2012).
51 Ibid., ref. 12.
52 Skilled birth attendants (or "medically trained providers” in DHS parlance) include the categories of qualified doctor (present at 22.2% of deliveries), nurse/midwife/paramedic (8.9%), FWV (0.3%), CSBA (0.3%), and MA/SACMO (no % given;
probably negligible) in DHS statistics.
14
by untrained traditional birth attendants and 4%
by relatives or friends. Among deliveries with a
skilled health worker present, about 70% were
attended by doctors, who are located mostly
in urban facilities. As a result, there is a large
contrast in the proportion of births with skilled
attendance—53.7% in urban areas and 25.2% in
rural areas.
Until recently, Bangladesh has not had a cadre
of certified midwives. This deficiency is being
addressed partially through the education of
3,000 midwives by 2015 as part of the commitment made by Bangladesh in September 2010
at the launch of the UN Secretary-General’s
Global Strategy for Women’s and Children’s
Health.53,54 These midwives will be recruited
from among current nurse-midwives,55 who,
after a 6-month advanced midwifery training
programme, will be accredited as “Certified midwife” by the Bangladesh Nursing and Midwifery
Council (BNMC). In addition, graduates of a
3-year direct-entry diploma course that began
in December 2012 will obtain the Diploma of
Midwifery and certification as “Diploma midwife” by BNMC. Both categories of midwives will
be trained in the ICM Essential Competencies
for Basic Midwifery Practice.56
DOMAIN B:
The RMNH Workforce
Workforce composition, size,
distribution
Personnel providing RMNH care comprise ten
categories of health workers: doctors, including
obstetrician/gynaecologists, anaesthetists and
medical assistants (also known as SACMOs—
sub-assistant medical officers); nurses and
nurse-midwives, including certified and registered midwives; and FWVs, family welfare
assistants (FWAs), health assistants (HAs) and
CSBAs. Their designations, available workforce
numbers in the government sector and comparative data from the private and NGO sectors,
where available, are shown in Table B.1. There
are in total approximately 107,000 health workers involved in the delivery of care.
Figure B.2 provides estimates of the RMNH
workforce by class (used for health worker classification and pay system) and by administrative
division for 2012.57 It highlights the unusual
nurse-doctor ratio in all seven divisions. Overall,
there are nearly 50% more doctors (Class I) than
nurses and nurse-midwives (Class II) whereas
the opposite (more nurses than doctors) is the
rule in most developing countries.58 The figure
also illustrates the high percentages of vacancies among sanctioned posts. For Class I, 30% or
more of posts are vacant in all divisions except
the Dhaka division, where 17% of sanctioned
posts are vacant. While overall fewer posts are
vacant in Class II, at 20% of sanctioned positions
for all divisions combined, values range from a
low of 12% in Khulna to a high of 44% in Sylhet,
a division with very poor maternal and newborn
health indicators. Class III, which is the largest
class consisting of FWVs, FWAs and HAs, has
the lowest overall vacancy rate, at 16%. Values
range from 11% in Rajshahi to 22% in Sylhet. For
the three classes combined, the proportion of
unfilled positions in Sylhet, at 28.5%, is almost
double that in Dhaka, at 14.5%.
53 United Nations Secretary-General. Global Strategy for Women’s and Children’s Health. Geneva: Partnership for Maternal,
Newborn and Child Health, 2010. Available at http://www.who.int/pmnch/activities/jointactionplan/en/index.html (accessed
on 31 August 2012).
54 Every Woman, Every Child. Summary of Commitments for Women’s and Children’s Health. Available at http://www.everywomaneverychild.org/images/EWECCommitments2010.pdf (accessed on 3 September 2012).
55 The nurse-midwives being trained already have the Diploma in Nursing Science and Midwifery after previously training
for four years (three years of nursing, one year of midwifery). http://www.bnmcbd.com/index.php (accessed on 31 August
2012).
56 International Confederation of Midwives. Essential Competencies for Midwifery Practice 2010, 2011. Available at http://
www.internationalmidwives.org/Portals/5/2011/DB%202011/Essential%20Competencies%20ENG.pdf (accessed on 31
August 2012).
57 The classification of health workers in Bangladesh does not follow the International Classification System of Health
Workers. See http://www.who.int/hrh/statistics/Health_workers_classification.pdf (accessed on 14 April 2013).
58 World Health Organization. World Health Statistics 2012. Part III. Global Health Indicators. Geneva: World Health
Organization. Available at http://www.who.int/healthinfo/EN_WHS2012_Part3.pdf (accessed on 8 September 2012).
15
TABLE B.1
ESTIMATED RMNH WORKFORCE NUMBERS, BY CADRE, IN PUBLIC AND PRIVATE PRACTICE (2011)
Type of health-care provider
Specialist in obstetrics and gynaecology
Anaesthesiologists
Total number practising in the
government sector
Number practising in other sectors
(NGO, private, etc.)
457a
802
a
246
354
16,977 including specialistsb
Doctors
Nurses and nurse-midwives
16,419
SACMOs [also known as Medical Assistants (MAs)]
6,651d
Family Welfare Visitors (FWVs)
5,172d
Family Welfare Assistants (FWAs)/Health Assistants
Certified midwives
Actuals not available
c
2,385
e
40,389 (21,111 FWAs and 19,278 HAs)
537f
Community-based skilled birth attendants (CSBAs)
7,106
g
Community Health Care Provider (CHCP)
12,822g
Sources:
a DGHS-Health Management Information system (HMIS) 2013; b HRMU-Human Resource Management Unit, Ministry of Health and Family Welfare 2013;
c BNMC June 2012; d HRMU June 2013; e DGFP 2013 and DGHS 2013, respectively; f BNMC, December 2012; g DGHS 2013
The numbers of filled positions shown in
Figure B.2 are estimated figures rather than
actual due to the weakness of the centralized
human resources information systems. These
estimates constitute a “best-case” scenario for
at least two reasons. First, not all these workers are directly involved in providing RMNH
services, and those who are providing these
services do not necessarily do so 100% of their
time. It has been estimated that only 20% of
nurse-midwives perform midwifery services
at any given time.59 To refine projections of
workforce needs, it will be critical to have data
or estimations on the proportion of time that
cadres with wider health duties (i.e. specialist
doctors, general practitioners, nurses, medical
assistants) devote to RMNH services. Second,
absenteeism is pervasive among posted healthcare staff in the public sector. Chaudhury
and Hammer found an absentee rate of 35%
averaged over all job categories and types of
facilities, with a rate of 40% for physicians at
larger clinics and 74% at smaller sub-centres
with a single physician. Factors affecting attendance included whether the medical provider
lived near the health facility, the opportunity
cost of his/her time, road access, and rural
electrification.60 To combat absenteeism, the
MOHFW has introduced an Office Attendance
Monitoring System, which includes a promising remote biometric time and attendance
system that is gradually being rolled out.61
Other healthcare providers engaged in the provision of the Essential Interventions for RMNH
but not included in this study include neonatologists, paediatricians and laboratory staff as
well as those working in the private and NGO
sectors, which have been providing services to
an increasing proportion of the population.62
59 Minca M. Midwifery in Bangladesh: in-depth country analysis. Background document prepared for The State of the World’s
Midwifery 2011. Delivering Health, Saving Lives. May 2011, unpublished. Available at http://www.unfpa.org/sowmy/
resources/docs/country_info/in_depth/Bangladesh_SoWMYInDepthAnalysis.pdf (accessed on 16 August 2012).
60 Chaudhury N, Hammer JS. Ghost doctors: absenteeism in rural Bangladeshi health facilities. World Bank Economic Review
2004; 18:423-441.
61 Government of the People’s Republic of Bangladesh. Ministry of Health and Family Welfare. Health Bulletin 2011. Dhaka,
Bangladesh: Management Information System (MIS), Directorate General of Health Services (DGHS), undated.
62 Pomeroy A, Koblinsky M, Alva S. DHS Working Papers. Private Delivery Care in Developing Countries: Trends and
Determinants. Calverton, Maryland, USA: ICF Macro, 2010.
16
NUMBER OF GOVERNMENT POSITIONS (SANCTIONED AND FILLED) AND PERCENTAGES
OF POSITIONS VACANT FOR HEALTHCARE CADRES UP TO CLASS III, BY DIVISION
FIGURE B.2
20,000
Sanctioned but vacant
13%
number of government positions
Filled
Vacant
15,000
19%
Vacant
10,000
17%
Vacant
17%
5,000
Vacant
36%
Vacant
0
Class I
Class I: doctors
17%
Vacant
Vacant
30%
Vacant
25%
35%
Vacant
13%
Vacant
30%
12%
Vacant
Vacant
Vacant
Class II Class III Class I
Barisal division
11%
Vacant
17%
14%
Vacant
Chittagong division
Dhaka division
Class II: mainly nurses and nurse-midwives
Class II Class III
Class I
Khulna division
22%
20%
Vacant
33%
Vacant
28%
Vacant
Rajshahi division
Vacant
34%
Vacant
Rangpur division
44%
Vacant
Class II Class III
Sylhet division
Class III: FWVs, FWAs, HAs, etc.
For nurse and nurse-midwives, data are as follows: diploma in nursing = 20,165, diploma in nursing and 1-year diploma in midwifery = 18,276,
4-year diploma in nursing and midwifery/orthopaedics = 7,393, 3-year diploma in nursing and midwifery = 3,201. For Class III only HA data are
available (data source is DNC).
No centralized database exists on the number and categories of healthcare workers
employed by these sectors. Moreover, the risk
of double-counting is great since healthcare
staff employed full time in the public sector
frequently work both during and outside office
hours in the private and NGO sectors to increase
their earnings.
Also not shown in Figure B.1 are the many
types of unqualified or semi-qualified informal
healthcare workers,63 who make up 95% of the
currently active workforce in health, compared
with 5% who are medically trained personnel
(doctors, nurses and dentists).64 Many of these,
such as traditional birth attendants, village
doctors, homeopaths and herbalists/spiritualists in particular, provide some aspects of
MNH care.65
How equitable is the distribution of
RMNH personnel?
An informative approach to measuring inequality is to analyze the distribution of RMNH
staff in relation to actual reproductive health
needs in defined geographical areas. Figures
B.3 and B.4 present such an analysis of the
main categories of healthcare worker by district, using Lorenz curves.66,67 The figures should
be interpreted with caution, since they show
the distribution of staff engaged in all types of
healthcare rather than just those specifically
engaged in provision of RMNH care.68
The analysis demonstrates that the distributions of FWVs and of FWAs/HAs approximate
the line of equity, indicating that these types of
health workers are fairly equitably distributed
among the districts in relation to the number
63 These providers include, among others, traditional healers, traditional birth attendants, village doctors, drug sellers,
homeopaths, herbalists and spiritualists.
64 Bangladesh Health Watch. The State of Health in Bangladesh 2007. Health Workforce in Bangladesh. Who Constitutes the
Healthcare System? Dhaka, Bangladesh: BRAC University, 2008.
65 Parkhurst JO, Rahman SA. Non-professional health practitioners and referrals to facilities: lessons from maternal care in
Bangladesh. Health Policy and Planning 2007; 22:149-155.
66 Regidor E. Measures of health inequalities: part 1. Journal of Epidemiology and Community Health 2004; 58:858-861.
67 A curve deviating from the 45° line of absolute equality identifies an inequity in the distribution of the particular cadre.
68 Not all doctors and nurses/nurse-midwives provide RMNH care, and those who do spend only part of their time providing
these services. In the case of FWAs and (male) HAs, the average proportion of time devoted to caring for pregnant women
and their newborns may be even lower; they have little or no involvement in pregnancy and delivery care.
17
GEOGRAPHICAL DISTRIBUTION OF MAIN
HEALTH CADRES, BY DISTRICT, 2011
FIGURE B.3
Equity
FWVs
FWAs & HAs
Doctors
Nurse-midwives
Dhaka
100%
90%
Cumulative health worker density
80%
70%
60%
50%
40%
30%
20%
The RMNH workforce pipeline
10%
0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Cumulative pregnancies (districts from least to highest density)
Source: AsiaPop, 2012 ; ICCDR,B
GEOGRAPHICAL DISTRIBUTION OF
SPECIALIST CADRES, BY DISTRICT, 2011
FIGURE B.4
Equity
Paediatrics/Neonatologists
Anaesthesia Specialists
Anaesthesia Workforce
Gynae/Obstetrics Specialists
Dhaka
100%
90%
80%
Cumulative health worker density
of pregnancies. However, the distributions of
nurse-midwives and doctors are greatly skewed,
favouring the district of Dhaka (on the extreme
right of the curve). Significantly, Dhaka has
only 8% of all pregnancies in Bangladesh, but
31% of the nurse-midwives and 37% of doctors
(including general practitioners and specialists).
In contrast, in districts with fewer pregnancies
per km2, these cadres are in short supply. For
instance, the districts on the left side in Figure
B.3 that together account for 60% of all pregnancies have only 34% of doctors and about 44% of
the nurse-midwives. For specialist cadres (Figure
B.4) the inequity is even more pronounced, with
only 27% of specialists in the districts with 60%
of the pregnancies, and 45% of these cadres in
the district of Dhaka.
Between 2009 and 2011 the number of people
admitted to public-sector training programmes
in nursing increased by about 15% (Figure B.5).69
In the advanced nursing training courses, on the
other hand, it more than tripled. These advanced
courses include the one-year post-basic B.Sc. in
Nursing and the two-year post-basic Diploma in
Nursing/Public Health Nursing. Offered previously only at the College of Nursing, University
of Dhaka, these programmes are now also offered
at three public institutions and eight private
institutions, as well as in the armed forces, for
those with two years of work experience. In addition, a direct entry B.Sc. programme in nursing
began in 2008.
In 2010, in order to fulfil the GOB’s commitment to train 3,000 midwives by 2015,
a 6-month accelerated programme was created to train qualified nurse-midwives to be
“Certified Midwives.” It will be scaled up in
coming years. In December 2012, a direct-entry,
3-year Diploma in Midwifery programme began.
70%
60%
50%
40%
30%
20%
10%
0%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Cumulative pregnancies (districts from least to highest density)
Source: AsiaPop, 2012 ; ICCDR,B
18
90%
100%
69 The admission figures cannot be directly equated with
output numbers for the same year because the duration of training for the different health cadres varies.
Although output can be affected by dropouts, it is generally thought that attrition rates during training are low.
In-service trainees receive a stipend, which may help to
keep dropout rates low.
FIGURE B.5
NUMBER OF ADMISSIONS TO PUBLIC EDUCATION INSTITUTIONS FOR SELECTED HEALTH CADRES
(2009 TO 2011)
3500
2009
2010
2011
Total (public): 6,948
3000
3,075
2500
2,523
2,439
2,288
2000
2,116
1500
1,585
1,454
1,360
1000
1,140
Total (public): 839
839
647
500
0
620
468
Total (public): 240
0
Nursing (Diploma)
Nursing (B. Sc.) and
Nurse (post-basic
Diploma and
2 yr work experience)
Sub-Assistant
Community
Medical Officer
Nurses
However, for these new education programmes
to have an impact, it will be imperative to create
the necessary numbers of sanctioned positions
for midwives (which currently do not exist)
and to keep delays in filling these new posts to
a minimum, as well as to deploy these newly
trained midwives where needs are greatest.
Time commitments of RMNH personnel
Although various healthcare workers possess a
range of competencies, no cadres are engaged
full time in provision of RMNH services. Even
in the case of certified midwives, it is not
clear whether they are exercising their newly
acquired skills on a full-time basis. After their
6-month training, they go back to their nursemidwife positions, since no sanctioned posts
for midwives have yet been created. It may well
be that they are continuing to carry out a wide
0
In-service Family Welfare
Visitor
60
60
120
In-service Advanced midwifery
course for
nurse-midwives
leading to accreditation
as “Certified midwife”
In-service CSBA course
for FWVs and HAs
range of nursing activities rather than devoting
themselves exclusively to the care of pregnant
women and their newborns.
CSBAs and nurse-midwives, who come the closest to fully trained midwives in terms of skills,
do not possess the complete range of Essential
Competencies for Basic Midwifery Practice
as laid down by ICM. Despite their additional
training, which prepares them to conduct home
deliveries in rural areas, they also have many
other healthcare duties. As a result, the number
of deliveries attended by CSBAs is relatively
small, averaging only about 23–28 per year.70
Quality of maternal and newborn
healthcare
Quality of care is a critical element of service
delivery, but detailed discussion of this issue is
70 Pathmanathan I, Rahman S, Biswas T, Nazeeen QN, Khatun A, Mustafa M. Evaluation of the community skilled birth attendant programme, Bangladesh. Report submitted to Ministry of Health and Family Welfare, Government of Bangladesh &
UNFPA, Bangladesh, 2010.
19
beyond the scope of this report; just a few examples relating to outpatient care are given here.
Quality of emergency obstetric care is discussed
in Domain C.
ing to poor service quality. Inadequate staffing
levels, absenteeism and poor laboratory service
compounded these conditions, particularly at
lower levels of healthcare delivery.
Exit interviews in 2000 with 1,913 randomly
chosen clients leaving government services
after consulting for family planning, maternal
or other female care, child care and common
diseases indicated that the majority of clients
(68%) expressed satisfaction with the services
received.71 The most powerful predictor of client
satisfaction was the behaviour of the provider,
especially their respect and politeness. Clients
considered this aspect of care more important
than the technical competence of the provider
(characterized by such elements as explaining
the nature of the problem, physical examination, and giving advice). However, 28% of clients
were not satisfied with the time that they had
to wait—a figure that reached 38% for women
attending for maternal care.
DOMAIN C:
More recently, a more negative picture of the
quality of services emerged in research by
Chowdhury and others published in 2009.72 In
this study, both clients and providers expressed
dissatisfaction with the quality of services
because of poor cleanliness, long waiting times,
short consultation times, and providers’ lack of
compassion. Respondents also listed inadequate
supply of drugs and unexpected informal
expenditures (bribes, tips, etc.) as contribut-
The Work Environment
Global evidence confirms that the healthcare
workforce is enabled or constrained in providing quality care by its work environment. This
includes the physical infrastructure and capacity of health facilities, as well as more complex
health systems dynamics such as regular supply
of equipment and drugs,73 effective referral,74
supportive supervision,75 teamwork76 and staff
retention/attrition.77
Quality of emergency obstetric
care systems
Much emphasis has been placed in recent
years on the need to have fully functional
systems for providing emergency obstetric
care (EmOC) as a critical element for reducing maternal mortality.78 Such EmOC services
must be able to provide 24/7 care by staff
with the necessary life-saving skills, such as
being able to carry out caesarean delivery and
blood transfusion, and who have access to all
required drugs and equipment. While there
is no available comprehensive assessment
of all EmOC facilities in Bangladesh to
determine whether they carry out the
71 Aldana JM, Piechulek H, Al-Sabir A. Client satisfaction and quality of health care in rural Bangladesh. Bulletin of the World
Health Organization 2001; 79:512-517. For similar findings see Syed Saad A, Siddiqui N and Khandakar S. Patient satisfaction with health services in Bangladesh. Health Policy and Planning 2007; 4:263-273.
72 Chowdhury S, Hossain SA, Halim A. Assessment of quality of care in maternal and newborn health services available in
public health care facilities in Bangladesh. Bangladesh Medical Research Council Bulletin 2009; 35:53-56.
73 World Health Organization. Working Together for Health. The World Health Report 2006. Geneva: World Health
Organization, 2006.
74 Murray SF, Pearson SC. Referral systems in developing countries: current knowledge and future research needs. Social
Science and Medicine 2006; 62: 2205-2215.
75 Criel B, De Brouwere V. Managerial supervision to improve primary health care in low- and middle-income countries:
RHL commentary (last revised: 1 March 2012). The WHO Reproductive Health Library. Geneva: World Health Organization,
2012.
76 Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database of Systematic Reviews 2009, Issue 3. Art. No.: CD000072.
77 World Health Organization. Increasing access to health workers in remote and rural areas through improved retention:
global policy recommendations. Geneva: World Health Organization, 2010. Available at http://www.who.int/workforcealliance/knowledge/resources/retentionguidelines/en/index.html (accessed on 4 September 2012).
78 Paxton A, Maine D, Freedman L, Fry D, Lobis S. The evidence for emergency obstetric care. International Journal of
Gynecology & Obstetrics 2005; 88:181-193.
20
“signal functions”79 of Basic (BEmOC) and
Comprehensive (CEmOC) emergency obstetric
care, surveys indicate that EmOC provision
is seriously inadequate. In their nationwide
assessment of facilities providing maternal,
newborn and child health and family planning services, Mridha and colleagues find that
about one-third of CEmOC facilities were not
functional due to lack of providers to perform
caesarean delivery and administer anaesthesia.80 Similarly, Khan and others report that less
than 2% of officially designated obstetric care
facilities actually had the required drugs, injections and personnel on site and that 80% of
referral hospitals at the district level were not
ready to provide CEmOC.81
Human resource constraints were found to be
the major reason for differences in obstetric
care in public-sector facilities in districts in
Khulna (a relatively high-performing division) and districts in Sylhet (a relatively
low-performing division).82 The number of
sanctioned posts for nurses was inadequate in
the rural areas of both divisions, and deployment and retention of trained staff were
problematic—more so in the rural areas of
Sylhet than in those of Khulna (with equivalent levels of expected pregnancies). In many
facilities CEmOC could not be provided due to
the absence of one or both members of “the
pair” (obstetrician and anaesthetist). Other
problems identified included lack of blood
for transfusion in rural areas and poor use of
evidence-based interventions.
Number of emergency obstetric
care facilities
Successive government plans and strategies
have recognized the need to build new and to
upgrade existing facilities to provide BEmOC
and CEmOC.83 In spite of these efforts, it was
estimated in 2011 that the country had only
419 BEmOC and 132 CEmOC facilities.84 These
numbers fall far short of the 2001 WHO recommendation of at least four BEmOC and
one CEmOC facility per 500,000 population.85
By this recommendation, Bangladesh should
have 1,200 BEmOC and 600 CEmOC facilities
to address the needs of its nearly 150 million
people. If one uses the 2005 WHO recommendation of two BEmOC facilities and one
CEmOC facility per 3,600 births,86,87 the deficit
is even more striking: Bangladesh would need
1,900 BEmOC and 950 CEmOC facilities, i.e.
4.5 and 7.2 times more facilities, respectively,
than the 2011 estimates.
In their survey of 7,680 MNCH service points,
Mridha and colleagues88 found an increase in
the number of facilities capable of carrying out
caesarean delivery and blood transfusion, but
79 Signal functions are “key medical interventions that are used to treat the direct obstetric complications that cause
the vast majority of maternal deaths around the globe. The list of signal functions does not include every service that
ought to be provided to women with complicated pregnancies or to pregnant women and their newborns in general.
The signal functions are indicators of the level of care being provided.” Definition taken from Monitoring Emergency
Obstetric Care – A handbook. Geneva: World Health Organization, 2009. Available at http://whqlibdoc.who.int/publications/2009/9789241547734_eng.pdf (accessed on 23 March 2013).
80 Ibid., ref. 45.
81 Khan MM, Hotchkiss D, Dmytraczenko T, Zunaid Ahsan K. Use of a balanced scorecard in strengthening health systems
in developing countries: an analysis based on nationally representative Bangladesh Health Facility Survey. International
Journal of Health Planning and Management 2012; doi:10.1002/hpm.2136.
82 Anwar I, Kalim N, Koblinsky M. Quality of obstetric care in public-sector facilities and constraints to implementing
emergency obstetric care services: evidence from high and low-performing districts of Bangladesh. Journal of Health,
Population and Nutrition 2009; 27:139-155.
83 Mridha MK, Anwar I, Koblinsky M. Public-sector maternal health programmes and services for rural Bangladesh. Journal
of Health, Population and Nutrition 2009; 27:124-138.
84 The State of the World’s Midwifery 2011. Delivering Health, Saving Lives. New York: UNFPA, 2011.
85 World Health Organization. Reproductive health indicators for global monitoring. Report of the second interagency meeting. Geneva: World Health Organization, 2001.
86 Ibid., ref. 73.
87 World Health Organization. Estimating the Cost of Scaling-up Maternal and Newborn Health Interventions to Reach
Universal Coverage: Methodology and Assumptions. Technical Working Paper. Geneva: World Health Organization, 2005.
Available at http://www.who.int/whr/2005/td_two_en.pdf (accessed on 19 August 2012).
88 Ibid., ref. 45.
21
PERCENTAGE OF CAESAREAN SECTIONS, BY WEALTH QUINTILE
FIGURE C.1
50%
2004
2007
2011
40%
41.1
Ratio, highest/lowest
30%
2004: 144 to 1
2007: 14.3 to 1
2011: 15.2 to 1
25.7
22.6
20%
17.1
14.3
10%
0%
14.4
9.6
0.1
1.8
2.7
Lowest quintile
0.9
1.9
Second quintile
8.5
1.7
3.3
Middle quintile
7.5
3.5
3.1
Fourth quintile
Highest quintile
Total
Source: Bangladesh Demographic and Health Surveys for 2004, 2007 and 2011. See ref. 12 for full citation.
these interventions were available only at the
tertiary level and were much more common
in private facilities than in public-sector and
NGO facilities. For instance, caesarean delivery
was available in only 184 tertiary public-sector
services and 129 NGO services compared with
1,589 private-sector facilities. In the case of
blood transfusion, the corresponding numbers
were 169, 112 and 1,488. This survey suggests
that the total number of facilities providing
caesarean section and blood transfusion in
Bangladesh may be adequate. However, these
services are overwhelmingly found in privatesector facilities, which are predominantly
located in and near urban areas and are often
beyond the financial reach of poor people. As
a result, the proportion of caesarean deliveries
among women in the poorest quintile of the
population continues to be a small fraction of
that among the wealthiest quintile, where rates
have increased dramatically in recent years
(Figure C.1).
Care at birth
As mentioned earlier, the most recent BDHS89
reported that the 2011 level of skilled attendance
at delivery90 was only 32%, still well below the
2015 target of 50%. Only 29% of births were
delivered in health facilities—15% in a private
facility, 12% in a public facility, and 2% in a NGO
facility; the other 71% of births were delivered
at home, mostly by untrained traditional birth
attendants (53% of all births), by relatives and
friends (4% of all births) and to a smaller extent
by skilled providers. In its World Health Report
2005, WHO recommended that maternal and
newborn care be provided at the primary level
in midwife-led birthing centres, which would
combine cultural proximity in a non-medicalized
setting with professional skilled care, the necessary equipment and provision for emergency
evacuation of cases that could not be handled
on-site.91 Because there is no dedicated cadre
of appropriately trained midwives, this ideal
model of care provision for pregnant women
89 Ibid., ref. 12.
90 Ibid., ref. 52.
91 World Health Organization. The World Health Report 2005. Make Every Mother and Child Count. Geneva: World Health
Organization, 2005.
22
and their newborns is currently not achievable
in Bangladesh. As a result, doctors provide the
bulk of care at delivery, performing some 70% of
deliveries with a skilled attendant present.
Frequently, the skills of individual health workers or the skill mix of the team are inefficiently
employed. However, from the interviews carried out during the course of this assessment,
service providers and managers do not consider the skills of providers to be a significant
problem in Bangladesh.92 For instance, the
overwhelming majority (91%) of the providers
considered that the training programme had
prepared them adequately to provide maternal
and newborn care. Moreover, the same percentage (91%) felt that the level of practical work
during training was adequate to prime them for
their current jobs. In fact, one-fourth (25%) of
the providers reported that the training school
set higher expectations for them in their jobs.
Nearly four-fifths of the respondents (79%)
said that they could perform all of the tasks for
which they were trained. But 20% expressed
disappointment that they were not able to carry
out all the tasks for which they had been trained
because other providers thought that they were
not qualified to perform them. Similarly, some
23% of providers expressed frustration that they
were not allowed to do all that they should be
allowed to do as part of their job.
DOMAIN D:
Management and Policies
Major RMNH policies
RMNH services in Bangladesh have evolved
over time, guided by global and national
strategies and plans.93 Figure D.1 lists the most
relevant national strategies since 2000 and some
of their key objectives. Since its independence
in 1971, Bangladesh has emphasized reducing the high fertility rate
through wider use of family
planning. Both the GOB
and United Nations statistics show that these policies
have had the desired effect:
the total fertility rate (TFR)
has declined dramatically,
from 6.9 births per woman
in the period 1970–1975
to 2.4 in 2005–2010, while
the net reproduction rate
fell from 2.0 to 1.1 per
woman.94 As noted, the fertility reduction has made a
major contribution to the
marked decrease in
maternal mortality.
Filling the gap in
skilled healthcare
workers will depend
not just on training
but on creating
sanctioned posts
and supportive HR
policies.
GOB’s maternal and newborn health policies
over the years have had two main objectives: (1)
achieving greater professionalism among staff
caring for pregnant women and their newborns,
including increasing the proportion of births
attended by a skilled health worker and promoting institutional delivery; and (2) enhancing the
number and quality of facilities able to provide
EmOC and ENC. In general, progress towards
these goals has been slow and achievements
have often fallen short of targets. Initially, in
the early 1980s Bangladesh tried to resolve the
issue of skilled attendance at birth by training
traditional birth attendants, an approach later
discredited as ineffective.95 Then, in 2001, the
Bangladesh National Strategy for Maternal
92 In-depth interviews using structured questionnaires were carried out with a total of 110 service providers and 10 managers
from the public, private and NGO sectors in three districts: a high- (Rajshahi), a medium- (Madaripur) and a low-performing district (Habiganj). For the purpose of this study “performance” was assessed by considering the proportion of
deliveries assisted by skilled health personnel at the district level. In the selection of the districts, poverty headcount ratio
of the districts and geographical distribution also were considered. The sampled districts were selected in such a way that
they were not concentrated in any particular region.
93 Ibid., ref. 83.
94 Ibid., ref. 16.
95 Bergström S, Goodburn E. The role of traditional birth attendants in the reduction of maternal mortality. In De Brouwere V,
Van Lerberghe W (eds.) Safe Motherhood Strategies: A Review of the Evidence. Studies in Health Services Organisation &
Policy 2001; 17:77-95.
23
FIGURE D.1
KEY NATIONAL POLICIES BY YEAR OF PUBLICATION
A
Bangladesh
National
Strategy for
Maternal
Health
2001
2004
C
E
Bangladesh
Adolescent
Reproductive
Health Strategy
Proposed Strategic
Directions for
Midwifery Services
of Nurse-Midwives
2006
2007
Bangladesh
Population
Policy
B
KEY OBJECTIVES
A
B
• Strengthen the provision of essential (including
emergency) obstetric care
• Train one community midwife for all 18,000
community clinics
Demand Side
Financing Pilot
for Maternal
Health Voucher
Scheme
D
• Reduce total fertility rate and increase the use of family planning methods
among eligible couples
• Achieve net reproduction rate of 1 by 2010
C
D
• Increase the demand for maternal health services among poor women
• Increase institutional deliveries
E
• Develop strategies for effective utilization of nurse-midwives, including
policy for their additional training to become Certified Midwives
• Develop comprehensive HR plan for nursing and midwifery personnel
F
• Improve health workforce planning including development of a HR
master plan
• Strengthen recruitment and career development and retention
G
• Improve quality and delivery of family planning and reproductive health
services
• Increase male involvement in family planning and reproductive health
H
• Strengthen service delivery at all levels using evidence-based
interventions
• Increase awareness among mothers and their families of newborn health
issues
I
• Ensure equity in access to quality healthcare services
• Ensure safety net for the poor to protect them against catastrophic health
expenditures
Some key objectives in the area of maternal and newborn health:
• Improve quality of maternal and newborn health services, including
evidence-based interventions notably to address haemorrhage and
eclampsia
• Strengthen EmOC services gradually through improving HR management,
placement and retention, with appropriate skill mix at various tiers of
service delivery
• Train 3,000 midwives by 2015 to accelerate achievement of MDG 5
Some key objectives in the area of population and family planning:
• Promote delay in marriage and childbearing
• Promote use of family planning postpartum, post-abortion and for
appropriate segments of the population
24
2009
Bangladesh
Health Workforce
Strategy
• Reduce the incidence of early marriage and pregnancy among
adolescents
• Provide all adolescents with easy access to adolescent-friendly health
services
J
2008
F
National
Communication
Strategy
for Family
Planning and
Reproductive
Health
I
Bangladesh
Health Policy
2011
National
Neonatal
Health
Strategy and
Guidelines for
Bangladesh
Health,
Population &
Nutrition Sector
Development
Program
(HPNSDP)
2011-2016
H
J
G
Health recommended creation of one community midwife for each of the 18,000 community
clinics, which became a national programme
to train 13,500 CSBAs96 (two CSBAs per union)
by 2010, later changed to 2015. However, an
evaluation in 201097 found that CSBAs assisted
at births mainly for women who lived close by
and/or who were their relatives. As a result,
CSBAs hardly increased the percentage of births
attended by skilled healthcare workers. The
new accelerated midwifery training programme
(to graduate 3,000 certified midwives by 2015)
and the 3-year direct-entry midwifery training,
begun in early 2013, may help to meet future
targets, but much will depend on having sanctioned posts and appropriate human resources
(HR) policies in place regarding deployment,
utilization, remuneration, career development
and the like for these new cadres.
Infrastructural expansion and upgrading also
generally has not kept pace with needs or policy
96 Ibid., ref. 49.
97 Pathmanathan I, Rahman S, Biswas T, Nazeeen QN,
Khatun A, Mustafa M. Evaluation of the community
skilled birth attendant programme, Bangladesh. Report
submitted to Ministry of Health and Family Welfare,
Government of Bangladesh & UNFPA, Bangladesh, 2010.
projections. As noted (see Domain C), the numbers of BEmOC and CEmOC facilities fall below
recommended WHO standards, and many of
the facilities, particularly those in the public
sector, cannot carry out the full complement of
“signal functions”.
Governance and accountability
The current Health, Population and Nutrition
Sector Development Program 2011–2016
(HPNSDP)98 has attempted to reduce the
fragmentation and duplication caused by the
existence of two separate wings—Directorate
General of Health Services (DGHS) and
Directorate General of Family Planning (DGFP)—
within the MOHFW.99 Consolidation is to take
place across three Operational Plans (OPs), uniting all human resource management, financial
management and sector-wide programme management and monitoring within the Ministry.
These measures may alleviate some of the
problems affecting the RMNH workforce, such
as training, regulation and licensing; recruitment
and deployment; and retention of staff, all of
which depend to varying degrees on the functionality of HRIS.
Training, regulation and licensing
The GOB’s current sixth 5-year plan
(2011–2015) acknowledges the weakness of
mechanisms to ensure the excellence of RMNH
worker training. Private-sector involvement in
educating healthcare workers has expanded
considerably in recent years; maintaining the
quality of that education has become crucial
to achieving the ambitious health goals of
HPNSDP and Vision 2021.
Interviews with key informants revealed a
range of problems with education and training of RMNH staff. Underlying these problems
is the absence of a comprehensive HRH plan
that covers the public, private and NGO sectors
and all cadres of healthcare workers, including those providing RMNH services. Currently,
training of the RMNH workforce is spread
among several OPs within HPNSDP, with little
apparent coordination and little, if any, interaction with other relevant ministries such
as Education, Labour and Employment, and
Planning. Training curricula need to be revised
and attuned to current health realities. Also,
the institutional capacity of academic and
training institutes requires strengthening by
improving the quality of teaching, upgrading
facilities (laboratory, information technology,
library, etc.) and formalizing quality-insurance
schemes.100
Recruitment and deployment
One of the biggest problems affecting the
country’s public health sector is the absence of
an efficient recruitment system, particularly
for healthcare staff in the higher professional
categories, Classes I and II (Figure D.2). As a
result, a substantial proportion of sanctioned
posts in the public sector are not filled101 (see
Figure B.2). Although there is a constant supply of doctors and nurses graduating from the
teaching institutes, and a substantial pool of
unfilled positions, recruitment of graduates into
these positions is not systematic. Many qualified
staff start working in the private or NGO sector or remain unposted until they can enter the
public-sector workforce. An estimated 12,000
98 Government of the People’s Republic of Bangladesh, Ministry of Health and Family Welfare, Planning Wing. Strategic
Plan for Health, Population & Nutrition Sector Development Program HPNSDP 2011-2016 Program. Dhaka, Bangladesh:
Government of Bangladesh, Ministry of Health and Family Welfare, 2011.
99 DFID Health Resource Centre (HRC). Development of administrative and financial management capacity for sector-wide
approaches (SWAPs): the experience of the Bangladesh health sector, 2001. Available at http://www.sti.ch/fileadmin/
user_upload/Pdfs/swap/swap135.pdf (accessed on 25 August 2012).
100 Government of the People’s Republic of Bangladesh. Ministry of Health and Family Welfare. Health Bulletin 2011. Dhaka,
Bangladesh: Management Information System (MIS), Directorate General of Health Services (DGHS), undated.
101 A contributory factor is the requirement that 30% of new recruits for any type of civil servant position – in the health and
other sectors – needs to be from among Freedom Fighters and their offspring. If there are not enough qualified applicants
from this group, their legally allotted share of positions remains totally or partially unfilled. Similarly, a smaller quota (5%)
has been established for persons from indigenous people.
25
FIGURE D.2
PROCESS FOR CREATING POSTS AND RECRUITMENT PROCESS
Creation of new health posts
National
Implementation
Committee for
Administrative
Reforms
Recruitment process
Need
identified
and
determined
Ministry of Health
and Family Welfare
Justification
approved
for new
post
Cabinet
Cabinet
Approval to
Ministry create new
post
Committee
of Secretaries
PSC, DGHS/DGFP, MOHFW
DGHS/DGFP, MOHFW, MOPA, MOF
Final
Approval
for creation
of new post
Preparation
for
submission
to Cabinet
Funding of
new post
approved
Ministry of
Public
Administration
Ministry of
Finance
MOPA, MOHFW, DGHS/DGFP
Facility identifies need
to fill vacancy
Short listing and
final selection
Job offer made
Request to fill
vacancy submitted
to DGHS/DGFP
Conduct hiring
process
Acceptance of offer
MOHFW request approval
of MOPA (for existing post)
& MOF (for new post)
Request to PSC for
recruitment &
selection
Posting assigned
Sources: El-Saharty S, Ahsan KZ. Bangladesh human resources for health: Bridging the gap. Available at http://www.healthreformasia.com/resources/
downloads/presentations/El-Saharty_O065.pdf (accessed on 12 September 2012).
qualified nurse-midwives102 were not active in
the public sector in 2012.
Since doctors and nurses working in the public sector are civil service employees, they are
recruited through a centralized process involving the Bangladesh Public Service Commission
(PSC). Delays at this level are not uncommon
and may last several months, or even years,
between MOHFW putting up unfilled posts for
recruitment and the actual deployment of successful applicants. If Bangladesh is to build a
sizeable cadre of midwives rapidly, creation of
new positions must keep pace with, and ideally
precede, the formation of new graduates, and
new midwifery graduates must be strategically
deployed with minimal delay.
Retention
In spite of the generally substandard working environment, poor pay and lack of
performance-based incentives, the scarcity of
opportunities for promotion and career development, as well as inconsistencies in transfer and
posting policies, retention rates of healthcare
staff employed in the public sector are high
(attrition is below 5%) because positions provide
life-long employment and ample opportunity
to combine the public-sector employment with
private practice, particularly for medically
qualified personnel. Serving as evidence of this
are the mean age of the doctors and nurses (41
to 43 years)103 and the long average length of
service in the public sector.
The survey of RMNH personnel conducted for
this assessment confirmed these observations:
among the 120 people interviewed, 35% were age
45 or older, and the average duration of service
in the health sector was 16.6 years. Respondents
(among whom 17.5% were involved in private
practice or other paid role) confirmed the importance of an adequate salary and other financial
and non-financial incentives in decisions about
staying in their posts. Of the top five reasons for
staying in their jobs, three were linked to remuneration: a higher salary was most frequently
cited; awards (money, prizes, etc.) for highperforming workers ranked third; and support
for children’s primary/secondary education fees
or special admission into university education
ranked fifth. The two other top five determinants
102 This estimate was made on the basis of 23,472 (2011) registered nurse-midwives compared with 14,350 (2012) working in the
government sector. The latest data (June 2012) show that there are 27,117 nurse-midwives, and thus possibly an additional
3,500 nurse-midwives not working in the government sector, hence raising the estimate to over 12,000 instead of 9,100.
(based on data provided by the MOHFW and the BNMC).
103 Ibid., ref. 64.
26
were: quality of the facility (or nearest linked/
referral facility), with sufficient staff and necessary equipment in good working order (ranked
second) and modern facilities and work environment with electricity, water supply and other
utilities (ranked fourth).
Unlike several other Asian countries (for
instance, the Philippines, India and Thailand)
emigration of health workers for jobs abroad
is not currently a significant problem for
Bangladesh.104
HR management information systems
One of the main obstacles to compiling information for this assessment was the absence of a
central MOHFW database to provide standardized information on all healthcare staff in both
the public and private sectors. Currently, DGHS
and DGFP maintain separate and outdated
systems, do not cover all categories of health
workers, and have incomplete and out-of-date
information on their personnel. Neither database includes staff employed in the private
and NGO sectors. The Directorate of Nursing
Services (DNS) maintains a separate database
of nurse-midwives (as registered nurses) but
lacks information on the employment status of
the large cohort of these workers that are not
posted in public-sector nurse-midwife positions
and may be unemployed, working in the private
sector, or employed in the public sector in nonnursing posts.
Because limited training capacity initially
will constrain the numbers of newly trained
midwives, their effective use will dependent
critically on their strategic deployment at appropriate levels, taking into account the geographic
locations of greatest need. Thus, a modern,
online HR management information system
must be built that provides real-time information on all Certified and Diploma midwives,
irrespective of the nature of their employer.
DOMAIN E:
Financing
RMNH budget estimates: levels
and trends
When Bangladesh launched its Health and
Population Sector Program (HPSP) (1998–2003)
in July 1998, it was one of the world’s first
developing countries to embark on a sector-wide
approach (SWAp) to financing the health sector.
HPSP was costed at US$3.3 billion over five years,
or US$5.50 per capita per annum, i.e. about 60%
of average total health expenditure per capita
over that period (Figure E.1). At the end of the
HPSP, expenditure was only 63% of original
allocations if actual exchange rates are applied.
The rate of development budget spending was
markedly lower than the rate of revenue budget
spending, at 65% and 86%, respectively.107,108
The Health, Nutrition and Population Sector
Program (HNPSP) (2003–2011), which followed
HPSP, had a total estimated budget of US$5.4
billion over eight years. Of that, 55.7% (US$3.0
billion) was non-development (revenue) budget,
and 44.3% (US$2.4 billion) was development
budget. Development partners were expected
to contribute 62% of the development budget.
During the period of the programme, total
104 Aminuzamman SM. Migration of Skilled Nurses from Bangladesh: an Exploratory Study. University of Sussex, Brighton, UK:
Development Research Centre on Migration, Globalisation & Poverty, 2007. Available at http://www.migrationdrc.org/publications/research_reports/Migration_of_Skilled_Nurses_from_Bangladesh.pdf (accessed on 12 September 2012).
105 The financial year in Bangladesh runs from 1 July to 30 June.
106 Cassels A, Janovsky K. Better health in developing countries: are sector-wide approaches the way of the future? The Lancet
1998; 352:1777-1779.
107 National Policy Review Forum 2003. Health, Nutrition and Population Policy. Available at http://www.cpd.org.bd/html/
policy%20brief/sub%20folders/PB03/policy/health_1.PDF (accessed on 5 September 2012).
108 The budget in Bangladesh is divided into a revenue budget and a development budget, on both the receipts and the expenditures sides. The revenue budget pays for the normal functioning of the government and is intended to be fully financed from
domestically generated sources. It includes, for example, salaries and pension entitlements of government-employed healthcare staff. The development budget includes items often funded with foreign assistance through projects and sector-wide
programmes, such as HPNSDP. In principle, when such projects or programmes are integrated into regular activities, they
should be moved to the revenue budget. See Ensor T, Dave-Sen P, Ali L, Hossain A, Begum SA, Moral H. Do essential service
packages benefit the poor? Preliminary evidence from Bangladesh. Health Policy and Planning 2002; 17:247-256.
27
HEALTH EXPENDITURE PER CAPITA, BANGLADESH, 1995–2010
FIGURE E.1
60
Per capita, PPP (constant 2005 international $)
Per capita (current US$)
Health expenditure per capita
50
40
30
20
10
0
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Source: The World Bank. World DataBank. World Development Indicators and Global Development Finance. Available at
http://databank.worldbank.org/data/Views/Reports/Chart.aspx (accessed on 12 September 2012).
investment reached only US$4.3 billion, or 79% of
the planned budget. A total of US$2.9 billion were
national resources for the revenue budget and the
GOB’s contribution to the development budget
(i.e. well below the projected US$3.9 billion), and
US$1.3 billion came from donor aid (as opposed
to the projected US$1.5 billion).109 The main reasons given for the low utilization of funds110 were:
lack of sufficient resources from development
partners and consequent reduction of the GOB’s
matching funding; delays in procurements due to
the complex procedures; and slow absorption of
funding due to frequent changes of Line Directors
in charge of the 38 OPs.
The current HPNSDP has a total budget of
US$7.7 billion, consisting of a revenue budget of
US$4.7 billion (61%) and a development budget of US$3 billion (39%).111 Projections of the
annual development budgets as a proportion
of the total 5-year HPNSDP were 17% in financial year 2011/2012, 23% in both 2012/2013
and 2013/2014, and 37% for 2013/2014 and
2014/2015 combined.112,113
The Program Implementation Plan (PIP) of
HPNSDP114 has a total budget of US$7.5 billion,
with a revenue budget of US$4.7 billion (62%)
and a development budget of US$2.9 billion
109 Central Data Warehouse, Ministry of Health and Family Welfare. Fact Sheet (HNPSP). Health, Population and Nutrition Sector
Program (HNPSP), 2011. Available at http://dmis-bd.homelinux.net/dmis/index.php?option=com_content&view=article&id=100
&Itemid=117 (accessed on 5 September 2012).
110 Government of the People’s Republic of Bangladesh, Ministry of Health and Family Welfare, Planning Wing. HPNSDP –
Health, Population and Nutrition Sector Development Program 2011-2016 – PIP – Program Implementation Plan – Volume 1.
Dhaka, Bangladesh: Government of Bangladesh, Ministry of Health and Family Welfare, 2011.
111 The estimated budget for MOHFW during the period of 2011–2016 is slightly higher, at approximately US$8.0 billion, since it
includes a number of projects that fall outside the OPs of HPNSDP.
112 Government of the People’s Republic of Bangladesh, Ministry of Health and Family Welfare, Planning Wing. Strategic
Plan for Health, Population & Nutrition Sector Development Program HPNSDP 2011-2016 Program. Dhaka, Bangladesh:
Government of Bangladesh, Ministry of Health and Family Welfare, 2011.
113 There are no separate figures for the budgets of the final two financial years of HPNSDP.
114 Ibid., ref. 110.
28
(38%). Total contributions by development
partners over the life of HPNSDP are estimated
at US$1.8 billion (24% of the total budget, or
about 61% of the development budget), with
the remaining US$5.7 billion, or about 76%,
contributed by the GOB. The 32 OPs115 include
a new OP under DGHS entitled Maternal,
Neonatal, Child and Adolescent Health, which
is scheduled to receive 13.6% of the total development budget, or some US$395 million, most
of it contributed by reimbursable project aid
(RPA) (54%) and development partners (34%).
The largest component in this new OP is the
Expanded Programme on Immunization (EPI),
with 66.2% of the budget, followed by MNH
(28.5%), integrated management of childhood
illness (IMCI) (3.6%), school health (0.8%) and
reproductive and adolescent health (0.6%).116
Under DGFP, all seven OPs from HNPSP will be
continued, some with slightly modified titles,
objectives and content. Their total share of
the development budget constitutes 18.6%, or
about US$1.56 billion. The three largest of these
seven OPs are Maternal, Child, Reproductive
and Adolescent Health (4% of the total development budget), Clinical Contraceptive Services
Delivery (6.1%), and Family Planning Field
Services Delivery (7.3%). In sum, the MNH component of these programmes amounts to almost
one third (32.2%, or about US$900 million) of
the development budget.
Because of the budget approach used in the
Bangladesh sector programmes and the SWAp
financing, it is not possible to determine how
much the country actually spends on RMNH.
Moreover, the National Health Accounts do not
allow for that determination, either.117 It could
be postulated that the non-development budget (US$4.7 billion) of HPNSDP contributes
the same percentage (32.2%) as the development budget to the seven DGFP OPs and the
MNH component of the new DGHS OP on
Maternal, Neonatal, Child and Adolescent
Health described above. Under this assumption, the revenue budget contribution would
be some US$1.51 billion; thus, both parts of
the HPNSDP budget combined would provide
some US$2.41 billion to RMNH over the 5-year
period, or an average of about US$480 million per year. However, this figure is probably
an underestimate since it assumes, contrary
to fact, that no other OPs or activities outside
HPNSDP in the MOHFW or other ministries
contribute to RMNH.118
For comparison, a MDG needs assessment
and costing for Bangladesh119 estimated that
US$1.84 billion would be needed over the
period 2009–2015 (i.e. an annual average of
about US$264 million) to reach MDG 5 and
US$682 million (or an annual average of US$97
million) for primary and referral infant care.120
115 The reduction in OPs from 38 in HNPSP to 32 in HPNSDP is the result of merging Micronutrient Supplementation and the
National Nutrition Programme into one OP (National Nutrition Services) and merging the former OPs on Improved Hospital
Services Management and Quality Assurance (Health) into one OP on Hospital Services Management and Safe Blood
Transfusion. Furthermore, HPNSDP now has only one OP on Human Resource Management, through the merger of the
three formerly separate OPs on human resource management for DGHS, DGFP and MOFHW; one OP on Improved Financial
Management, created by merging the three separate OPs on improved financial management for health, family planning and
MOFHW; and one OP on Sector-Wide Program Management and Monitoring, made by merging the three former separate
OPs on sector-wide management for health, family planning and MOHFW. New in HPNSDP is an OP on Community Based
Health Care and, most importantly in the context of this document, the division of the old OP on Essential Service Delivery
into an OP on Essential Services Delivery and a new OP on Maternal, Neonatal, and Child Health Care, which is also referred
to as Maternal, Neonatal, Child and Adolescent Health.
116 Ibid., ref. 110.
117 Government of the People’s Republic of Bangladesh, Ministry of Health and Family Welfare, Health Economics Unit.
Bangladesh National Health Accounts 1997-2007. Dhaka, Bangladesh: Ministry of Health and Family Welfare, 2010.
118 For instance, the OPs on Essential Services Delivery, Community Based Health Care, In-service Training, Pre-service
Education, National Nutrition Services, and Nursing Education and Services all have one or more elements that contribute to
RMNH. Together, these OPs make up 21.75% of the development budget, but the available data do not allow determining the
proportion of these OPs that is exclusively directed to RMNH care.
119 Government of the People’s Republic of Bangladesh, Planning Commission, General Economics Division. Millennium
Development Goals – Needs Assessment & Costing 2009-2015 Bangladesh. Dhaka, Bangladesh: General Economics Division,
Planning Commission, Government of the People’s Republic of Bangladesh, 2009.
120 A separate budget estimate for attaining newborn health goals was not made.
29
In addition, it was estimated that health systems needed a total of US$11.38 billion (or an
annual average of US$1.62 billion) to meet the
health-related MDGs 4, 5 and 6.121 Adding these
estimates yields a total of US$1.99 billion per
annum—well above the US$480 million estimate
referred to above.
HPNSDP: modest targets for RMNH
HPNSDP does not anticipate attaining universal coverage for all Essential Interventions of
RMNH. For instance, the 2016 target for deliveries attended by a skilled birth attendant is set
at only 50%.122 Similarly, by 2016, “Antenatal
coverage (at least four visits)” and “Postnatal
care within 48 hours (at least 1 visit)” are also
planned to reach only 50%.123 Clearly, reaching universal coverage for these three Essential
Interventions will require financial resources
well beyond the amounts budgeted under
HPNSDP.
Further analysis of the PIP reveals that several
other indicators will also fall far short of the
levels necessary to provide optimal RMNH care.
For instance, by 2016, unmet need for family
planning would still be at 9% (compared with
the 2011 BDHS figure of 14%), the percentage
of union-level facilities124 upgraded to provide
BEmOC services would be 50% (from the current 16%), and the number of CEmOC facilities
would grow from about 120 to 204.
Current and projected costs for RMNH
To inform scenarios and costed options for the
RMNH workforce (see next section), estimates
were obtained for the key unit costs for pre-service education, salaries, benefits and in-service
training. These costs were identified through
grey literature, estimates provided by educational institutions and the GOB as part of the
stakeholder consultation, and through the MNH
assessment process. A technical consultation in
Dhaka reviewed all costs in detail and reached
agreement on the units, ranges and assumptions
to be used in the scenarios.
Pre-service education costs per graduate were
reviewed for the main cadres of the RMNH
workforce (identified in Domain B) and the
new 3-year, direct-entry midwife education
programme. Published and grey literature
provided varying estimates of education and
in-service training costs per cadre, perhaps due
to inconsistencies in their methods to quantify a cost per graduate. GOB projections of
the cost of pre-service education to reach the
health-related MDGs 4, 5 and 6 put the total
for the 7-year period 2009–2015 at US$2.06
billion, or US$294 million on average per year.
The report provides no breakdowns for the
individual MDGs or the different cadres of
health workers.125 Figure E.2 shows estimated
unit education/training costs of the various
existing RMNH cadres and of the new midwifery cadre.
Financing RMNH workforce expansion
The SWAp model of healthcare financing provides a measure of flexibility for re-allocating
financial resources in line with government
priorities. The political will to create an effective midwifery workforce is currently strong in
Bangladesh. The GOB’s commitment to train
3,000 midwives by 2015, made in September
2010 at the launch of the UN SecretaryGeneral’s Global Strategy for Women’s and
Children’s Health,126 was a clear manifestation
of that political will.127 This training has been
budgeted in the HPNSDP. Also budgeted is
the training of an additional 8,200 CSBAs by
the end of 2016, a policy decision that may be
121 A separate estimate excluding MDG 6 and including only MDG 5 and the infant, or preferably newborn, health component of
MDG 4 was not provided.
122 Ibid., ref. 110.
123 The reference figure for “Antenatal coverage (at least 4 visits)” is 25.5% in BDHS 2011. The corresponding percentage for
“Postnatal care within 48 hours (at least one visit)” is 27.6% (BDHS 2011 Ref 12).
124 In 2006 the MOHFW decided to upgrade 1,495 Union health and family welfare centres (UHFWCs) to provide BEmOC. See
also Ref 83
125 Ibid., ref. 119.
126 Ibid Ref. 53.
127 Ibid., ref. 54.
30
FIGURE E.2
CADRES AND UNIT COSTS
Years of training
Type of
healthcare provider
Requirement
for entry
Level of
competency
General Physicians (GPs)
12 years
of schooling
General training
Internship (post general)
Nurses/nurse-midwives
12 years
of schooling
Nursing and
general training
SACMOs [also known as
Medical assistants (MAs)]
10 years
of schooling
Generalist training
Family Welfare Visitors
(FWVs)
12 years
of schooling
MCH and family
planning training
Family Welfare Assistants
(FWAs)
10 years
of schooling
Family planning
training
Health Assistants (HAs)
10 years
of schooling
Training on ltd. prev. &
curative care, incl. imm.
Certified midwives
Diploma in Nursing
Science and Midwifery
ICM approved advanced
midwifery programme
Community-based skilled
birth attendants (CSBAs)
FWA or female HA
Registered midwives
CHCP
Estimated cost of training (US$)*
Public Sector
(recurrent costs)
Private sector
(fees only)
13,284 per student
20,910
3 years
61,500 to 73,800 for a center
with 50 students per cohort
(approx. 150 in the school)
1,661-1,845
3 years
9,840 per student
1,599-2,214
923 per student
including stipend
N/A
209 per student
including stipend
N/A
431 per student
including stipend
N/A
6 months
(in-service with stipend)
1,476 (based on per student
cost for new course)
N/A
Training on EOC & ENC
6 months
1,643 per student
including stipend
N/A
(newly introduced)
Diploma in Midwifery
(direct entry)
ICM approved
midwifery programme
3 years
12 years
of schooling
TBC
1
2
3
4
5
5 years
1 year
18 months
2 months
3 months
3 months
3,456 to 3,530 per student
(for est. course costs)
404 per student
including stipend
N/A
* Estimate from Core Group
questionable given that this cadre of healthcare worker does not attain ICM’s Essential
Competencies for Basic Midwifery Practice and
assists at relatively few deliveries, as noted. A
re-allocation of planned expenditure for CSBA
training to midwifery training could be one
mechanism to expand the formation of fully
competent midwives.
HPNSDP is the subject of Annual Programme
Review (APR) by an Independent Review
Team (IRT) and will undergo also a Mid-Term
Review. These assessments provide the GOB
with regular opportunities to adjust its RMNH
policies and programmes, including funding
allocations, in response to identified needs in
the field and in light of the costed scenarios
presented in the next section. The first APR
took place in September-October 2012.128 Its
findings confirm several of the weaknesses
in HR management, financing, governance,
etc., reported in the present assessment. Of
some concern in the area of financing are the
APR’s findings that the HPNSDP is currently
underfinanced, that systems for comprehensive resource planning and tracking do not
exist, and that resource allocation is not based
on need. The 2013 review showed increases
in the numbers of student midwives and the
training of CSBAs, but a continued need to
strengthen HR planning and management
including the distribution and retention of
critical staff.129
128 HPNSDP Document Repository. Bangladesh Health, Population and Nutrition Sector Development Program (HPNSDP) Annual
Program Review 2012. Volume I Consolidated Technical Report. Available at http://hpnconsortium.org/hpnsdp/annual-program-review (accessed on 24 March 2013).
129 HPNSDP Document Repository. Bangladesh Health, Population and Nutrition Sector Development Program (HPNSDP) Annual
Program Review 2013. Final IRT Consolidated Report on APR 2013. Available at http://hpnconsortium.org/hpnsdp/annualprogram-review (accessed on 7 November 2013).
31
OPTIONS, COSTS AND IMPACT
This final section considers the evidence
generated in Domains A through E as the
foundation to develop, model and cost potential options for the future development of
the RMNH workforce in Bangladesh. It takes
account of both the primary data and the collation and new analysis of secondary data.
In line with international efforts to enhance
accountability of RMNH expenditures130
and to promote the achievement of national
policy and commitments to the MDGs and
the United Nations Secretary-General’s Every
Woman, Every Child campaign,131 this section frames the discussion within the broader
context of the “results chain” of inputs, process, outputs, outcome and impact. WHO and
UNICEF have recently adopted this framework in new guidance on monitoring and
evaluation of national MNH programmes,
with greater emphasis on disaggregated data
within countries.132,133
process included the integration of data
prepared by the MOHFW, BNMC, and other
interested parties.
Modelling and scenarios
The modelling was based on recognized
frameworks from WHO and others134,135 used to
project changes in the stocks and flows of the
health labour market and the working lifespan
of personnel. The methodology follows similar
scenario exercises in high-, middle- and low-
Options and costs were developed in consultation with national stakeholders in a workshop
on 1 September 2012. Additional consultation
with stakeholders took place both before and
after this event until October 2013. The
The modelling addresses two key issues: (1)
the need to increase emergency obstetric care
and MNH skills to ensure capacity for planned
coverage in the short term; and (2) the development of a dedicated cadre with the full set
of competencies for managing births and complications, providing 24/7 service and reaching
universal coverage in the longer term, including strengthening of systems in preparation
for management and regulation of the new
cadre. These complementary strategies should
include expanding the education and training
programmes for midwives and increasing the
productivity of trained staff—for example, by
promoting deliveries in fully equipped health
facilities staffed with a team of midwives and
support staff who can provide 24/7 service.
130 Commission on Information and Accountability for Women’s and Children’s Health. Keeping Promises, Measuring Results.
Geneva, Switzerland: World Health Organization, 2011. Available at http://www.everywomaneverychild.org/images/content/
files/accountability_commission/final_report/Final_EN_Web.pdf (accessed on 13 September 2012).
131 Every Woman Every Child. Website at http://www.everywomaneverychild.org/ (accessed on 13 September 2012).
132 Ihp+ and World Health Organization. Monitoring, Evaluation and Review of National Health Strategies: a country-led
platform for information and accountability. Geneva: World Health Organization, 2011. Available at
http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Tools/Guidance_for_monitoring_NHS/
Monitoring%20%26%20evaluation%20of%20national%20health%20strategies.pdf (accessed on 10 April 2013).
133 Countdown to 2015, HMN, UNICEF, World Health Organization. Monitoring Maternal, Newborn and Child Health: understanding key progress indicators. Geneva: World Health Organization, 2011. Available at http://www.who.int/healthmetrics/
news/monitoring_maternal_newborn_child_health.pdf (accessed on 13 September 2012).
134 Ibid., ref. 73
135 World Health Organization. Models and Tools for Health Workforce Planning and Projections. Human Resources for
Health Observer. Issue No.3, 2010. Geneva: World Health Organization. Available at http://www.who.int/hrh/resources/
observer3/en/index.html (accessed on 13 September 2012).
32
income countries.136-139 The exercise focused on
nurse-midwives, FWVs and CSBAs already providing care closer to the community, who have
the potential for significant impact on rural
coverage in the short term. The longer-term
workforce modelling was focused on registered
midwives140 with the full set of competencies
and working in a dedicated role in maternal and newborn care. The Lives Saved Tool
(LiST)141 generated the impact data that can be
achieved in Bangladesh based on the current
coverage targets and the move towards universal coverage.
The modelling covers the period 2013–2021,
with costs separated for 2013–2016 and 2017–
2021. The first period aligns with the HPNSDP
(a short-term planning perspective). The second period aligns with VISION 2021 and is
intended to support scenario discussions on
scale-up to universal coverage (a medium-term
planning perspective), taking into account the
longer-term view to 2030 for moderate growth
of a new cadre. All cost estimates were run
through 2021.
Modelling applied the consensus reached
by national stakeholders on the underlying
rationale and assumptions for supply and
requirement projections:
• The base year for the options and costs is
2011/12, informed by MOHFW and BNMC
data, with reference to 2010 and 2009 data for
context and trends.
• Education supply was based on the number of expected graduates and the average
intakes and production of expected graduates in the short term where information
on intakes per year was available. For the
medium to longer term, the average cohort
sizes across the previous three years from
2009/2010 to 2011/2012 (adjusted for sudden low or high intake trends) were used.
An adjustment for estimated student attrition prior to graduation of 10% to 25% for
diploma midwives and 55 to 68% for nursemidwives was applied following stakeholder
consultations. FWVs, CSBAs, FWAs/HAs
receive training following a recruitment process and therefore were excluded from these
attrition assumptions.
• Involuntary exits took into account loss
due to retirement (calculated from the age
profile of the health workforce142) and a conservative estimate for illness and death (1%
per year). Information on the higher average age of FWVs led to a higher estimate for
retirements, with low and high estimates of
30% and 53% of the 2011 workforce expected to retire over the next ten years. Based
on the same survey data, retirement rates
for nurse-midwives were set to between
11% and 22%. There are no retirements
expected among midwives and CSBAs in the
next 10 to 15 years, as the groups undergoing training were all under 50 years of age
and recruits for Diploma midwives also
were young.
136 Dussault G, Buchan J, Sermeus W, Padaiga Z. Assessing Future Health Workforce Needs. Policy summary prepared for the
Belgian EU Presidency on Investing in Europe’s health workforce of tomorrow: scope for innovation and collaboration (La
Hulpe, 9-10 September, 2010). Copenhagen, Denmark: World Health Organization, 2010. Available at http://www.euro.who.
int/__data/assets/pdf_file/0019/124417/e94295.pdf (accessed on 13 September 2012).
137 Buchan J, Seccombe I. A Decisive Decade – Mapping the Future NHS Workforce. London, United Kingdom: Royal College
of Nursing, 2011. Available at http://www.rcn.org.uk/__data/assets/pdf_file/0004/394780/004158.pdf (accessed on 13
September 2012).
138 Starkiene L, Smigelskas K, Padaiga Z, Reamy J. The future prospects of Lithuanian family physicians: a 10-year forecasting
study. BMC Family Practice 2005; 6:41.
139 Tjoa A, Kapihya M, Libetwa M, Schroder K, Scott C, Lee J, McCarthy E. Meeting human resources for health staffing goals
by 2018: a quantitative analysis of policy options in Zambia. Human Resources for Health 2010; 8:15.
140 Please note that this includes both educational backgrounds of “certificate in midwifery” and “diploma in midwifery”.
141 Johns Hopkins Bloomberg School of Public Health, Department of International Health. LiST: the Lives Saved Tool. An
evidence-based tool for estimating intervention impact. Available at http://www.jhsph.edu/departments/international-health/
centers-and-institutes/institute-for-international-programs/list/ (accessed on 11 April 2013).
142 Ibid., ref. 64
33
• Voluntary exits (i.e. career breaks, transfer
to other professions or roles, or international
migration) were estimated at a low 1.5% per
cadre and per annum. This may increase
in the longer term, given the potential for
mid-level cadres to work in the international
setting. Therefore, the attrition was increased
(to 5%) between 2016 and 2021 for the longerterm projections only.
Based on these assumptions, the modelling produced estimates of the annual stock of certified
midwives, diploma midwives (new direct-entry
course), nurse-midwives, CSBAs, and FWVs (by
headcount) per year for the period 2013 to 2021.
TABLE O.1
Two requirement scenarios inform the options
and costs. Both scenarios grouped the midwives,
nurse-midwives, FWVs and CSBAs so as to estimate future requirements for the practising
RMNH workforce (i.e. in labour wards, delivery
rooms) by their full-time equivalent (FTE) number. The benchmarks applied take into account
the management of complications in the case of
midwives with full competencies and the parttime contribution to deliveries (applied as 20%
of FTE) for nurse-midwives, CSBAs and FWVs,
who have wider service remits. The scenarios
are based on expected pregnancies and expected
births as a sub-section with increasing coverage
targets (Table O.1). In both scenarios the work-
COVERAGE TARGETS (%) USED IN ESTIMATING WORKFORCE REQUIREMENTS TO REACH
UNIVERSAL COVERAGE FOR EXPECTED PREGNANCIES.
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
31%
31%
36%
41%
46%
50%
55%
60%
65%
70%
75%
2. Urban
54%
56%
59%
61%
63%
66%
68%
70%
73%
75%
3. Rural
25%
31%
36%
42%
47%
53%
58%
64%
69%
75%
4. Institutional total (10% less
than Target 1)
28%
31%
33%
40%
45%
50%
53%
56%
60%
65%
5. Institutional urban (10% less
than Target 2)
49%
50%
51%
52%
53%
56%
58%
60%
63%
65%
6. Institutional rural (10% less
than Target 3)
23%
25%
28%
32%
37%
43%
48%
54%
59%
65%
1. Total (based on HPNSDP
and stakeholder consultation)
FIGURE O.2
PROJECTED SUPPLY BY HEADCOUNT OF SKILLED PROFESSIONALS
(AT THE START OF THE CALENDAR YEAR), 2013-2021
18,000
Projected number of health workers
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
2013
2014
Nurse-midwives
34
2015
CSBAs
2016
FWVs
2017
Certified midwives
2018
Diploma midwives
2019
2020
2021
force requirement has been based on the WHO
estimate of one midwife or other healthcare provider with midwifery skills per 175 births.143
The scenarios were originally developed to take
into account the care provided at the time of
birth and do not include antenatal and postnatal
care or other types of services provided within
MNH, however, they provide a benchmark for
the average productivity level for the purposes
of planning. It is expected that home births may
be conducted by certified or diploma midwives
(full-time contribution) and CSBAs (part-time
contribution), and that institutional births can
be conducted by certified and diploma midwives
as full-time contribution, and nurse-midwives
and FWVs as part-time contributions.
Differences between supply and need
Figure O.2 provides estimates for the future
supply of the health cadres based on a baseline
and no-change scenario (for existing government-sanctioned titles), by headcount, to 2021.
The supply projections were based on the 2011
workforce stock, with estimations applied for
student attrition levels (and thus not entering
the workforce) and retirement rates, based on
the total number expected to exit the workforce
in the next 10 years (estimated to be those aged
50 years and over in the 2011 stock). Based on
current policies and a continuation of graduate
education (number and size of cohorts), the
total number of midwives will increase from
16,799 (19,253 based on high supply estimates)
in 2016 to 18,234 (23,159 based on high supply estimates) in 2021. Numbers of CSBAs and
FWVs are estimated to be around 11,500 by
2016, and increasing to 15,300 by 2021. These
projections are based on the current expectations for recruitment of skilled healthcare
providers based on external funding in the short
term and a limited number of new recruitments
for FWVs.
Figure O.2 is a supply projection based on
headcount and is not indicative of the supply
143 Ibid., ref. 91
available for pregnancy, labour and birth care.
Not all the cadres highlighted practice fulltime providing RMNH care. Most have a wide
remit to cover other healthcare provision or
work under a rotation system. Student attrition
was not applied to FWVs, as they are recruited
before they receive training.
Given the short training for this cadre, a
CSBA can be replaced within one to two years,
even with lag time for recruitment. The flow
for FWVs is also above replacement level
and increased recruitment plans from 2014
onwards of 556 per year is leading to a growth
in the workforce that may experience high
number of exits due to retirement. The supply estimates indicate a potential stagnation
in the CSBA workforce in the next decade, if
the assumed growth rate of 1000 new entries
per year is not maintained (Table O.3) through
government action.
The two national scenarios project the estimated
number of skilled healthcare providers required
by 2021 (in support of annual increases to attain
universal coverage) to 20,316 FTEs (Table O.4).
Because RMNH care in Bangladesh is delivered
by cadres with a wider remit in healthcare,
and therefore not working full time on RMNH,
universal coverage is based on a workforce that
TABLE O.3
PROJECTED NUMBERS
OF VOLUNTARY AND
INVOLUNTARY EXITS OF
CSBAs AND FWVs
BETWEEN 2013 AND 2021
CSBAs
FWVs
2013
-238
-289
2014
-258
-280
2015
-297
-272
2016
-337
-281
2017
-405
-290
2018
-469
-300
2019
-487
-309
2020
-505
-318
2021
-521
-326
35
works at a lower productivity rate for provision of care during pregnancy, childbirth and
the postnatal period (for example, 20% of fulltime equivalence). This means that, in this
example, the number of cadres needed with the
skills to deliver RMNH care for all pregnancies
increases five-fold, to approximately 70,440
in 2016 to provide 50% coverage and 101,580
in 2021 for 75% coverage of RMNH services.
Based on the training costs alone, a part-time
workforce for RMNH in 2021 could potentially
cost US$20.3million144 for a one-month refresher
training as opposed to US$5.4 million for a dedicated RMNH workforce of fewer cadres working
to high levels of productivity.
From the lowest and highest estimates for supply (headcount) based on the current flow for
joiners and leavers, and the scenarios for HRH
requirements, it is estimated that the gap for
skilled healthcare providers (in full-time equivalents) in Bangladesh will be between 4,534 for
expected births and 22,093 for expected pregnancies in 2016, expanding to between 14,557
and 48,184, respectively, in 2021 to meet the goal
of universal coverage (Figure O.5).
Based on the above analysis, two key themes
were identified for Bangladesh in developing
the RMNH workforce including (1) short-term
skilling-up of the existing workforce, and (2) the
long-term development of a dedicated workforce.
Key area 1: short-term “skill-up”
The task of developing a dedicated and specialist
workforce of a limited number of cadres with all
the competencies to deliver the essential RMNH
interventions is in its early stages in Bangladesh
and will not be achieved in the short term.
Therefore, one of the scenarios investigated as
part of the assessment is the development of
skilled cadres within the existing governmentsanctioned posts to meet the needs of the
population through 2016.
“Skill–up” includes the in-service training
required to deliver basic interventions at community and outreach levels and in facilities for
144 Calculations based on one-month training estimates of US$246 per trainee not including back-fill costs, applied to the parttime estimates for the average across the four scenarios for 2021, accounting for 77,144 trainees including the part-time
workforce as compared with 21,896 if all of the workforce could be dedicated full time to RMNH.
PROJECTED REQUIREMENTS FOR SKILLED PROFESSIONALS (2013–2021) BY FULL-TIME EQUIVALENT
TABLE O.4
Expected pregnancies
Total
expected
pregnancies
Expected births
Total
expected
births
Urban
Urban
Rural
Rural
Urban
Urban
Rural
Rural
Home
Institutional
Home
Institutional
Home
Institutional
Home
Institutional
2013
393
2,955
1,149
5,623
254
1,910
743
3,635
10,120
6,542
2014
473
3,015
1,731
6,243
305
1,946
1,118
4,031
11,462
7,401
2015
539
3,087
2,212
6,956
348
1,991
1,426
4,486
12,794
8,252
2016
593
3,165
2,188
8,142
382
2,037
1,408
5,240
14,088
9,066
2017
592
3,298
2,175
9,303
380
2,117
1,396
5,973
15,368
9,867
2018
591
3,430
2,162
10,450
379
2,197
1,385
6,694
16,633
10,655
2019
590
3,561
2,149
11,582
377
2,276
1,374
7,403
17,883
11,430
2020
589
3,692
2,137
12,701
376
2,354
1,363
8,100
19,118
12,192
2021
587
3,818
2,121
13,789
373
2,427
1,349
8,768
20,316
12,918
Note: Scenarios are aligned with HPNSDP 2011–2016 (with annual estimates and universal coverage at 95% scale-up for 2021). See Table O.1 for details.
Requirements are based on the AsiaPop projections, which take into account live births, stillbirths and abortions, which are totalled to project the
expected number of pregnancies in Bangladesh per annum. Expected births are a sub-section of expected pregnancies.
36
emergency care during childbirth for the mother and the newborn. Training requirements
for skill-up are estimated to be the equivalent
of one month’s training delivered to cadres
working close to the community. This option
assumes that all the midwives have already
received the relevant education and that all
CSBAs would require follow-up training, even
though there is an expectation that only 20%
of their time will be spent assisting childbirth.
As it is expected, also, that not all of the nursemidwives and FWVs will be contributing to
maternal and newborn care and that there will
be limitations in the number of skill-up training
places that can be established in a given period
of time, the estimates assume that certain proportions (estimated at 50%, 60% and 70%) of
the workforce will receive training.
Table O.6 highlights the number of healthcare
providers requiring skill-up to meet the shortterm needs. If 70% of the nurse-midwives and
FWVs receive skill-up training, and with an
increase in time spent by CSBAs on RMNH (to
33%), it is estimated that, by 2021, approximately 22,074 nurse-midwives, FWVs, CSBAs
and midwives will be available in the workforce
to deliver maternal and newborn care with upto-date essential skills. However, this equates
to only 4,415 FTEs when the additional roles of
nurse-midwives, FWVs and CSBAs are taken into
account. As this does not meet the estimated
requirements, the skill-up must be considered
part of a short-term solution, to be implemented
along with other options.
TABLE O.6
One of the key messages from the supply projections is the need to increase education outputs
and scale-up in the number of nurse-midwives.
Such an increase would also supply a government-approved and qualified workforce for the
NGO and private sectors as part of increasing
the density of workers in the health sector. In
addition, above-replacement-level growth of
the workforce could provide opportunities for
advanced courses in midwifery to continue, in
order to train existing cadres and build a dedicated and specialist workforce for maternal and
newborn care without reducing the numbers of
providers available for other areas of healthcare.
FIGURE O.5
ESTIMATIONS OF THE POTENTIAL GAPS IN THE
WORKFORCE NEEDED TO ACHIEVE UNIVERSAL
COVERAGE (IN FULL-TIME EQUIVALENTS) (FTE)
2021
2020
2019
2018
2017
2016
2015
2014
2013
-50,000
-40,000
-30,000
Variance based on supply attrition
-20,000
-10,000
All pregnancies in addition to births
0
For estimated births
ESTIMATIONS OF WORKFORCE NUMBERS REQUIRING “SKILL-UP” TO MEET SHORT-TERM NEEDS
2013
2014
2015
2016
2017
2018
2019
2020
2021
50% of the nurse-midwives and FWVs
to receive training
9,616
9,380
9,323
9,424
9,759
10,008
10,253
10,495
10,733
to receive training
11,539
11,256
11,187
11,309
11,711
12,010
12,304
12,594
12,880
to receive training
13,462
13,131
13,052
13,194
13,662
14,011
14,355
14,693
15,027
2,411
2,777
3,158
3,791
4,403
4,572
4,736
4,894
5,047
2,000
2,000
2,000
2,000
2,000
2,000
18,985
20,065
20,583
21,091
21,587
22,074
CSBA follow-up training
CSBA and equivalent follow-up training
Totals used for final estimates (based on
the assumption of 70% of nurse-midwives
and FWVs receiving training)
15,872
15,909
16,210
37
Key area 2: long-term development of
a dedicated health cadre for RMNH
and system strengthening
This model requires consideration of system
strengthening and scale-up of a dedicated cadre
such as midwives, as foreseen in the HPNSDP, to
make possible quality care, including regulatory
standards and guidelines, their implementation
with supportive supervision, and the development of pre-service education capacity.
An early win for institutional strengthening
would be the official integration of the 2011
Essential Interventions for reproductive, maternal and newborn health145 into national standards
and guidelines. The assessment confirms that
Bangladesh’s approach is generally aligned with
the latest international evidence. Linking the evidence to policy guidance, regulatory tools, scopes
of practice, protocols and the like, and supporting
their implementation at upazila and community
levels, would further enhance consistent applica-
tion of these standards in education and service
delivery. This is particularly pertinent for the
care of complications, which can be managed
through midwifery-skilled healthcare providers
with access to facilities equipped for basic emergency obstetric and newborn care (BEmONC)
without the need for referral. The estimate of
the anticipated programme costs to support
the acceleration of these processes is based on
implementation over the next three years in
preparation for the newly introduced midwife
cadre to be fully embedded in sanctioned publicsector posts, private practice and as part of the
sanctioned positions in the NGO teams.
Figure O.7 highlights the assumptions made
about the scale-up, reflecting current developments in advanced and direct-entry midwifery
programmes, which should result in growth in
the numbers of the certified and diploma midwives, and the additional educational capacity
required to fill the gap. The scale-up assumptions
145 Ibid., ref. 44
FIGURE O.7
SCALE-UP ASSUMPTIONS FOR MIDWIFERY COURSES THAT WILL RESULT
IN A DEDICATED WORKFORCE FOR MATERNAL AND NEWBORN HEALTH
IN BANGLADESH (BASED ON OUTPUTS ADJUSTED FOR 10% TO 25%
ATTRITION RATES)
30,000
Expected Graduates (2,400 per year from 2019)
Number of expected graduates (midwives)
25,000
20,000
15,000
10,000
5,000
0
2014
38
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
result in universal coverage (75%) being attained
through a dedicated workforce by 2029 or a few
years earlier.146
Estimated costs and the case
for investment
are US$160 million over nine years, with all cadres in RMNH being involved in the skill-up, the
new dedicated cadre being developed to achieve
universal coverage over the longer term, and
associated costs for supportive mechanisms and
regulatory systems included.
The estimated costs to support scale-up, institutional strengthening and skill-up, and retention
are detailed in Table O.8. The estimated costs
The options put forward call for the investment
of US$3.67 per expected pregnancy between 2013
146 The 2029 date is based on a scale-up plan with approximately 2,000 new workers produced per year and assumptions on
student attrition and workforce loss.
TABLE O.8
DETAILED BREAKDOWN OF THE COSTS OF THE OPTIONS (IN US$, NOMINAL RECURRENT
COSTS ONLY)
COSTS
Detailed breakdown of options and costs
Description
2013
2014
2015
2016
2017
2018
2019
2020
2021
2013-2021
2013-2016
2017-2021
42,404,728
16,476,223
25,928,505
40,955,425
13,011,425
27,944,000
45,316,294
–
45,316,294
Key Area 1 - Short-term skill-up: Emergency Obstetric Care and newborn care training (including all the cadres for MNH)
sub-total
3,904,633 3,913,587 3,987,573 4,670,430 4,935,964 5,063,537 5,188,358 5,310,522 5,430,124
Key Area 2 - Pre-service training for long-term scale-up: midwifery courses
sub-total
– 2,794,400 4,628,225 5,588,800 5,588,800 5,588,800 5,588,800 5,588,800 5,588,800
Key Area 2 - Salaries for long-term scale-up with 40% benefits package for midwives (based on public sector take-up)
sub-total
–
–
–
– 2,789,134 5,926,196 9,063,259 12,200,321 15,337,384
Key Area 2 - System strengthening for scale-up including programme costs, supervision and leadership for the new health cadre, and scale-up of regulatory
mechanism
sub-total
–
457,354 1,572,138 2,539,975 3,468,807 4,397,639 5,338,758 6,279,876 7,220,995
31,275,541
4,569,467
26,706,075
Total
recurrent
costs
3,904,633 7,165,341 10,187,936 12,799,205 16,782,704 20,976,172 25,179,174 29,379,520 33,577,303
159,951,987
23,797,886
136,154,104
Total cost
per year
3,904,633 7,165,341 10,187,936 12,799,205 16,782,704 20,976,172 25,179,174 29,379,520 33,577,303
159,951,987
23,797,886
136,154,104
INVESTMENT
Investment per pregnancy based on midwives, nurses and health officers for scale-up, skill-up and retention*
2013
Number of
pregnancies per
year (000s)
US$ per
pregnancy per
year
2021
2013-2021
2013-2016
2017-2021
4,918,693 4,904,778 4,890,863 4,866,695 4,842,526 4,818,358 4,794,190 4,770,021 4,740,299
43,546,424
14,714,335
28,832,090
3.67
1.44
4.81
0.79
2014
1.46
2015
2.08
2016
2.63
2017
3.47
2018
4.35
2019
5.25
2020
6.16
7.08
US$ per
pregnancy
TOTAL
(2013-2016):
1.44
US$ per
pregnancy
TOTAL
(2017-2021):
US$ per
pregnancy
TOTAL
(2013-2021):
4.81
3.67
* Total cost per year divided by total pregnancies per year
39
TABLE O.9
EXPECTED DEATHS AVERTED, 2013–2021
2013
2014
Neonatal
6,838
8,174
10,874
12,889
22,469
24,464
26,429
28,745
31,388
38,775
133,495
172,270
Maternal
408
451
582
678
1,550
1,659
1,766
1,901
2,067
2,119
8,943
11,062
Intrapartum stillbirth 10,750
13,543
17,824
21,160
41,142
45,441
49,738
54,652
60,171
63,277
251,144
314,421
Stillbirth
19,245
23,974
27,756
48,384
53,134
57,879
63,243
69,212
86,994
291,852
378,846
16,019
2015
2016
2017
2018
2019
and 2021 to provide the fiscal space for increasing pre-service education, salaries and incentives,
and the immediate skill-up to increase skills in
maternal and newborn care, including basic
emergency care, for the cadres involved.
2020
2021
2013-2016 2017-2021 2013-2021
averted in the nine-year period to 2021 are
188,197 neonatal deaths, 12,467 maternal
deaths, and 401,143 intrapartum deaths.
The main assumptions underlying the analysis
of impact are as follows:
Impact
As seen in Table O.9, after application of the
LiST analysis to the data presented in this report,
including gradual scaling up and skilling up in
line with current targets to 2016 and to universal
coverage of 75% (including 65% facility births) by
2021, it is expected that 172,270 neonatal deaths,
11,062 maternal deaths, and 314,421 intrapartum
deaths could be averted in the period 2013 to
2021. This equates to an estimated NMR of 19
and MMR of 142 by 2021.
However, when based on 95% coverage of facility births starting from 2013, the estimated
numbers of additional deaths that could be
• Targets are met for HPNSDP (2011–2016);
• Antenatal care targets are met and maintained for HPNSDP (2011–2016);
• Numbers of stillbirths are in line with 2012
analysis147 showing that intrapartum deaths
are 46.5% of all recorded stillbirths;
• Quality is assumed to be uniform, and the
effectiveness of the interventions is assumed
to be those of the LiST assumptions and not
adjusted for the quality issues identified in
the country.
147 Ibid., ref. 39
40
ANNEX 1: MAPPING MNH INTERVENTIONS: PMNCH GUIDELINES
AND THE BANGLADESH HEALTH SYSTEM
Mapping of Essential Health Care Interventions for Maternal and Newborn Health according to the Level of
Healthcare Delivery as per the PMNCH Guidelines1 and Current Implementation in the Bangladesh Health System
PRECONCEPTION/
PERI-CONCEPTUAL
INTERVENTIONS
PMNCH ESSENTIAL INTERVENTIONS
GUIDELINES
BANGLADESH HEALTH SYSTEM
Referral Level
1st Level
Community
Referral
Level
1st Level
Community
DGHS
DGFP
DGHS
DGFP
DGHS
DGFP
Family planning
Y
Y
Y
Y - Limited
Y
Y
Y
Y - Limited
Y
Prevent and manage sexually transmitted
illnesses including Mother-to-Child Transmission
of HIV and syphilis
Y
Y
Y
Y - Limited
Y
Folic acid supplementation for preventing neural
tube defects
Y
Y
Y
Y
Y
Y
Y
Y
Y
Management of unintended pregnancy:
availability and provision of safe abortion care
when indicated
Y
N
N
Y
Y
Y
Y
N
Y - Limited
Management of unintended pregnancy: provision
of post-abortion care
Y
Y
N
Y
Y
Y
Y
N
Y - Limited
Appropriate antenatal care package: screening
for maternal illnesses
Y
Y
N
Y
Y
Y
Y
Y
Y
for hypertensive disorders of pregnancy
Y
Y
N
Y
Y
Y
Y
Y - Limited
Y
for anaemia
Y
Y
N
Y
Y
Y
Y
Y
Y
Appropriate antenatal care package: iron and
folic acid to prevent maternal anaemia
Y
Y
N
Y
Y
Y
Y
Y
Y
Appropriate antenatal care package: tetanus
immunization
Y
Y
N
Y
Y
Y
Y
Y
Y
Appropriate antenatal care package: counselling
on family planning, birth and emergency
preparedness
Y
Y
N
Y
Y
Y
Y
Y - Limited
Y
Appropriate antenatal care package: prevention
and management of HIV, including with
antiretrovirals
Y
Y
N
Y - Limited
N
N
N
N
N
Appropriate antenatal care package: prevent and
manage malaria with insecticide treated nets
and antimalarial medicine
Y
Y
N
Y
Y
Y
Y
Y
Y
Appropriate antenatal care package: smoking
cessation
Y
Y
N
N
N
N
N
N
N
Reduce malpresentation at term with external
cephalic version
Y
N
N
Y
Y - Limited
N
N
N
N
Prevention of pre-eclampsia: calcium to prevent
hypertension
Y
Y
N
Y
Y
Y
Y
N
N
Prevention of pre-eclampsia: low-dose aspirin to
prevent hypertension
Y
N
N
Y - Limited
N
N
N
N
N
Magnesium sulphate for eclampsia
Y
Y
N
Y
Y
N
Y
N
N
Induction of labour to manage prelabour rupture
of membranes at term
Y
N
N
Y
Y
N
Y
N
N
Antibiotics for preterm prelabour rupture of
membranes
Y
Y
N
Y
Y
Y
Y
N
N
Corticosteroids to prevent respiratory distress
syndrome in newborns
Y
N
N
Y
Y
N
N
N
N
Y - Limited Y - Limited Y - Limited
Y – Limited,
No PMTCT
PREGNANCY
1
The Partnership for Maternal, Newborn & Child Health. A Global Review of the Key Interventions Related to Reproductive, Maternal, Newborn and Child Health. Geneva: PMNCH, 2011.
A NNEX ES
41
ANNEX 1 (continued)
PMNCH ESSENTIAL INTERVENTIONS
GUIDELINES
CHILDBIRTH
Referral
Level
1st Level
Community
BANGLADESH HEALTH SYSTEM
Referral Level
1st Level
Community
DGHS
DGFP
DGHS
DGFP
DGHS
DGFP
Induction of labour for prolonged pregnancy
Y
N
N
Y
Y
Y
Y
N
N
Prophylactic uterotonics to prevent postpartum
haemorrhage
Y
Y
Y
Y
Y
Y - Limited
Y
Y
Y
Active management of third stage of labour
(AMTSL) to prevent postpartum haemorrhage
Y
Y
N
Y
Y
Y
Y
Y
Y
Management of postpartum haemorrhage (e.g.
uterotonics, uterine massage)
Y
Y
Y
Y
Y
N
Y
Y - Limited
Y
Caesarean section for maternal/fetal indication
Y
N
N
N
N
N
N
Prophylactic antibiotics for caesarean section
Y
N
N
Y
Y - Limited
N
N
N
N
Family planning
Y
Y
Y
Y
Y
Y - Limited
Y
Y - Limited
Y
Prevent and treat maternal anaemia
Y
Y
N
Y
Y
Y
Y
Y
Y
Detect and manage postpartum sepsis
Y
Y
N
Y
Y
Y
Y
N
Y - Limited
Screen and initiate or continue antiretroviral therapy
for HIV
Y
Y
N
N
N
N
N
N
N
Immediate thermal care
Y
Y
Y
Y - Limited
Y
N
Y
Y
Y
Initiation of exclusive breastfeeding (within first
hour)
Y
Y
Y
Y
Y
N
Y
Y
Y
Hygienic cord and skin care
Y
Y
Y
Y
Y
Y
Y
Y
Y
Neonatal resuscitation with bag and mask
(professional health worker)
Y
Y
N
Y
Y
N
Y
N
N
Case management of neonatal sepsis, meningitis
and pneumonia
Y
Y
N
Y - Limited
Y
N
Y
N
Y - Limited
Kangaroo mother care for preterm and for less than
2000g babies
Y
Y
N
Y - Limited
Y
N
Y
Y
Y
Management of newborns with jaundice
Y
Y
N
Y
Y
Surfactant to prevent respiratory distress syndrome
in preterm babies
Y
N
N
Y - Limited
N
N
N
N
N
Continuous positive airway pressure (CPAP) to
manage babies with respiratory distress syndrome
Y
N
N
Y - Limited
Y
N
N
N
N
Extra support for feeding small and preterm babies
Y
Y
N
Y - Limited
Y
N
Y
N
N
Presumptive antibiotic therapy for newborns at risk
of bacterial infections
Y
N
N
Y
Y
Y - Limited
Y
Y - Limited Y - Limited
POSTNATAL (MOTHER)
POSTNATAL (NEWBORN)
42
Y - Limited Y - Limited Y - Limited Y - Limited
Y - Limited Y - Limited
ANNEX 2: ABBREVIATIONS
ABBREVIATIONS
Active Management of the Third Stage of Labour
ICM
International Confederation of Midwives
APR
Annual Programme Review
IMCI
integrated management of childhood illness
BDHS
Bangladesh Demographic and Health Survey
IRT
Independent Review Team
BEmOC
basic emergency obstetric care
MA
medical assistant
BEmONC
basic emergency obstetric and newborn care
MCH
maternal and child health
BNMC
Bangladesh Nursing and Midwifery Council
MDG
Millennium Development Goal
CEmOC
comprehensive emergency obstetric care
MMR
maternal mortality ratio
CEmONC
comprehensive emergency obstetric and newborn care
MNCH
maternal, newborn and child health
CHCP
community health care provider
MNH
maternal and newborn health
CPAP
continuous positive airway pressure
MOF
Ministry of Finance
CSBA
community-based skilled birth attendant
MOHFW
Ministry of Health & Family Welfare
DGFP
Directorate General of Family Planning (of the MOHFW)
MOPA
Ministry of Public Administration
DGHS
AMTSL
Directorate General of Health Services (of the MOHFW)
NGO
non-governmental organization
DHS
Demographic and Health Survey
NIPORT
National Institute of Population Research and Training
DNS
Directorate of Nursing Services
NMR
neonatal mortality rate
EmOC
emergency obstetric care
OP
Operational Plan (of HNPSP and HPNSDP)
ENC
essential newborn care
PIP
Program Implementation Plan (of HPNSDP)
EOC
essential obstetric care
PPH
postpartum haemorrhage
EPI
Expanded Programme on Immunization
PSC
Public Service Commission
FTE
full-time equivalent
RMNH
reproductive, maternal and newborn health
FWA
family welfare assistant
RPA
reimbursable project aid
FWV
family welfare visitor
RTMI
Research, Training and Management International
GDP
gross domestic product
SACMO
sub-assistant community medical officer
GOB
Government of Bangladesh
SBA
skilled birth attendant
H4+
the four original “Health 4” partners (UNFPA, UNICEF, WHO,
The World Bank) later joined by UNAIDS and UN Women
STI
sexually transmitted infection
SWAp
sector-wide approach
HA
health assistant
TWG
Technical Working Group (of the HBCI)
HBCI
High Burden Countries Initiative
UFPO
upazila family planning officer
HIV
human immunodeficiency virus
UHFWC
union health and family welfare centre
HNPSP
Health, Nutrition and Population Sector Program
UNAIDS
Joint United Nations Programme on HIV/AIDS
HPNSDP
Health, Population and Nutrition Sector Development
Program
UNFPA
United Nations Population Fund
HPSP
Health and Population Sector Program
UNICEF
United Nations Children’s Fund
HR
human resources
UN Women
United Nations Entity for Gender Equality and the
Empowerment of Women
HRH
human resources for health
UP
union parishad
HRIS
human resources information system
WHO
World Health Organization
ICDDR,B
International Centre for Diarrhoeal Disease Research,
Bangladesh
A NNEX ES
43
Supported by:
Foreign Affairs, Trade and
Development Canada
Affaires étrangères, Commerce
et Développement Canada

bangladesh - ICS Integrare

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