State of healthcare and Covid-19 management in Bangladesh

Bangladesh's health system has four key factors in its structure and functioning. Though the government sector is huge, the private sector is drastically getting bigger, as is private investment. Non-government organisations and donor agencies are also playing a significant role in the health sector. The government by contribution is solely responsible for policy, regulation, and provisions of healthcare services from primary to tertiary levels.

The government or the ministry of health, is constitutionally responsible for both policy and strategy, and the rules and regulations for implementation of the policies and strategies. The main objective is to ensure total healthcare for the whole population, with necessary services and provisions, including medical services necessary to obtain this goal.

The ministry of health implements its policies, and provide services through its two director generals of services. One of them on health services, and the other on family planning services. The services are offered through a dual system of general health and family planning, through districts, sub districts, "upazilla" health complexes, union health and family welfare centres. These are provided at union level and at ward level with community clinics in villages with population of 6,000.

The third is the vibrant non-profit healthcare services managed by NGO's, and supported by many donor partners/agencies, as well as local NGO's.

Different ministries also have their independent health establishments to provide services to their employees and families. Army, railway, police, and local governments for example. Municipal authorities have their own health establishments and provide healthcare services to their staff and family members. There is no proper coordination among all these healthcare establishments in the country.

The health budget in Bangladesh is one of the lowest among the countries in the South East Asian region. Moreover, there is corruption and misuse of the allocated funds and resources, which is an open secret. Patient satisfaction of the existing healthcare services is also questionable.

At the national level there are tertiary specialised hospitals, and at district level, there are districts hospitals. At subdistrict or upazilla level, there are upazilla hospitals with approximately 30-50+ indoor beds, as well as specialised services of internal medicine, surgery, OBS and more.

Below upazilla levels, there are union health centres and union sub centres for out-patient services. The speciality in the system is the community clinics. The community clinics are for 6,000 population in each rural setting and is the last tier of healthcare services.

Though such a unique health system structure is available in Bangladesh, its quality of service is questionable. The healthcare service providers are supposed to properly manage these robust healthcare services, though they are still not able to. The availability of doctors, nurses and other paramedic staff are also continuously being questioned.

Covid-19, like SARS and Swine flu, is also contagious and affects mainly the human respiratory system. Its symptoms are fever, fatigue, dry cough, loss of appetite, body ache, shortness of breath, mucus which begins two to fourteen hours after exposer to the virus. Apart from these, there might be loss of smell or taste and other symptoms like sore throat, headache, chills, congestion or runny nose, nausea, vomiting, and diarrhoea.

A woman taking advice from physicians, in hazmat suits, at the ticket counter of the capital’s Shaheed Suhrawardy Medical College Hospital, on March 23, 2020. PHOTO: ANISUR RAHMAN

But there may also be some emergency symptoms where hospitalisation or doctor's consultation is required. These are difficulty in breathing, pain or pressure on the chest, bluish discoloration of the face/lips and confusion/cluelessness. Stroke has also been reported in some cases of Covid-19. In case of children, common symptoms are fever, cough, and shortness of breath which is called Paediatric Multisystem Inflammatory Syndrome (PMIS) and includes rash, vomiting, belly pain, and diarrhoea.

The best way to protect from Covid infection is by washing hands with soap and water for 20 seconds, using alcohol-based sanitiser, keeping oneself six feet away from others, using mask in public places, avoiding sick people, avoid touching the eyes, nose and mouth without washing the hands.

The Covid-19 virus affects people of all ages but the elderly and people with underlying diseases are the most vulnerable to it. That's why the hospitals and care homes all over the world have been showing the high morbidity and mortality rate. An interesting thing about the disease, is that it can affect any organ of the body, and researchers are suspecting that there is long term damage in different organs which may later get diagnosed in a Covid patient.

When analysing the COVID situation from late 2019, we see initially the Chinese authorities had failed to foresee the gravity and strength of this virus. The actual data of morbidity and mortality was also initially not available. It took a significant amount of time for the state authorities to realise the situation which aided the spread of the virus so rapidly all over the world. There was also not enough scientific evidence available to tackle the virus.

To combat this new situation, all the countries called upon their health authorities, doctors, virologists, scientists and infectionologists, but the public health workers were not very involved and were ignored.

Eventually most of the countries issued lockdown. This situation lingered longer and longer, and people became frustrated. Some countries prioritised their economy over people's health, undermining the public health measures, eventually paying the price. Some countries with huge population are struggling to maintain social distancing. Cities with a lot of slum dwellers with poor health infrastructure and are burdened with poverty, also faced huge challenges under lockdown.

People are slowly starting to adapt to the situation, and it is now the new normal. The new normal is an interesting term. People were scared initially, but slowly they are being habituated in washing hands, wearing masks and maintaining social distancing. Internet and media have become the solutions for all our activity online, and home services and related business are offering takeaway services. Different web-based channels are doing good business and new ones are emerging. There is more and more demand on packaged food, dry food and tinned food in developed countries. People are getting accustomed and comfortable in the system of working from home. Every now and then, newer apps are launching with better features to communicate online, to purchase online and to do group activities and meetings.

Educational institutes are opening online portals and apps for students to continue their studies. Online curriculums too are now available.

After one year of sufferings if we look back to analyse the management of Covid-19, we can look at Vietnam as an example. "Preparedness to deal infectious disease is a key ingredient for protecting people and securing public health in time of pandemics such as Covid-19" (A UN resident coordinator blog, Vietnam). When in Vietnam there were only 16 cases in a village close to Hanoi, a 3-week village-wide quarantine was employed affecting 11,000 people.

As a result, there were no further cases for 3 weeks. It was followed by an imported case from the UK. Next, Vietnam closed its border and suspended flights from China. It was important to contain the virus transmission completely and to safeguard the economy. It was followed by other international flights from UK, USA and other part of the world being banned, while requiring all travellers entering the country including Vietnamese, to go into quarantine. While there was never a nationwide lockdown the prime minister issued a 2 week nationwide physical distancing which was extended by another week in major cities and hotspots. Both the army and local government were mobilised to provide testing, meals and amenities to all quarantine facilities free throughout the period. People were advised to stay at home, nonessential businesses were requested to close with limited public transport. The measures were a great success. By early May, there was not a single case. The people of Vietnam were exceptionally compliant with government directives as a result of trust built up by the ministry of health supported by WHO and other UN agencies. Poor and vulnerable populations across the country were protected by a social protection package.

If we consider the success story of Vietnam as a similar economy, Bangladesh with similar socio-economic conditions could have achieved the same success. Vietnam had one of the lowest numbers of cases of Covid-19 and related deaths. The credit goes to Vietnam's leadership, for its swift decision making, effective public health measures and aggressive contact tracing.  Countries with poor health infrastructure or poor healthcare management are suffering a lot. Countries burdened with poverty are also facing huge challenges to provide for the people.

By January, we now have more than 7 vaccines available. Pfizer/Bioentech, Moderna, Oxford/Astrazeneca, Sinovac/Biotech, Gamaleya, Cansino-biologics, and Sinopharma. Vaccination already started in different countries of the world including UK, USA, Russia, China, India and many others. Till today, globally, there have been about 8 crore confirmed cases of Covid-19, while total deaths are about 18 lakh as reported by international agencies.

Covid-19 is a public health issue. It needs to be addressed with a public health approach. As there is no remedy yet, and no cure, people must be made aware to avoid spreading of the virus. We are all now aware of the approaches to be taken by individuals, society and the government. Though it is not airborne, it spreads by droplets and we are to maintain a distance of 2 metres to avoid contamination. In close proximity, there may be cross contamination from the symptomless Covid-19 carriers. So, social distancing, wearing mask and hand sanitising are the most important measures to be kept mind.

The present-day health system of Bangladesh, with its infrastructure and community clinics in the periphery are unique. But when the functioning and the system with its establishments are taken into consideration, it is not properly managed or functioning. With the existing health problems and issues added to the current pandemic situation, are we capable of catering to the present health needs? The answer is a big "NO".

The best approach is to decentralise the system with more authority to districts office of the "Civil Surgeon" which will have full responsibility and account of total health of the populating district. A civil surgeon should be delegated and empowered with total responsibility and health of the population of the district and made accountable. The district hospitals will be the hospital referred to, from the upazilla health complex hospitals for specialised care, which once again is responsible for referring patients to national specialised and super specialised hospitals.

The upazilla hospitals should be properly equipped with isolation and observation units or beds for Covid-19 patients and be equipped with O2, Oxygen Mask, High-flow Nasal Cunnula, and other necessary logistics for primary covid management. The district hospitals should be equipped with ICU ventilators, and other covid management facilities, including CCU O2 supply system.

Civil surgeons should be made responsible for keeping all these upazilla health complex and district hospitals properly functional. The monitoring and supervision system should only be with the director General of Health services office. The civil surgeon should be given total authority of decision making for their district and be made accountable. In managing covid, the observation was that it was not managed properly in districts and upazillas. The government was trying to manage it from the national level which did not work.

Now as vaccination is about to start, the responsibilities should be shouldered by the civil surgeons of the districts. They can monitor and supervise as well as take the necessary measures for vaccinating people in their district. The civil surgeons should be made responsible and accountable to the director general of health services. All the necessary resources should be provided on time and preferably in the beginning of a financial year, on the basis of the requirements of each district. It will bring a healthy competition among the civil surgeons or districts, to bring qualitative and quantitative improvement in the healthcare services of the districts.

The civil surgeon should oversee the activities of NGO's in their districts. He will also ensure the standard and quality of service of private hospitals, NGO services and coordinate their activities. In brief, we need to bring a total change in our overall health system. While people want a functional health system covering the whole population of the country everywhere, they also want quality services from quality healthcare providers.

Our health system should be more upazilla based and all preventive, curative and rehabilitative services should be made available there for our rural people, who constitute 65 percent of our total population. An effective referral system also needs to be established, one from community clinic to union health center to upazilla health complex. And the other from upazilla to district and national/tertiary hospitals.

We need to strengthen our peripheral upazilla health system and its referral system with national tertiary health system. The government's primary responsibility should be to ensure greater decentralisation, establishing a functional district health authority or office of the civil surgeon with full functional autonomy.

M Muzaherul Huq, former adviser, South-East Asia region, World Health Organization (WHO), and founder, Public Health Foundation of Bangladesh.