High time to invest in nurses and community health care workers

Providing affordable and quality health care service is a big challenge for an over populated country like Bangladesh where inequities persists in the health system across different geographical locations and socio-economic groups. By 2031 Bangladesh is aiming to become a middle-income country and the health related targets are in place to end preventable maternal and neonatal deaths. In 2020 there were 163 maternal deaths per 100,000 live births. This needs to be lowered by 70 within 2030 if we want to meet the SDG-3 target.

During the MDG era (between 2000 and 2017) maternal mortality declined by 38 per cent by using modest spending on health, concentrating on primary care services, and advancing the social determinants of health. Research suggests that by increasing the coverage of nurses and midwifery services by 10% in low-income countries, maternal mortality could potentially reduce by 27%.

Unfortunately Bangladesh has only 24% of the nurses it needs following the doctor-nurse ratio (three nurses against one doctor). There are 5.8 nurses for every 10,000 people in urban areas and only 0.8 nurses for the same number of people in rural areas of Bangladesh. Despite the shortage in numbers, lacking of skilled and trained nurses and health care workers is also severe. In our country 53% of the births still take place at home and this significant percentage is being covered mostly by the untrained health care workers at the community level. BDHS 2017-18 data reveals that 35% of births assisted by untrained traditional birth attendants (TBAs).

Shortage of nurses in health care facilities impacts the quality of care provided and pushes poorer and marginalised populations to seek health care from unqualified providers. Hiring of unskilled and non-certified nurses in primary and tertiary health facilities has also been found. However, gender has major influence on the health care seeking behaviour of people in rural areas. But nursing as a profession has not been recognised formally for a long time in the country. The number of nursing colleges is also not proportionate with the population.

After liberation, Bangladesh government had taken various programme for the traditional birth attendants (TBAs), nurses and midwives and also reformed the health care education system at different phases. In the 1980s, the Ministry of Health and Family Welfare (MOH&FW) started to provide short training to TBAs that gradually evolved through initiating B.Sc. course for Nursing in 2006 and inclusion of midwifery education formally in 2016.

Over the last four decades, different initiatives have been taken in Bangladesh to increase the number of skilled healthcare workers. Community maternal and child health care services are provided mainly by family welfare visitors (FWVs), who are trained in the country’s public health administration and training institutions, named family welfare visitors’ training institutes (FWVTIs), under direction of the Family Planning Directorate (FPD). At the 65th General Assembly of the United Nations in 2010, the the prime minister of Bangladesh highlighted creating and deploying dedicated midwives and to have a permanent solution to the shortage of skilled birth attendants. Several private institutes and NGOs are also working to strengthen maternal health care services through providing education to the nurses and midwives.

To fill up the 76% shortage of nurses, joint intervention and investment from government, private and NGOs are required to promote nursing and midwifery education. Such dispersed and diversified health care workers (trained and untrained) should be integrated with the formal health care training courses and education system. To develop capacity of TBAs and midwives, the number of seats in nursing and midwifery colleges and institutes (both government and private) needs to be increased. The quality of existing training institute and colleges and the conventional education system need to be improved. Exchange of knowledge from root level workers such as TBAs, health volunteers and the academicians can also strengthen the practical skills of learners.

To gear up the learning process, deployment in primary health care facility can boost up their experience, capacity and system management with low cost solutions. Bangladesh has tackled COVID-19 pandemic with limited workforce and resources, now it is high time to invest on rebuilding the system and skills of health care workers. Bangladesh Nursing and Midwifery Council (BNMC) should take effective screening mechanism to deploy qualified and certified nurses and midwives. A separate plan, allocation of resources and zoning of health service providers to establish nursing schools can be a great help for the implementers and policy makers.

Different stakeholders, such as the technical training institute, public health experts, other health professionals, researchers, media, and educationists should be involved in the process. “Invest in Nursing and respect rights to secure global health” - the theme of International Nurses’ Day 2022 must be upheld to ensure affordable health care coverage, reduce expenditure and to prepare nurses and midwives with the competence of providing health care services.

* Md. Abdul Karim is former Principal Secretary and Executive Director of UCEP Bangladesh

* Anamika Debnath is an urban planner and public health professional