Bangladesh has made immense progress in food security and nutrition, maternal and child mortality rates along with other socio-economic indicators over the past decades. However, the Covid-19 pandemic has not only ravaged the economic metrics in Bangladesh but has also led to indirect and long-term health adversities manifested in starvation, malnutrition, maternal and child health hazards. These are threatening to alter progress in the associated socio-economic indicators.
"Left behind" and "pushed behind" populations (LNOBs and PNOBs) were particularly vulnerable to the recent realities. Given the pre-existing economic and health inequalities together with the disagreeable coping mechanisms of vulnerable groups to the multidimensional challenges of the pandemic, scope and intensity of such societal repercussions have magnified many folds. A February 2021 survey of around 1,600 households from nine marginalised groups (LNOBs and PNOBs) illustrates the concerned issues.
COVID-19 VACCINATION AND FALLOUTS: The government of Bangladesh inaugurated the countrywide vaccination programme on January 27, 2021, intending to inoculate 80 per cent of the total adult population. The vaccines were to be distributed primarily through tertiary healthcare centres in metro cities, district hospitals and upazila health complexes. Nevertheless, various literature and miscellaneous sources indicate widespread disparities related to Covid-19 vaccination.
Due to poor levels of digital literacy, marginalised communities had difficulty registering for vaccination. A scarcity of vaccination information was prevalent across the communities. Moreover, vaccine distribution and administration were insufficient to ensure uniform coverage at the grassroots level. The minimum eligibility age for immunisations could not be reduced to 18 years in the initial rounds due to limited availability of vaccines and various pre-existing institutional challenges. Furthermore, during the earliest phase of vaccine rollouts, potential migrant workers faced significant barriers to obtaining the necessary shots. A number of marginalised communities were not fully inoculated with the required vaccine doses. The transgender community was not included in mass vaccination programmes and was subjected to harassment at the centres.
CHANGES IN NUTRITIONAL INTAKE: Income losses stemming from pandemic-induced adverse economic shocks manifested in declined food consumption and diminished dietary quality. Marginalised households of a larger size responded by restricting food intake. Almost 90 per cent of households with loss of employment reported a decline in food consumption. The corresponding figure for families that have not experienced job loss is also relatively high at nearly 78 per cent.
Marginalised households adjusted their dietary patterns by reducing consumption of food sources rich in protein. Significant reduction took place in non-food and food expenditures along with loan repayment. Savings withdrawal and asset liquidation were widespread. Higher cost of maintaining urban residence in the face of income loss have increased the risks of hazardous adjustment in nutritional intake.
Among LNOBs, people living in the char areas, persons with disability (PWD), and slum dwellers had the highest number of households who had lost jobs and reduced their food intake. Micro, small and medium enterprise (MSME) households, on the other hand, accounted for the lion's share of "new poor".
OBSTACLES TO MATERNAL AND CHILD CARE: Non-institutional births saw a rise during the pandemic. Approximately, half of the total expecting mothers from the disadvantaged communities opted for deliveries at home which was higher than the national average of 47 per cent in 2019. Roughly 61 per cent of rural women and 43 per cent of urban women gave birth at home. In the pre-pandemic period, rural home births accounted for 51 per cent of births nationally, whereas urban home births accounted for 32 per cent.
In general, a greater proportion of LNOB women than PNOB were compelled to give birth at home during the pandemic. In both rural (65 per cent) and urban areas (48 per cent), LNOB households had a higher rate of home births. About 64 per cent of the indigenous women accounted home births, which was the highest within the LNOB groups. However, a reverse trend was observed for the migrant households where about 67 per cent of rural and 75 per cent of urban women opted for institutional child delivery.
The pandemic also created a marked disparity in accessing pre- and postnatal maternal healthcare. Half of the rural slum households failed to attend all of their prenatal care appointments. The frequency was also high among households headed by people with disabilities (34 per cent) and migrants (34 per cent). Moreover, the rate of missing all postnatal care visits was extremely high among rural dalit households (67 per cent), followed by rural slum households (33 per cent).
The survey data on child immunisation rate during Covid-19 show a similar pattern of inequity. LNOB households missed child immunisation at a higher rate than PNOB households in both rural and urban locations. The proportions were higher among dalit and persons with disability headed households with a missed immunisation rate of 20 per cent and 19 per cent, respectively. It is noteworthy that, with the exception of dalit and indigenous households, none of the communities in metropolitan areas failed to receive the required child vaccinations.
LESSONS AND WAY FORWARD: Vaccination rates of the vulnerable population, particularly those living in remote places, are much lower than the national average. Pursuing a focused approach to identifying, sensitising, and immunising the marginalised communities can help mitigate vaccination shortfalls. Social campaigns at the grassroots level can help provide the general populace with the necessary information on Covid-19 vaccination. Simultaneous provision of proper digital assistance to individuals who lack digital literacy and streamlining the registration processes can also help increase turnout rates among vulnerable groups. Setting up dedicated Covid-19 vaccination distribution centres or camps in difficult-to-reach communities should be considered. Involving non-governmental organisations (NGOs) in the inoculation process can help expand vaccination coverage of marginalised communities.
Nutritional intake decreased dramatically for a disproportionately large section of marginalised households, regardless of job loss status during the pandemic. Direct financial transfers and food assistance to the most marginalised demographic groups, namely char, PWD, slum, and MSME households, can help improve the situation.
Increased funding for public maternal health centres can make institutional childbirths available to low-income population at no cost. Involving NGOs and community workers in educating targeted groups about the availability of cost-free deliveries will further promote institutional childbirths.
Since LNOB communities, particularly the dalit and PWD households, are more prone to missing out on child immunisation, the authorities need to dedicate more effort to include all segments of the diverse LNOB communities. Updating the existing database and strengthening partnership between governmental and non-governmental organisations can be defining a way to alleviate the deficits in immunisation programmes and other measures dealing in the health-related fallouts.
Debapriya Bhattacharya, Distinguished Fellow, Centre for Policy Dialogue (CPD); Towfiqul Islam Khan, Senior Research Fellow, CPD;
Fabiha Bushra Khan, Research Associate (Project), CPD; Faria Tahmeen Momo, Former Research Associate, CPD. [email protected]