Acute physician crisis in 196 upazilas causes severe patient suffering
Over half of the upazila health complexes in the country run without adequate number of physicians which caused severe suffering among the patients.
The data of the Directorate General of the Health Services (DGHS) showed there are 8,452 posts of the physicians are vacant among the 16,784 posts till 1 September, in the 492 upazilas hospitals across the country. The rate of vacant posts is 51 percent.
The crisis has taken a severe turn in 196 upazilas across 51 districts. It is worst in 34 upazilas of the Khulna division and best in the Rajshahi division. Due to shortage of doctors, most diagnostic tests have been suspended in various hospitals, essential medicines are also unavailable.
At Amtali Upazila Health Complex in Barguna, 24 of the 39 sanctioned posts for doctors, including junior consultants, medical officers and anesthetists, are vacant, accounting for 62 percent of the posts. The crisis of nurses and third- and fourth-class staff has also become acute.
At Nikli Upazila Health Complex in Kishoreganj, there are 17 sanctioned posts for doctors, but only six are currently working. None of them is a specialist. Yet the hospital is the main source of healthcare for poor and low-income people in the area. In the absence of specialist doctors, the authorities struggle to provide treatment to patients with complex illnesses.
Nikli Upazila Health and Family Planning Officer Dr Sajib Ghosh said the hospital has no consultants in medicine, surgery or gynecology.
"Not only doctors, there is also an acute shortage of other manpower. We are trying to continue providing services with limited manpower," he said.
Crisis in 51 Districts
The shortage of doctors at the upazila level is not limited to Amtali or Nikli. The Directorate General of Health Services (DGHS) has said that minimum healthcare services are unavailable in nearly 200 upazilas due to a shortage of doctors.
Only a handful of doctors are available in these upazilas. Between 60 and 70 percent of the sanctioned posts remain vacant. Most diagnostic tests have been suspended in the majority of upazilas. Although some medicines are available, the supply is negligible compared with demand.
Experts believe that upazila-level healthcare is failing due to the inability to decentralize healthcare services, the lack of necessary diagnostic facilities at the local level, the absence of experienced specialists in rural areas and a weak referral system. They also say that improved healthcare cannot be ensured simply by constructing infrastructure.
Recently, the health authorities instructed civil surgeons to collect information on the shortage of doctors at the upazila level. An analysis of the information received in response showed that the shortage of doctors has become severe in 196 upazila hospitals across 51 districts in eight divisions. The worst affected are 34 upazilas in nine districts of the Khulna division. The shortage is least severe in the Rajshahi division.
Apart from these, there are severe shortages of doctors in 20 upazilas in six districts of the Barishal division, 24 upazilas in eight districts of the Chattogram division, 29 upazilas in eight districts of the Dhaka division, 20 upazilas in four districts of the Mymensingh division, 12 upazilas in four districts of the Rajshahi division, 31 upazilas in seven districts of the Rangpur division and 26 upazilas in four districts of the Sylhet division.
Upazilas Facing the Crisis
Khulna Division: The 34 affected upazilas in this division include Dakop, Paikgachha, Rupsa, Terokhada and Dumuria in Khulna; Chitalmari, Fakirhat, Mollahat, Mongla, Morrelganj, Rampal and Sharankhola in Bagerhat; Damurhuda and Jibannagar in Chuadanga; Abhaynagar, Bagherpara, Keshabpur and Sharsha in Jashore; Harinakunda, Kotchandpur and Maheshpur in Jhenaidah; Mohammadpur and Shalikha in Magura; Gangni and Mujibnagar in Meherpur; Kalia in Narail; Ashashuni, Kalaroa, Debhata, Shyamnagar and Tala in Satkhira; and Khoksa, Kumarkhali and Mirpur in Kushtia.
Barishal Division: The 20 affected upazilas include Amtali, Bamna, Betagi, Patharghata and Taltali in Barguna; Borhanuddin, Daulatkhan, Lalmohan, Monpura and Tazumuddin in Bhola; Bakerganj, Mehendiganj and Muladi in Barishal; Nalchity, Rajapur and Kathalia in Jhalokathi; Galachipa in Patuakhali; and Kaukhali, Mathbaria and Nazirpur in Pirojpur.
Chattogram Division: The 24 affected upazilas include Nasirnagar and Bijoynagar in Brahmanbaria; Naikhongchhari and Ruma in Bandarban; Kutubdia, Maheshkhali, Eidgaon and Ukhia in Cox’s Bazar; Panchhari and Guimara in Khagrachhari; Raipur and Ramganj in Lakshmipur; Begumganj, Chatkhil, Companiganj, Hatiya, Senbagh and Subarnachar in Noakhali; Baghaichhari, Bilaichhari, Juraichhari, Langadu and Naniarchar in Rangamati; and Nangalkot in Cumilla.
Dhaka Division: The 29 affected upazilas include Alfadanga, Bhanga, Charbhadrasan, Nagarkanda and Saltha in Faridpur; Kaliganj in Gazipur; Tungipara, Kotalipara, Kashiani and Muksudpur in Gopalganj; Ashtagram, Bajitpur, Karimganj, Katiadi, Mithamain, Nikli, Pakundia and Tarail in Kishoreganj; Shibchar and Dasar in Madaripur; Baliakandi, Goalanda, Kalukhali and Pangsha in Rajbari; Bhedarganj, Damudya, Gosairhat and Naria in Shariatpur; and Ghatail, Kalihati, Madhupur and Sakhipur in Tangail.
Mymensingh Division: The 20 affected upazilas include all six upazilas of Jamalpur—Bakshiganj, Dewanganj, Islampur, Madarganj, Melandaha and Sarishabari. The list also includes Bhaluka, Phulpur, Gafargaon, Haluaghat, Ishwarganj and Nandail in Mymensingh; Atpara, Barhatta, Kendua, Madan and Purbadhala in Netrokona; and Nakla, Nalitabari and Sreebardi in Sherpur.
Rajshahi Division: The 12 affected upazilas include Adamdighi, Dhunat, Dupchanchia, Gabtali, Sariakandi and Sonatala in Bogura; Bholahat in Chapainawabganj; Akkelpur and Kalai in Joypurhat; Manda and Mahadebpur in Naogaon; and Shahjadpur in Sirajganj.
Rangpur Division: The 31 affected upazilas include Phulbari, Birganj, Biral, Bochaganj, Chirirbandar, Ghoraghat, Khansama and Parbatipur in Dinajpur; Gobindaganj, Palashbari, Sadullapur and Sundarganj in Gaibandha; Chilmari, Nageshwari, Rajarhat, Char Rajibpur, Roumari and Ulipur in Kurigram; Aditmari and Hatibandha in Lalmonirhat; Domar, Jaldhaka and Kishoreganj in Nilphamari; Atwari, Boda, Debiganj and Tetulia in Panchagarh; Pirganj and Taraganj in Rangpur; and Haripur and Ranishankail in Thakurgaon.
Sylhet Division: The 26 affected upazila hospitals include Ajmiriganj, Bahubal, Baniachong, Chunarughat and Madhabpur in Habiganj; Barlekha, Juri, Kamalganj, Kulaura, Rajnagar and Sreemangal in Moulvibazar; Beanibazar, Bishwanath, Golapganj, Gowainghat, Jaintapur, Kanaighat, Zakiganj and Osmaninagar in Sylhet; and Bishwambharpur, Derai, Dharampasha, Dowarabazar, Madhyanagar, Jamalganj and Tahirpur in Sunamganj.
According to DGHS sources, there are 16,784 sanctioned posts for doctors, including medical officers, residential medical officers, surgeons, assistant surgeons, anesthetists and pathologists, in the country’s 492 upazila hospitals. As of September 1, 8,452 of these posts were vacant. This represents approximately 51 percent of the total posts.
Patients Heading to Cities
The shortage of doctors across the country is increasing pressure on hospitals in Dhaka. Patients returning from upazila hospitals without being able to see specialist doctors are headed to district headquarters or divisional hospitals. However, these facilities are also unable to provide quality treatment due to various limitations, including shortages of manpower and funding compared with the number of patients. As a result, patients are flocking to the capital in search of advanced treatment, increasing their healthcare expenses.
Abdul Gaffar Mia, a resident of Amirganj in Raipura upazila of Narsingdi, is a 55-year-old farmer. He has developed fluid accumulation in his abdomen and his weight is increasing rapidly. Although he has spent six days at Dhaka Medical College (DMCH) Hospital, he has not been given a bed. He has been forced to receive treatment on a mattress laid out on the hospital floor.
Abdul Gaffar is not alone. The Dhaka Medical College Hospital is overcrowded with patients arriving from different parts of the country, leaving hardly any space to walk.
The country’s largest government healthcare institution officially has 2,600 beds. However, the authorities are struggling to provide services to more than twice the number of patients it is designed to accommodate.
While Abdul Gaffar was suffering on the floor of Dhaka Medical College after failing to get a bed, beds were lying vacant at the health complex in his own upazila, Raipura. The 50-bed hospital has an average of 40 to 41 admitted patients per day.
Abdul Gaffar’s son, Riaz Hossain, spoke at Dhaka Medical College on August 30. He said, “There are not enough doctors at the upazila hospital, so patients do not receive proper treatment there. When they go to the district hospital, the doctors do not examine them and send them to Dhaka. Later, when we had tests done at a private facility, cancer was detected, so we brought him here. But even after admission, we still have not received a bed.”
The situation at Mithapukur Upazila Health Complex in Rangpur is also grim. This 50-bed upazila hospital is relied upon by nearly six lakh people. On paper, however, its manpower is allocated according to a 31-bed hospital.
Why are people heading to cities from here? Patients and doctors were interviewed about this. They said that upazila hospitals do not have adequate facilities for critically ill patients. In addition, patients are heading to cities because there are no specialist doctors in various departments and diagnostic facilities are unavailable.
Abdur Rahim, a resident of Khoragachh Union in Mithapukur, was referred from Mithapukur Upazila Health Complex to Rangpur Medical College Hospital. He told Asia Post, “I was admitted to the upazila hospital by ambulance with chest pain. Without conducting any tests, the doctor suspected heart disease and sent me to Rangpur Medical College. Then what is the benefit of having an upazila hospital?”
Dr Md Mir Hossain, Mithapukur Upazila Health and Family Planning Officer, told Asia Post, “There is no condition here to provide treatment to critical patients. Therefore, when serious and critical patients arrive, they are sent to the divisional hospital.”
Rangpur Medical College (RMC) Hospital is struggling to cope with patients from eight upazilas of Rangpur as well as neighboring Kurigram, Lalmonirhat, Nilphamari and Gaibandha districts.
Although officially a 1,000-bed facility, the principal healthcare center in northern Bangladesh has between 2,500 and 3,000 admitted patients every day—nearly three times its capacity. Yet its manpower remains based on the staffing allocation for a 600-bed hospital from a decade ago.
Under pressure from patients exceeding its capacity, the healthcare facility is unable to meet demand in any area, from medicines to diagnostic services.
Brigadier General Ashikur Rahman, director of Rangpur Medical College Hospital, said, “Due to budget and financial constraints, we cannot provide all medicines. Because of the shortage of manpower, it is not possible to keep all tests running 24 hours even when the necessary reagents [testing materials] are available. There are some limitations.”
He said, “In other districts, there are 250- or 500-bed district hospitals, but Rangpur does not have one. Rangpur Medical College Hospital is a tertiary or referral hospital where only complex patients are supposed to come. But because there is no district hospital, other patients are also coming here.”
80 Percent of Upazila Patients Involved in Legal Cases
Despite the shortage of doctors, upazila hospitals remain crowded with patients. Although beds are sometimes vacant, there are often more admitted patients than the number of beds. Field visits found a different reason behind some of the patients’ presence.
Visits to Raipura Upazila Hospital in Narsingdi and Mithapukur Upazila Hospital in Rangpur found that around 80 percent of admitted patients were staying at the hospitals to obtain medical certificates for cases related to land disputes or family fights. Even after recovering, many patients do not want to be discharged because they want to use the medical certificate against the police or an opposing party.
Raipura in Narsingdi is a 50-bed upazila hospital. Despite being the healthcare center for more than six lakh people, who would be expected to put considerable pressure on the hospital, beds are instead often vacant.
One of the patients, Nabi Hossain from the Bahadurpur area of North Bakhrnagar in the upazila, said he had been injured after being attacked by an opposing party over a land dispute. A complaint has been filed with the police.
Afroza Sultana, the hospital’s nurse in charge, told Asia Post, “Eighty percent of the patients admitted to this hospital are related to some kind of case or police case.”
A similar picture was found after speaking with patients and doctors at Mithapukur Upazila Health Complex in Rangpur. Around 80 percent of the admitted patients there are related to cases involving fights.
Ripon Mia, a patient from Latibpur in the upazila, said, “There is a land dispute with my brother. I was admitted after fighting with my brother, sister-in-law and nephews. I filed a complaint with the police. A medical certificate is required to file a case. That is why I was admitted.”
Soma Pramanik, a medical officer at Mithapukur Upazila Health Complex, told Asia Post, “Most of the patients are related to disputes, fights and legal cases. Even after being discharged, many do not want to go home.”
Increasing the Number of Beds Is Not the Solution
Although manpower, including doctors, and sector-wise allocations have not been increased, the government has decided to upgrade 30- and 50-bed upazila hospitals to 101-bed facilities to provide improved healthcare at the grassroots level. Health and Family Welfare Minister Sardar Md Sakhawat Hossain disclosed this at the Secretariat on June 3.
Prime Minister Tarique Rahman subsequently assured people at several public gatherings that his government’s plan would be implemented quickly. However, health experts consider infrastructure development alone, without increasing manpower and budgets, to be “meaningless.”
Health management expert Professor Dr Abdus Sabur Khan told Asia Post, “Even if buildings are constructed by expanding infrastructure at the upazila level, they will remain empty like the Taj Mahal if there are no doctors. First, a policy decision must be taken to ensure the appointment of doctors and specialists.”
Former president of the Bangladesh Medical Association (BMA) Professor Dr Rashid-e Mahbub believes that the fundamental problems in the health sector cannot be solved simply by increasing hospital beds, constructing buildings or purchasing medical equipment.
He said, “Increasing the number of beds will require additional electricity and water supplies. There will have to be space for doctors to sit. Adequate manpower will be required. Where doctors cannot even be found for the existing posts, where will the additional manpower come from after increasing the number of beds?”
The former BMA president recommended taking pilot initiatives rather than increasing the number of beds indiscriminately across the country.
He said, “If you want to implement the plan, you first have to make it fully operational in at least two to four upazila hospitals and demonstrate its effectiveness. Increasing empty beds and buildings alone, without increasing the overall capacity to provide services, is completely meaningless.”
Government Sees New Recruitment as the Solution
Professor Dr Jalal Uddin Mohammad Rumi, director (administration) of the Directorate General of Health Services, told Asia Post, “The shortage of doctors and other manpower in government hospitals, particularly at the upazila level, is a longstanding problem. Even when a hospital has 100 beds, its manpower is based on a 50-bed facility; similarly, a 250-bed hospital is operating with manpower allocated for 100 beds. On average, half of the posts at the upazila level are vacant. Among them, we have identified 80 upazila hospitals where there is a severe shortage of manpower.”
While the shortage of doctors is enormous, the government has appointed only 184 new doctors through the 48th BCS. They were posted last Monday (September 7).
Health Minister Sardar Md Sakhawat Hossain told Parliament on Monday that 30,311 people are currently working against 41,806 sanctioned posts in government hospitals across the country. The number of vacant posts for doctors is 11,495.
The minister said, “According to World Health Organization standards, the country needs 88,909 doctors. Through the government’s ongoing recruitment process, vacant posts at government healthcare institutions will be filled gradually, and new posts will be created as necessary to ensure healthcare services for the people.”
Reporters in Rangpur and Narsingdi contributed information to this report.