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The health workforce crisis in Bangladesh: Shortage, inappropriate skill-mix

and inequitable distribution

Article  in  Human Resources for Health · January 2011

DOI: 10.1186/1478-4491-9-3 · Source: PubMed

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RESEARCH Open Access

The health workforce crisis in Bangladesh:

shortage, inappropriate skill-mix and
inequitable distribution
Syed Masud Ahmed1*, Md Awlad Hossain1, Ahmed Mushtaque RajaChowdhury2, Abbas Uddin Bhuiya3

Abstract
Background: Bangladesh is identified as one of the countries with severe health worker shortages. However, there
is a lack of comprehensive data on human resources for health (HRH) in the formal and informal sectors in
Bangladesh. This data is essential for developing an HRH policy and plan to meet the changing health needs of
the population. This paper attempts to fill in this knowledge gap by using data from a nationally representative
sample survey conducted in 2007.
Methods: The study population in this survey comprised all types of currently active health care providers (HCPs)
in the formal and informal sectors. The survey used 60 unions/wards from both rural and urban areas (with a
comparable average population of approximately 25 000) which were proportionally allocated based on a
‘Probability Proportion to Size’ sampling technique for the six divisions and distribution areas. A simple free listing
was done to make an inventory of the practicing HCPs in each of the sampled areas and cross-checking with
community was done for confirmation and to avoid duplication. This exercise yielded the required list of different
HCPs by union/ward.
Results: HCP density was measured per 10 000 population. There were approximately five physicians and two
nurses per 10 000, the ratio of nurse to physician being only 0.4. Substantial variation among different divisions
was found, with gross imbalance in distribution favouring the urban areas. There were around 12 unqualified
village doctors and 11 salespeople at drug retail outlets per 10 000, the latter being uniformly spread across the
country. Also, there were twice as many community health workers (CHWs) from the non-governmental sector
than the government sector and an overwhelming number of traditional birth attendants. The village doctors
(predominantly males) and the CHWs (predominantly females) were mainly concentrated in the rural areas, while
the paraprofessionals were concentrated in the urban areas. Other data revealed the number of faith/traditional
healers, homeopaths (qualified and non-qualified) and basic care providers.
Conclusions: Bangladesh is suffering from a severe HRH crisis–in terms of a shortage of qualified providers, an
inappropriate skills-mix and inequity in distribution–which requires immediate attention from policy makers.

Background outcomes such as immunization coverage, primary

Human resource for health (HRH) is the critical limiting health care outreach, and infant, under-5 and maternal
factor determining the health of the population besides survival. This is because “in health systems, workers
socioeconomic, behavioural and environmental factors function as gatekeepers and navigators for the effective,
[1,2]. Globally, there is a close correlation between the or wasteful application of all other resources such as
concentration of qualified health workers (doctors, drugs, vaccines and supplies” [3]. The shortage of quali-
nurses, dentists and midwives together) and key health fied health workers, especially in low-income countries,
has drawn attention in recent times, as it seriously
* Correspondence: [email protected]
1
threatens the attainment of the millennium development
Research and Evaluation Division, BRAC, 75 Mohakhali, Dhaka-1212,
Bangladesh
goals (MDGs) [4,5].
Full list of author information is available at the end of the article

© 2011 Ahmed et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Ahmed et al. Human Resources for Health 2011, 9:3 Page 2 of 7
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The countries of WHO’s South-East Asia Region also following a PPS (Probability Proportion to Size) sampling
face several common health workforce related problems technique. Table 1 shows this proportional allocation of
and issues concerning shortage, skill-mix, migration, the sample PSUs by division. Thus, the sampling provided
work environment, knowledge-base and other areas amply representative estimates of the density of health care pro-
articulated in the ‘Dhaka Declaration’ [6]. Bangladesh is viders for the country as a whole, for the urban and the
no exception in this regard and it is one of the coun- rural areas separately, and for each of the six administra-
tries with ‘severe shortages’ of health workers [3]. tive divisions (note that the study was done prior to the
Given the shortage of supply of qualified health care 2010 creation of a seventh Bangladeshi division). Since a
providers in Bangladesh, patients, especially the poor PSU may not be large enough to have sufficient HCPs in
and the disadvantaged, mostly seek health care from terms of number as well as diversity, we used the Union
the nonqualified providers in the informal sector [7,8]. and the Ward (lowest administrative units having compar-
On the demand side, due to lack of health awareness, able population size of around 25 000) containing the
the overall health service consumption (from any selected PSU as the sampling unit for the rural and the
source) in Bangladesh is low compared to other devel- urban areas respectively. Data collection was done during
oping countries, as is level of need [9,10]. Evidence July-September 2007.
shows that overall levels of per capita consumption of
essential service package (ESP) would have to increase Inventory of health care providers
by 40% in order to achieve the higher average level of All the villages, markets and health facilities/centres under
other developing countries [11]. each PSU (Union/Ward) were visited by the field enumera-
To develop an effective, efficient and equitable health tors (social science graduates) who were recruited and
system for meeting the goal of improved and equitable trained by the research team. They started by identifying
population health, human resources for health (HRH) the initial batch of key informants through informal discus-
should be appropriate in relation to number, skill-mix, sion (asking questions such as “Who in your locality can
and distribution with optimum competency and motiva- give valid information about the number and types of the
tion. There is a lack of comprehensive, nationally repre- HCPs?”) with community members in the markets and vil-
sentative data on HRH in the formal and informal sectors lages. Further key informants were then identified from this
in Bangladesh. This is essential for developing an HRH information using a ‘snowball’ technique. The key infor-
policy and plan and its implementation to meet the chan- mants were then asked to list all the practicing HCPs they
ging health needs of the population. A population-based, knew in the locality (free listing), and an inventory of practi-
nationally representative survey covering all types of health cing HCPs was made for each of the geographical areas vis-
care providers in the formal and informal sectors was done ited. The key-informants sometimes provided information
in 2007 by Bangladesh Health Watch (BHW) to fill in this about the HCPs’ names in different ways (e.g., nick name,
knowledge gap [12]. BHW is a civil society initiative “to family name, title, etc.). These were cross-checked with
regularly and systematically measure and monitor the other key informants and village people for proper identifi-
country’s progress and performance in health”. This paper cation, and to avoid duplication and omission, especially in
presents data from this survey and discusses its implica- the case of the informal sector providers. Also, they visited
tions for HRH problems in Bangladesh. the residences of the HCPs for on-the-spot confirmation
whenever confusion arose. It was relatively easy to get the
Materials and methods list of working HCPs from the administrative authorities in
Study population and sampling different public and private sector healthcare facilities. The
The study population in this survey comprised of all types enumerators also frequently checked authenticity of infor-
of health care providers (HCPs)–allopathic and non- mation with the HCPs whenever feasible. During this pro-
allopathic, trained and untrained, and in public or private cess, they explained the purpose of the inventory and
sector–who were currently active in providing healthcare sought their cooperation for improving the validity of the
services to the community in the study areas. The survey data. Finally, this exercise yielded a list of different HCPs by
used 60 primary sampling units (PSUs, a cluster of around Union/Ward (PSU).
200 households) drawn randomly from the nationally
representative 1000 PSUs that are used by the Bangladesh Categorization of the informal health care providers
Bureau of Statistics (BBS) for its Sample Vital Registration The informal health care providers (not registered with
System, yielding estimates up to the level of district [13]. any government regulatory body) were categorized into
The number of sample PSUs (n = 60) was conveniently the following groups:
determined given constraints in time and resources. From
the total number of PSUs in each of the division, the 1) Semi-qualified allopathic providers: include provi-
required number of sample PSUs was taken randomly, ders who have received training of varying duration
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Table 1 Number of sample Primary Service Units (PSUs) by division and rural/urban areas according to PPS
(Probability Proportion to Size)
Division Total PSUs enumerated by Bangladesh Number of sample PSUs taken
Bureau of Statistics for Sample
Registration Survey
All Urban All Rural Urban
Barisal 79 11 4.7 ≈ 5 4 1
Chittagong 172 41 10.3 ≈ 10 8 2
Dhaka 307 105 18.4 ≈ 18 12 6
Khulna 125 25 7.5 ≈ 8 6 2
Rajshahi 263 39 15.8 ≈ 16 14 2
Sylhet 55 7 3.3 ≈ 3 2 1
Rural 774 — 46.5 ≈ 46 — —
Urban 225 — 13.5 ≈ 14 — —
Total 1000 60 46 14
Note: Urban area included the statistical metropolitan area (SMA), municipality area and other urban areas (e.g. ‘thana sadar’ area which has the quality of
municipality).

from a formal institution in the public or private 3) Traditional healers: ‘Kabiraj’, whose practice is
sector such as the non-profit NGOs. based on diet, herbs, and exercise. They are mostly
a. Para-professionals: comprised of the medical self-trained, but some may have training from gov-
assistants who completed a three-year medical ernment or private colleges of Ayurvedic medicine.
assistant training programme from a public insti- Some of them combine ayurvedic, unani (traditional
tution, mid-wives (family welfare visitor (FWV)) muslim medicine originating from Greece) and allo-
with 18 months training in midwifery and clini- pathic medicine to provide ‘totka’ treatment. This
cal contraception management from public/ category also includes non-secular faith healers.
private institutions, and lab-technicians/ 4) Traditional birth attendants: includes both trained
physiotherapists and non-trained providers who deliver home-based
b. Community health workers (CHWs) from services only.
both public and non-governmental organisation 5) Homeopaths: mostly self-educated, but some pos-
(NGO) sectors. The CHWs in the NGO sector sess a recognized qualification from government or
outnumber those in the public sector by a ratio private homeopathic colleges.
of 2:1 [12]. CHWs have variable lengths of basic
preventive and curative health care training,
from various health care providing NGOs mainly, The survey
but also from the public sector. The study passed the ethical review board of the James
2) Unqualified allopathic providers: included in this P. Grant School of Public Health, BRAC University for
category are village doctors and drug store sales peo- ethical approval. Informed consent was taken before
ple/drug vendors. interviewing. All enumerators hired for the survey
a. The village doctors (also known as rural medi- underwent a five-day training which consisted of didac-
cal practitioner, RMP) mostly received short tic lectures followed by practice sessions outside the
training (from a few weeks to a few months) on study areas. The day-to-day field activities of the teams
some common illnesses/conditions, from semi- were overseen by a field researcher based in the Upazila
formal private institutions which are unregistered (sub-district) field office. The whole survey activity was
and unregulated and do not follow a standard supervised and managed by the authors who made fre-
curriculum. A negligible proportion of them quent field visits and provided assistance and guidance
received twelve months training from a short- when needed. SPSS PC+ ver.12 was used for data
lived government sponsored programme (the analysis.
‘Palli Chikitsok’ (PC) training programme, which
followed the China’s model of barefoot doctors) Results
in the ‘80s. Table 2 presents the density (per 10 000 population) of
b. Drug store salespeople: most of have had no doctors, nurses and dentists by region (division), geogra-
training in dispensing, not to speak of training in phical location (rural/urban) and sex (male/female).
diagnosis and treatment. There were around five physicians and two nurses per
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Table 2 Distribution of doctors, nurses and dentists per village doctors and the CHWs were mainly concentrated
10 000 people in various Bangladeshi divisions in the rural areas while the paraprofessionals were con-
Doctors Nurses Dentists All Nurse per centrated in the urban areas. Dhaka had the lowest num-
Doctor ratio ber of village doctors and Sylhet the lowest number of
Division CHWs than other divisions. The village doctors and the
Barisal 1.7 0.9 0.3 3.08 0.5 drugstore salespeople were predominantly male com-
Chittagong 4.8 3.6 0.3 8.8 0.7 pared to the CHWs who were predominantly female.
Dhaka 10.8 2.8 0.5 14.2 0.2 Finally, Table 4 presents the density of non-allopathic
Khulna 1.3 1.9 0.05 3.3 1.4 health care providers such as traditional healers and
Rajshahi 2.1 1.1 0.0 3.2 0.5 homeopaths. There were large numbers of faith healers
Sylhet 2.2 0.4 0.0 3.2 0.1 as well as Kabiraj and other traditional healers (31 and
Location 33 per 10 000 population respectively), who were pro-
Rural 1.1 0.8 0.08 2.1 0.7 viding health care services as revealed from this inven-
Urban 18.2 5.8 0.8 24.9 0.3 tory. This was supplemented by 3 qualified and 2.5
Sex unqualified homeopaths per 10 000 population in the
Male 4.5 0.2 0.2 5.0 0.05 country. The traditional practitioners were mostly male,
Female 0.8 1.8 0.03 2.7 2.1 concentrated in the rural areas of Chittagong, Rajshahi
All 5.4 2.1 0.3 7.7 0.4 and Khulna divisions. On the other hand, the homeo-
paths were concentrated in the urban areas, mainly in
the Khulna and Rajshahi divisions. Interestingly, about
10 000 population, the ratio of nurse to physician being one provider (per 10,000 population) was engaged in
0.4 only (i.e. 2.5 times more doctor than nurses). The delivering health related services such as circumcision,
ratio was equal in Khulna (1.4), but very low in Sylhet cleaning ears and extracting painful tooth at a nominal
(0.1) and low in Dhaka (0.2). Substantial variation in the cost, mainly to the poorer section of the population.
density of physicians and nurses among different divi-
sions was found, Dhaka having the highest density of Discussion
physicians followed by Chittagong, while in the case of Bangladesh is declared by WHO as one of the 58 crisis
nurses, this trend was reversed. Gross imbalance in den- countries facing an acute HRH crisis [3]. However, this
sity favouring urban areas was also observed, especially is given little importance in national health activities [
for the physicians. Similarly, there was also gross imbal- and there exists a dearth of information on these aspects
ance in sex ratio, favouring males in the case of physi- at national level [14]. The Health Care Provider Survey
cians (four males to one female), and females in the 2007 [12] attempted to fill in this critical knowledge gap
case of nurses (nine females to one male). Together, and help guide in formulating appropriate policies to
there were 7.7 formally qualified registered health care improve the health system’s ability to reach the people
professionals per 10 000 population. with an acceptable quality of services [15], and rational
The density of the other categories of allopathic health skill-mix in foreseeable future.
care providers (semi-qualified/unqualified) is presented The survey is unique in that it had included all types
in Table 3. There were around 12 village doctors and 11 of healthcare providers in the formal and informal sec-
sales people at drug retail outlets (providing diagnosis tors and thus presents a comprehensive picture of the
and treatment) per 10 000 population. Thus, there were healthcare scenario prevailing in the country. It used a
about 2.5 times more village doctors and 2 times more nationally representative sample frame, and a PPS sam-
drug store salespeople than were physicians who provide pling strategy to take care of the size of the divisions
treatment/curative services to the population. There was and the rural/urban divides. However, due to constraint
not much variation in the density of the drug store in time and resources, the number of sample clusters
salespeople between urban and rural areas (13 and 11 had to be limited to 60, a multiple of the six administra-
per 10 000 population) indicating their uniform spread tive divisions in the country.
across the country. However, their density was lowest in
Barisal and Sylhet divisions compared to others. Also, Shortage
there were twice as many CHWs from the NGO sector Findings revealed that the density (per 10 000 popula-
per 10 000 population (6) than from the government tion) of physicians and nurses has increased over the
sector (3) and an overwhelming number of traditional last decade (from 1.9 physicians and 1.1 nurses in 1998
birth attendants (TBAs) and/or trained traditional birth to 5.4 physicians and 2.1 nurses in 2007) [9] though it
attendants (TTBAs). The TBAs/TTBAs were involved in remains much lower than the estimated average for low
providing delivery-related services at home only. The income countries in 1998 [16]. The density of dentists
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Table 3 Distribution of semi-qualified and unqualified allopathic providers per 10 000 populations, various
Bangladeshi divisions
Semi-qualified allopathic providers* Unqualified allopathic providers
Paraprofes- Community Health Workers
sionals
Govt. Non-Govt.(including All Village doctors** (rural medical Dug store All
traditional birth practitioners/’Palli Chikitsok’ village salespeople, drug
attendants) doctors) vendors
Division
Barisal 0.7 4.5 37.9 42.4 15.5 6.5 22.1
Chittagong 1.6 4.6 50.9 55.5 17.1 8.7 25.8
Dhaka 0.8 2.6 26.6 29.2 9.8 11.9 21.8
Khulna 0.6 3.0 46.3 49.9 11.3 12.3 23.6
Rajshahi 1.3 3.0 48.3 51.4 13.5 13.4 26.9
Sylhet 0.6 3.8 41.4 45.3 12.7 6.3 19.0
Location
Rural 0.8 3.6 49.5 14.1 13.8 10.8 24.6
Urban 1.6 2.0 10.1 12.1 8.8 13.2 22.1
Sex
Male 0.3 1.2 0.2 1.4 12.0 11.0 23.0
Female 0.7 2.0 39.4 41.4 0.4 0.4 0.9
All 1.0 3.2 39.7 42.9 12.5 11.4 23.9
*received varying length of training from formal institutions, GO or NGO.
**the Palli Chikitsok village doctors are included in this group because they are few in number, were trained on or before 1982 without any further re-training,
and no different from the rural medical practitioners in practice.

has also increased, but remains at a very low level (from achieving the MDG targets [3]. During this time, the
0.01 in 1998 to 0.3 in 2007). However, the density of density (per 10 000) of traditional birth attendants
formally qualified health care professionals (HCPs) (doc- declined (from 55 in 1981 to 33 in 2007), presumably
tors, nurses and dentists) (7.7) is lower than other south due to the stoppage of TBA training by the Government
Asian countries (e.g. 21.9 in Sri Lanka, 14.6 in India, of Bangladesh in 1998 [17].
and 12.5 in Pakistan) and falls far short of the estimate On the other hand, the increase in the number of
projected by WHO (23.0) which would be needed for unqualified allopathic providers during the past decade

Table 4 Distribution of traditional healers, homeopaths and others per 10,000 populations, various Bangladeshi
divisions
Traditional healers Homeopaths Others*
Kabiraj, Faith All Qualified Unqualified All
Totka healers
Division
Barisal 12.8 17.7 30.5 1.0 2.3 3.3 1.7
Chittagong 49.3 40.6 89.9 3.0 1.6 4.7 2.2
Dhaka 29.6 20.3 49.8 3.6 1.2 4.7 2.6
Khulna 38.2 28.0 66.2 3.9 4.7 8.6 0.9
Rajshahi 35.7 45.8 81.6 3.6 3.9 7.5 1.1
Sylhet 14.9 38.1 53.1 3.8 2.2 6.1 0.0
Location
Rural 42.1 40.5 82.6 2.5 2.9 5.5 1.05
Urban 4.4 4.2 8.6 6.1 0.9 7.0 4.02
Sex
Male 23.4 22.2 45.6 3.2 2.3 5.5 1.4
Female 9.3 9.3 18.6 0.3 0.1 0.4 0.3
All 32.7 31.5 64.2 3.4 2.5 5.9 1.7
*Circumcision practitioners, ear cleaners, tooth extractors, etc.
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has been phenomenal compared to the qualified or produce the huge numbers of estimated healthcare pro-
semi-qualified allopathic providers. For example, the viders by the public and private sectors combined [12],
number of unqualified allopathic providers (village doc- the disease profile in the country does not always war-
tors and drug store salespeople) (24 per 10 000) has rant provision of services by qualified health profes-
increased to about twice that estimated by the research sionals. According to the Bangladesh Bureau of
agency, ‘Org-Marg Quest’ at the higher range (14.5 per Statistics [23], the most common illnesses (both sexes)
10 000) [18]. Similarly, the density of traditional healers in order of frequency are: fever (55%), pain (10%), diar-
(64 per 10 000) in this study has been found to be more rhoea (6%) and dysentery (4%). The above pattern of
than 2.5 times than the density estimated by Ali at the disease burden, at least in the primary care level, can be
higher range (24 per 10 000) [19]. handled by the paraprofessionals (medical assistants,
family welfare visitors (FWVs)), including CHWs, with
Inappropriate skill-mix the establishment of a functional referral system to a
The current nurse-doctor ratio of 0.4 (i.e. 2.5 times higher level of facilities [24,25].
more doctors than nurses) is far short of the interna- The CHWs have been increasing in size since the nine-
tional standard of around three nurses per doctor. Inter- ties, with the expansion of the government and NGO
estingly, the equal nurse-doctor ratio in Khulna and health network in the country. They have been found to
very low nurse-doctor ratio in Sylhet is also associated be cost-effective [26,27] and useful in the management of
with better health indicators in Khulna and worse health childhood pneumonia [28], acute respiratory infections of
indicators in Sylhet. The importance of the nursing children [29], screening childhood hearing impairment
population for healthier communities (compared to indi- [30], and DOTS treatment of tuberculosis [31] in rural
vidual outcomes in case of doctors) cannot be overem- Bangladesh. Training may also be provided to improve
phasized [20]. There is also a gross imbalance in the the competency of the vast army of unqualified providers
doctor-technologist ratio as well, the ideal being five (especially village doctors) in rational and harmless
technologists for one doctor. An estimate of shortage healthcare provision [32]. Any concern that upgrading
based on the doctor-population ratio currently prevalent their diagnostic and curative skills may lead to abuse and
in low-income countries revealed a shortage of over malpractice may be contained by managerial and regula-
60 000 doctors, 280 000 nurses and 483 000 health tory interventions by the public sector [33].
technologists in Bangladesh [12].

Inequitable distribution Conclusions

It is interesting to note that the overwhelming urban Bangladesh is suffering from a severe HRH crisis in
bias of the distribution of the formally qualified HCPs, terms of a shortage of qualified providers (when mea-
noted a decade ago, has remained a persistent phenom- sured against the WHO estimate for achieving MDG
enon [16]. Also, these providers are inequitably concen- targets), inappropriate skills-mix and inequity in distri-
trated in the Dhaka and Chittagong regions. The CHWs bution. This desperate situation demands immediate
from the non-government sector and the village doctors attention from policy makers. Reducing the ‘income-ero-
are mainly concentrated in the rural areas. Interestingly, sion’ effect of illness through a pro-poor health system
the salespeople at drug retail outlets (shops) are evenly is urgently needed in Bangladesh, a country besieged
distributed between the rural and urban areas, showing with large out-of-pocket payments for healthcare.
their unhindered expansion across the country. Accord-
ing to an estimate, there are about 80 000 unlicensed Acknowledgements
drugstores in the country [21]. This mushrooming of The authors wish to acknowledge gratefully the time and experiences
unregulated drug shops is facilitated by easy availability shared by the respondents in this study. The study was funded by the
Swedish International Development Agency (SIDA). Thanks are also due to
of essential drugs at low price following the National the Bangladesh Health Watch, a civil society initiative ‘to regularly and
Drug Policy of 1982 [22] and also the availability of pre- systematically measure and monitor the country’s progress and performance
scription drugs over-the-counter. in health’, who sponsored the larger Bangladesh Health Care Provider Survey
2007.

Addressing shortage and skill-mix problems: Author details

1
what can be done? Research and Evaluation Division, BRAC, 75 Mohakhali, Dhaka-1212,
Bangladesh. 2James P Grant School of Public Health, BRAC University, 66
The large-scale shortage of qualified healthcare provi- Mohakhali, Dhaka-1212, Bangladesh. 3ICDDRB, Mohakhali, Dhaka-1212,
ders, coupled with an inappropriate skill-mix (more doc- Bangladesh.
tors than nurses and technologists) needs urgent
Authors’ contributions
attention to cater to the healthcare needs of the popula- SMA, AMR, and AB conceptualized and designed the study; MAH helped in
tion. While in the short-term it is nearly impossible to sampling and fielding the study. SMA and MAH analysed and interpreted
 Ahmed et al. Human Resources for Health 2011, 9:3 Page 7 of 7
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the data; AMR and AB also helped in its interpretation. SMA drafted the Economics Unit, Ministry of Health and Family Welfare, Government of
manuscript and MAH, AMR and AB put critical inputs in improving the draft. Bangladesh; 2001.
SMA revised and prepared the final draft. All authors read the final draft and 20. Bigbee JL: The relationships between nurse and physician-to-population
approved it for submission. ratios and state health rankings. Public Health Nurs 2008, 25(3):244-252.
21. Anonymous: Fake drugs flood Bangladesh. Pharmacochronicles 2004
Competing interests [http://www.pharmabiz.com/NewsDetails.aspx?aid=24463&sid=21].
We declare that we have no competing interests in conducting the research 22. Islam N: Bangladesh national drug policy: an example for the third
and writing the manuscript. world? Trop Doct 1999, 29:78-80.
23. BBS (Bangladesh Bureau of Statistics): Statistical Pocket Book 2007. Dhaka:
Received: 11 February 2010 Accepted: 22 January 2011 BBS, Planning Division, Ministry of Planning, GoB; 2008.
Published: 22 January 2011 24. Kruk ME, Prescott MR, de Pinho H, Galea S: Are doctors and nurses
associated with coverage of essential health services in developing
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