Bangladesh is declared by WHO as one of the 58 crisis countries facing an acute HRH crisis . However, this is given little importance in national health activities [and there exists a dearth of information on these aspects at national level . The Health Care Provider Survey 2007  attempted to fill in this critical knowledge gap and help guide in formulating appropriate policies to improve the health system's ability to reach the people with an acceptable quality of services , and rational skill-mix in foreseeable future.
The survey is unique in that it had included all types of healthcare providers in the formal and informal sectors and thus presents a comprehensive picture of the healthcare scenario prevailing in the country. It used a nationally representative sample frame, and a PPS sampling strategy to take care of the size of the divisions and the rural/urban divides. However, due to constraint in time and resources, the number of sample clusters had to be limited to 60, a multiple of the six administrative divisions in the country.
Findings revealed that the density (per 10 000 population) of physicians and nurses has increased over the last decade (from 1.9 physicians and 1.1 nurses in 1998 to 5.4 physicians and 2.1 nurses in 2007)  though it remains much lower than the estimated average for low income countries in 1998 . The density of dentists has also increased, but remains at a very low level (from 0.01 in 1998 to 0.3 in 2007). However, the density of formally qualified health care professionals (HCPs) (doctors, nurses and dentists) (7.7) is lower than other south Asian countries (e.g. 21.9 in Sri Lanka, 14.6 in India, and 12.5 in Pakistan) and falls far short of the estimate projected by WHO (23.0) which would be needed for achieving the MDG targets . During this time, the density (per 10 000) of traditional birth attendants declined (from 55 in 1981 to 33 in 2007), presumably due to the stoppage of TBA training by the Government of Bangladesh in 1998 .
On the other hand, the increase in the number of unqualified allopathic providers during the past decade has been phenomenal compared to the qualified or semi-qualified allopathic providers. For example, the number of unqualified allopathic providers (village doctors and drug store salespeople) (24 per 10 000) has increased to about twice that estimated by the research agency, 'Org-Marg Quest' at the higher range (14.5 per 10 000) . Similarly, the density of traditional healers (64 per 10 000) in this study has been found to be more than 2.5 times than the density estimated by Ali at the higher range (24 per 10 000) .
The current nurse-doctor ratio of 0.4 (i.e. 2.5 times more doctors than nurses) is far short of the international standard of around three nurses per doctor. Interestingly, the equal nurse-doctor ratio in Khulna and very low nurse-doctor ratio in Sylhet is also associated with better health indicators in Khulna and worse health indicators in Sylhet. The importance of the nursing population for healthier communities (compared to individual outcomes in case of doctors) cannot be overemphasized . There is also a gross imbalance in the doctor-technologist ratio as well, the ideal being five technologists for one doctor. An estimate of shortage based on the doctor-population ratio currently prevalent in low-income countries revealed a shortage of over 60 000 doctors, 280 000 nurses and 483 000 health technologists in Bangladesh .
It is interesting to note that the overwhelming urban bias of the distribution of the formally qualified HCPs, noted a decade ago, has remained a persistent phenomenon . Also, these providers are inequitably concentrated in the Dhaka and Chittagong regions. The CHWs from the non-government sector and the village doctors are mainly concentrated in the rural areas. Interestingly, the salespeople at drug retail outlets (shops) are evenly distributed between the rural and urban areas, showing their unhindered expansion across the country. According to an estimate, there are about 80 000 unlicensed drugstores in the country . This mushrooming of unregulated drug shops is facilitated by easy availability of essential drugs at low price following the National Drug Policy of 1982  and also the availability of prescription drugs over-the-counter.
Addressing shortage and skill-mix problems: what can be done?
The large-scale shortage of qualified healthcare providers, coupled with an inappropriate skill-mix (more doctors than nurses and technologists) needs urgent attention to cater to the healthcare needs of the population. While in the short-term it is nearly impossible to produce the huge numbers of estimated healthcare providers by the public and private sectors combined , the disease profile in the country does not always warrant provision of services by qualified health professionals. According to the Bangladesh Bureau of Statistics , the most common illnesses (both sexes) in order of frequency are: fever (55%), pain (10%), diarrhoea (6%) and dysentery (4%). The above pattern of disease burden, at least in the primary care level, can be handled by the paraprofessionals (medical assistants, family welfare visitors (FWVs)), including CHWs, with the establishment of a functional referral system to a higher level of facilities [24, 25].
The CHWs have been increasing in size since the nineties, with the expansion of the government and NGO health network in the country. They have been found to be cost-effective [26, 27] and useful in the management of childhood pneumonia , acute respiratory infections of children , screening childhood hearing impairment , and DOTS treatment of tuberculosis  in rural Bangladesh. Training may also be provided to improve the competency of the vast army of unqualified providers (especially village doctors) in rational and harmless healthcare provision . Any concern that upgrading their diagnostic and curative skills may lead to abuse and malpractice may be contained by managerial and regulatory interventions by the public sector .