A hospital may own an X-ray machine, but that does not mean patients can get an X-ray. An ultrasound machine may be fully functional yet effectively useless if there is no trained technologist to operate it. This distinction between possessing health system inputs and actually delivering healthcare is becoming increasingly important for Bangladesh.
Successive Bangladesh Health Facility Surveys (BHFS), however, show real progress in infrastructure and equipment. Between 2017 and 2022, the proportion of public facilities connected to the national electricity grid rose from 57 percent to 85 percent. At upazila health complexes, average capacity to conduct five basic diagnostic tests increased from 3.4 in 2014 to 4.3 in 2022, while the share with functioning X-ray machines rose from 22 percent to 47 percent. These gains matter, but the question arises: are we just counting health sector inputs, or should we rather ensure that the inputs, combined with how they are managed, produce healthcare?
Public sector management is often organised around inputs. We count machines purchased, posts sanctioned, medicines procured, and budgets spent. But these indicators do not tell us whether a patient actually received a service. For instance, in 2022, 59 percent of upazila health complexes possessed an X-ray machine, but only 47 percent had one that was functioning; similarly, 58 percent possessed an ultrasound machine, but 49 percent had a functioning one. Across public facilities other than community clinics, average capacity was only 1.8 of five basic diagnostic tests.
A recent government-funded study by the Power and Participation Research Centre for the Health Economics Unit makes the problem especially visible. Among the 22 public facilities assessed, reagent shortages accounted for 43 percent of diagnostic service disruptions, non-functional equipment for 34 percent, and shortages of trained medical technologists for 19 percent. Imaging services were reportedly available and functioning only 17-33 percent of the time, while nearly 40 percent of sanctioned medical technologist positions were vacant. Although the sample of the study is too small to treat these figures as national estimates, the findings indicate a similar challenge: machines, medicines, consumables, and human resources are managed as separate inputs when they are, in practice, components of the same service delivery system.
To address this long-standing crisis, we need to establish a national medical equipment management system that would be built around functionality, not ownership. Bangladesh needs to establish a comprehensive registry of major equipment in public facilities. Each asset should have a unique identity and a minimum data set: facility and department, make and model, serial number, purchase and installation dates, warranty and maintenance contract, last servicing and calibration, required reagents or consumables, availability of trained operators, and current operational status.
Given the complex budgeting process of the health ministry, it should also record the funding sources. The most important field should be functionality. Equipment could be classified as: i) functional and in use; ii) functional but underused; and iii) temporarily non-functional, awaiting repair or spare parts; and iv) beyond economic repair. For critical equipment, the system should also record uptime and the number of days between reporting a fault and completing repair. This is consistent with the World Health Organization’s lifecycle approach to equipment management, which links inventory information to maintenance, performance and replacement decisions. International experience points in this direction. Tanzania’s medical device management reforms linked a national equipment inventory with planning, budgeting, and disposal, while also expanding biomedical engineering training and government positions.
The human resource (HR) problem is critical because it is not only about a shortage of staff, but also about weaknesses in how careers, posts, and skills are managed across the health service. Limited and irregular promotion, vacancies in senior positions despite the availability of qualified personnel, and delays in creating posts as new hospitals, services, and medical education institutions expand have created bottlenecks in career progression. These problems can weaken motivation and retention while also affecting the quality of clinical care, administration, and medical education.
A more coherent HR strategy should therefore complement any HR information system. Bangladesh needs timely and regular promotion processes, adequate posts across all grades, including senior grades. One option is to establish distinct administrative, clinical and academic streams, potentially including public health, with defined competencies and progression routes for each. Better workforce data would allow the government to identify vacancies, skills gaps, and promotion bottlenecks in real time; but data must be matched by institutional reform so that recruitment, deployment, promotion, and career development are managed as a single workforce system.
The database should go beyond sanctioned and filled posts. It should show who is actually working at each facility, their cadre, competencies, specialist skills, training history, vacancy duration, attendance or deployment status, and whether the skills mix matches the services and equipment assigned to that facility. Bangladesh also needs to review and update the Bangladesh Health Workforce Strategy 2015 to connect recruitment, training, deployment, retention, and career progression of the health workforce.
Persistent vacancies in hard-to-reach locations cannot be addressed by transfer orders alone. Thailand’s experience with recruiting students from rural backgrounds, training them partly in regional settings and returning them to their home areas illustrates why workforce policy must be designed around retention, not merely posting. A credible HR strategy should therefore identify shortage cadres, forecast future needs, create rural recruitment and retention packages, expand relevant training pipelines, establish transparent posting and transfer rules, and link career incentives to service in underserved areas.
The third agenda concerns medicines, reagents and consumables. Bangladesh already has experience with electronic logistics management from the Covid-19 response. That infrastructure should be expanded to essential medicines, laboratory reagents and critical consumables, with facility-level reporting of stock on hand, consumption, minimum stock thresholds, stock-out days, expiry risks and replenishment status. Nepal’s experience with electronic logistics systems is instructive because the objective was not simply to record procurement, but to monitor whether facilities actually had minimum stocks and whether stock-outs were occurring.
These three information systems—equipment, human resources, and supplies—should ultimately converge into one management view. The health ministry should be able to see, on a single dashboard, three things: which equipment is functional and being used; which medicines, reagents, and consumables are available; and which trained personnel are actually in position to deliver the service in each public facility.
Bangladesh has already invested substantially in facilities and equipment. The shift required is from inventories of inputs to accountability for providing quality health care.
Dr Rumana Huque is professor in the Department of Economics at Dhaka University and executive director at ARK Foundation.
Views expressed in this article are the author's own.
Follow The Daily Star Opinion on Facebook for the latest opinions, commentaries, and analyses by experts and professionals. To contribute your article or letter to The Daily Star Opinion, see our guidelines for submission.
