Introduction

Human Resources for Health (HRH) is an essential pillar to achieve Universal Health Coverage (UHC) [1] and a crucial “building block” in national health systems [2]. As quality care and patient satisfaction largely depend on skilled HRH, lack of experienced health professionals adversely affects the quality and quantity of the healthcare services, and undermines progress towards UHC [3]. The need to strengthen the health workforce is an almost universal agenda [4]. Low, middle and even high income countries report difficulties in recruiting and retaining experienced and qualified doctors [5–8]. According to WHO, in 2006 there was a global shortage of 4.3 million healthcare workers [9] which is particularly acute in rural remote and hard-to-reach areas [8, 10, 11]. Also ubiquitous is the high concentration of doctors in urban areas and related efforts to reallocate healthcare workers to enable a more equitable and appropriate skill mix across rural and urban areas [8, 12, 13].

In Bangladesh, a closer examination of the urban health system reveals another layer of inequities in HRH distribution that privileges specialist care and the private sector. The skilled HRH shortage is particularly acute at the primary care level where no publicly organized system is in place [12, 14–16]. Not only the HRH shortage, due to several other factors including education of the parents, financial condition, housing, water and sanitation system, inequities abound specially when it comes to slum areas [17, 18]. According to the recent estimates, the national average of 4+ Antenatal Care (ANC) coverage is 37% (48.8% urban and 33.1% rural) [19]. But disaggregation within urban areas reveals a two-fold difference in 4+ ANC between urban slum (66.4%) and urban non-slum (32.9%) [20]. Again, in urban slums, the prevalence of stunting is 1.53 times higher than non-slum areas [17]. Such urban/rural or slum/non-slum disparities are longstanding and Government of Bangladesh recognized it decades ago. To bridge this gap, Bangladesh’s Ministry of Local Government, Rural Development and Cooperatives (MOLGRD&C), under whose mandate urban primary healthcare falls, has contracted-out Non-Governmental Organizations (NGOs) to meet the primary care need of the urban poor under the Urban Primary Health Care Project (UPHCP) [21, 22]. Initiated in 1998, the original aim of the Contracting-Out (CO) process was to serve the urban poor as well as to gradually build capacity of the local government bodies (e.g. municipalities, city corporations) to supply and manage services themselves [22]. A variety of actors participated in the CO process including donors, the Government of Bangladesh, NGOs and other collaborating partners which changed over the three phases of the project: Phase 1 (1998–2005), Phase 2 (2005–2012) and Phase 3 (2012–2018). Presently, the project’s fourth phase (2018–2023) is ongoing [23]. A separate body named the Project Management Unit (PMU) was formed to oversee the CO process and its monitoring and management. Under the PMU, the implementing agencies of the project were the respective City Corporations (CCs) and municipalities working through a Project Implementation Unit (PIU). Partner NGOs were responsible for managing clinical service provision [24, 25].

Though this CO model brought much needed primary care services to otherwise underserved urban dwellers, various implementation challenges were experienced, one of which was the rapid turnover of doctors [26, 27]. Project documents revealed several issues around human resources including poor staff retention, partly due to reductions in incentive mechanisms and capacity building opportunities [25, 28, 29]. In this paper, we analyzed the key challenges to doctor recruitment and retention in the first three phases of the project, with a view to identifying how these might be overcome. To create a more responsive and efficient health workforce, it is imperative to understand labor market dynamics as well as project-related factors which influence doctor retention. Insights from this analysis will be useful in guiding future CO efforts in similar low- and middle-income urban settings with weak public systems.

Methods

Study setting and period

In rural Bangladesh, the Ministry of Health and Family Welfare (MOH&FW) provides free access to basic primary health care services, reproductive and family planning services through a well-structured system of community clinics, and sub-district and district level hospitals, albeit subject to widespread human resource shortages at every level [12, 30]. By contrast, the urban health system is governed jointly by two ministries: the MOH&FW and the MOLGRD&C [18]. The MOH&FW is responsible for healthcare provision in urban secondary and tertiary hospitals, many of which are overstretched due to patient load [25]. Urban Primary Health Care provision falls under the purview of local municipal government under the MOLGRD&C [31], but remains largely undeveloped due to inadequate human and financial resources [25, 31]. This bifurcated system of health governance in urban areas has served to complicate healthcare provision pathways and resulted in the growth of the private sector in health [18, 32]. Concerns about quality of care and equitable access of private sector services, and weak regulatory systems are the focus of the latest national strategic plan of Bangladesh [33–35]. One way of engaging with the private sector in expanding health services coverage in urban areas is through contracting-out arrangements. The UPHCP is one such example and the subject of this paper.

This paper focuses on HRH issues and is based on data from a larger study. The larger study aimed to explore the evolution of the CO process over the UPHCP’s first three phases in Bangladesh and was published elsewhere [36]. Forty-two key informant interviews (KIIs) were conducted with donors, officials from the MOH&FW, UPHCP personnel and NGO representatives. Data collection was conducted from November 2015 to April, 2017 (Table 1).

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Table 1. Distribution of study respondents.

https://doi.org/10.1371/journal.pone.0262358.t001

Results

A number of barriers and challenges were faced by doctors in managerial and provider roles which relate to poor retention and compromised service quality.

Discussion

Drop-out and turnover of health professionals represent a significant economic burden to CO projects and systems that support them [39], resulting in loss of resources invested in training and education, and decreased quality of care and healthcare coverage [3, 40]. In Bangladesh, poor doctor retention contributes to the country’s HRH crisis and poses a key obstacle to achieving the goal of UHC [12]. In rural and remote areas, vacancy and absenteeism in the medical sector is wide spread [12, 16, 41], with almost 20% of total posts remaining vacant each year [35]. Of note, in this study, government CO primary care services in urban areas are also experiencing severe HRH shortages that compromise quality of care especially among poor and underserved populations.

Motivational factors behind doctor retention are undoubtedly context-specific but a recent systematic review identified three core considerations, among which financial issues are central [42]. Correspondingly, our study found that wage inequalities (vis a vis the public sector), and insufficient financial incentives, were key factors de-motivating CO doctors to remain in their posts. Over the three phases of the project, government sector salaries rose in fairly frequent intervals (twice in 2009 and 2015) [43, 44] to levels nearly double that of equally trained doctors working for CO NGOs, contributing to a “brain drain” of doctors hired by project NGOs. Similar effects of low salaries on doctor recruitment and retention in health sector reform arrangements have been noted in other studies conducted in Bangladesh [45], and other parts of the world [46, 47]. Although measures to rectify the problem were approved by ADB, a revised salary scale was not implemented until the third phase of the project due to bureaucratic complications. Interestingly, while the literature suggests that CO mechanisms can minimize bureaucratic inefficiencies associated with public sector provision, i.e. it usually involves six ministries to create a new HRH post, and a recruitment wait-time of two to three years to fill a vacant post in the public sector, our findings suggested otherwise [12, 48, 49]. Delays in fund disbursement and salary support occurred regularly especially in the initial phases of the project, and were further exacerbated during transition periods between CO contracts. Similar delays in disbursements of funds have been reported in previous donor-funded projects involving non-state providers [35, 50].

Numerous countries have adopted financial and performance-based incentives and other salary supplement policies to prevent the attrition of physicians [10, 51] by augmenting low base pay and improving quality of life when base pay is insufficient. Incentives have also been successfully employed to improve provider performance, service quality and health outcomes [52]. Even though the third phase of UPHCP had provision to offer performance-based incentives for qualified NGOs and their project staff, these were not actioned. Our study showed that financial incentives were initially accommodated, but insufficient and reduced phase-by-phase [25, 28, 29]. The low-cost bidding procedure introduced in Phase 3 to select partner NGOs resulted in a further erosion of incentives as cost reduction was prioritized over efforts to motivate the retention of skilled human resources, and NGOs focused on more on winning contracts versus improving service quality. This finding emphasizes the importance of bolstering managerial authority so that capacity to implement evidence-based strategies is strengthened, and donors or monitoring agencies have the authority to intervene if implementation processes are not followed.

Another key issue affecting doctor retention was failure to adopt measures that would increase doctor motivation such as opportunities for promotion and career development. In fact, over each phase of the project these opportunities were reduced, leading to even greater doctor attrition. This is partly due to the value placed on specialization in the Bangladesh context, and the post-graduate degree (MD/MS/FCPS/Diploma) [53]. The post-graduation examination in Bangladesh requires completion of at least two to three years of in-house training as a precondition to sit for the examination. Jobs in the public secondary and tertiary level facilities are counted as in-house training. This was not the case for the CO project given that service in primary care settings usually involves referring critical cases, versus offering senior supervision around their in-facility management. The desire for career growth driven by the focus on specialization as a measure of competence and professionalism, and fear of “career death” within the CO system, was a major factor provoking the sustained loss of project doctors to public sector. To counter this attrition, the implementation of CO projects requires much greater attention to creating career paths that emphasize professional growth and development.

The emphasis on specialization also relates to larger systemic biases against primary care in terms of remuneration and perceived value [54, 55]. Primary health care providers or “Generalists” play an important role in health prevention, maternal and child care, the treatment of uncomplicated cases and referral to specialized services, yet do not command the same wages or value as specialist providers. In Bangladesh, specialized doctors have access to improved and up-to-date medical technologies and both public and private healthcare markets, and account for a large proportion of out-of-pocket expenses which currently exceed 67% of total national healthcare expenditure [56]. A bifurcation of care has resulted, whereby poorer and marginalized populations are disproportionate users of lower cost public primary care services provided by healthcare practitioners who are relatively underpaid. By contrast, affluent patients prefer and pay for more costly services from specialists working in the urban private sector. These tendencies in the healthcare system have worked to limit the attraction of doctors to stay in PHC sector, and encourage the drift towards high prestige and remunerative specialized training as echoed in previous studies [54, 55]. In this context, the importance of creating a socially committed primary healthcare workforce is even more important, as is the use of incentives, and professional development opportunities that reward a holistic, close-to-community approach. This involves reforms in medical curricula that strengthen primary care training, drawing on experiences from industrialized and developed countries [54]. One such movement started in Brazil, where in order to slow a hemorrhage of physicians to specialized healthcare, a unified Health System was created with a strong commitment to reforms in professional medical education that emphasize primary healthcare as a gateway to specialized care [55]. Similar reforms could be considered in Bangladesh, whereby strong referral mechanisms are created and regulated to stem the overuse of specialists and promote primary healthcare as a frontline service that initiates referral.

Contributing to the lack of sensitivity to career development was the project’s situation in the MOLGRD&C, a Ministry without expertise in implementing health-related projects, and its leadership by a career bureaucrat with no health-related background. While it could be argued that doctors lack capacity and training to become good managers due to deficiencies in medical curriculum identified in the country’s latest Health Workforce Strategy 2015 [57], a clear gap is apparent that needs to be addressed. In filling higher administrative positions in health-related projects, sensitization to health sector issues is critical, as is a good grasp of management for increased efficiency and transparency.

Along with stressors related to job security and career development, fear of abuse and disrespect are common issues affecting healthcare workers even in urban areas [45, 58]. In rural Bangladesh two-thirds of healthcare providers reported having experienced disrespect from community members when they were unable to fulfill expectations regarding the provision of medicine or healthcare support [45, 59]. In this study, similar experiences were shared. Serving a largely poor and marginalized urban population with low literacy, failures in communication with community—i.e. that critical care services are not provided–likely accounted for this problem. Greater efforts to increase community awareness about service offerings, and more security during night shifts would mitigate this cause of attrition.

A final issue undermining doctor retention relates to contract design, and in particular, the adoption of the “low cost bidding” approach in the third phase of the project. By valuing financial criteria over quality considerations, the importance of investing in HRH skills, capacity and motivation was underestimated and overlooked.

Our findings point toward several areas of improvement in the design of future contracting out arrangements that address the problem of doctor retention. Given the project’s concern for population health improvement in underserved urban settings, contract design should privilege the ‘Contractee’ so that health workforce investments are prioritized even if higher project costs may result [48]. Another area needing focus are investments in collaboration and communication between donor agencies, government and NGOs around evidence-based strategies to promote doctor retention and affordable, quality healthcare [60]. In Uganda, donors led evidence generation and dissemination activities to “push” the abolition of healthcare fees in public facilities [61]. Even in Bangladesh, during the HPNSDP (Health, Population and Nutrition Sector Development, 2011–2016) preparation phase, the Planning Wing of MOH&FW utilized the technical assistance offered by donors to strategize and prioritize health sector investments [62]. As such, funding agencies like ADB have a crucial role to play by emphasizing evidence-informed changes to project design. Specifically, findings from donor-commissioned research or, midterm evaluations can inform dialogue between the PMU, NGOs and donors, help address gaps in project implementation.

The study has some limitations. As the study design was retrospective and KIs were asked to recall their experiences and recollect important events and milestones that happened twenty years ago, there is a possibility of recall bias. To minimize the impact of these biases, we drew inferences from different categories of participants and also triangulated with project documents. Several potential KIs, who were directly involved with the project, declined the interview request. In addition, the representative personnel from the lead donor, ADB were also inaccessible. The researchers communicated with past and present project consultants from that institution, and had to rely on them to capture ADB’s views.

Conclusions

Doctors’ retention in CO arrangements for urban primary care is a challenge that requires financial and strategic investment. To this end, job security, incentives and opportunities for training and professional development, would reduce costs related to high doctor turnover and support a more efficiently functioning healthcare system, better quality of care, and ultimately, improved health outcomes. Complementing these reforms are strategies that support formal collaboration between relevant ministries, NGOs, medical universities and international donors working in the health sector, in terms of workforce planning and training for the provision of urban primary healthcare.

In the context of CO arrangements in low-resource settings, project design and the structure of bidding processes and contracts must balance a concern for minimizing administrative costs with the value of an efficient and motivated workforce. But there is no one pathway through which this can be achieved. Each setting may require context-specific solutions that work within its particular culture and health system. Bangladesh’s long history of CO points to the central, cross-cutting importance of the role of health human resources in enabling the efficient and sustainable delivery of front-line services. Recognizing the value of primary care providers, and investing in their professional development, remuneration and security are critical first steps in making CO a more viable delivery strategy in urban settings.

Supporting information

Acknowledgments

icddr,b acknowledges with gratitude the commitment of The Alliance for Health Policy and Systems Research, to its research efforts. icddr,b is also grateful to the Governments of Bangladesh, Canada, Sweden and the UK for providing core/unrestricted support. The authors express their gratitude to the study participants. We are thankful to the dedicated research assistants for undertaking the most crucial task of data transcription.