3 years ago

Health system responsiveness to contain Covid-19

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Health systems in both developed and developing countries are now struggling to respond to the challenges posed by Covid-19. As of April1 15, 210 countries and territories have been affected by the pandemic with more than 20,84,042 cases and 134,669 deaths globally. Though the number of detected cases (1231) and deaths (50) are relatively low in Bangladesh compared to many other countries, we may have to think about how our health system should respond to address the challenges of such pandemic now and in future. We are at the risk of dengue outbreak soon, and our health system needs to be ready to tackle both the disease outbreak. We have to remember that Bangladesh has made great strides in improving the health of its population through a combination of political engagement, socio-economic development and a range of health and health related interventions and services in the last decade. Bangladesh is often cited as a success story with good progress against many of the Millennium Development Goals (MDGs). The country has one of the best health infrastructure in South Asia, and Ministry of Health and Family Welfare (MOHFW) can hopefully combat the outbreaks through a coordinated and whole-society approach.

The Prime Minister has announced to allocate Tk 1.0 billion (100 crore) for government physicians, nurses and health workers treating Covid-19 patients, and Tk 7.5 billion (750 crore) for health and life insurance for those affected while on duty. MOHFW has already taken a number of immediate actions to combat Covid-19. It should develop a 'Comprehensive National Covid-19 Response Management Policy' outlining short-, medium- and long-run action plans. The policy must adopt a whole-society approach, consider both preventive and curative measures, and strengthen World Health Organisation's (WHO's) six building blocks of the health system.

  1. Health service delivery
  2. a) This is really important that safety of health professionals receive high priority in the policy, planning, resource allocation, coordination and service delivery systems. Unless the doctors, nurses and lab technicians are safe to provide care, the fight against such pandemic will not be possible. Hence, adequate resources should be allocated to respective units within Directorate General of Health Services (DGHS) and tertiary/specialised/medical college hospitals for i) procuring personal protective equipment (PPE) for health professionals; ii) proper distribution of the PPE as per need; iii) providing training to health professionals on proper use of PPE for their own safety and safety of others. Monitoring of the quality of PPE is required to ensure compliance with the standard safety measures.
  3. b) Treatment protocol, guidelines and manuals need to be reviewed and updated periodically to provide care during such outbreak. It is important that health professionals are well trained and follow standardised guidance to provide care at all levels for all age groups, including pregnant women, people living with multi-morbidity and mental illness, as per treatment protocol. System should be in place to provide short training/orientation of the health professionals during such outbreak, due to the evolving knowledge and evidence related to the management of such new pandemic. In addition, this might be an opportunity to revisit the curriculum of different health professionals, and include the preventive and curative care, as appropriate, in their medical curriculum to provide quality care during the outbreak.
  4. c) For active, exhaustive case finding and immediate testing, isolation and treatment, MOHFW needs to do 'district level' planning. MOHFW should assess the need of the districts, allocate resources based on need, develop capacity of diagnosis and treatment at district and sub-district levels, and procure and distribute test kits as per need across the districts and sub-districts. A proportion of patients infected with Covid-19 virus becomes serious and critical, and requires mechanical ventilation and intensive care. MOHFW has to increase the capacity of government hospitals at national, district and sub-district levels to provide such care.
  5. d) Such epidemic and the consequent social isolation, domestic violence, unemployment, death may cause depression, anxiety, stigma and suicidal tendency among patient, family members and general population during and post-emergency situation. Mental health of the people should therefore be prioritised in addition to preventive and curative measures. Directorate General of Health Services, National Institute of Mental Health (NIMH) and the psychiatric units of Medical College Hospitals and District Hospitals should work closely to ensure that the mental health is adequately addressed in policy and service delivery during such crisis and post-crisis period.
  6. e) Ministry of Local Government, Rural Development and Cooperatives (MOLGRD) provides primary health care in urban areas through their network of selected NGOs (non-governmental organisations) under the Urban Primary Health Care Project. They have their own plan, service delivery, monitoring and supervision, and recording and reporting system. For a comprehensive management of epidemic such as dengue and Covid-19, it is important that MOHFW coordinates with MOLGRD to ensure access to quality care - both preventive and curative - for urban population. This issue has been discussed for long, and 'Urban health' has been prioritised in the 4th Health Sector Programme. This is the high time for action, and MOHFW should take the leadership role to ensure access to quality health care for urban population.
  7. f) The private-for-profit sector plays a crucial role in providing health care in Bangladesh, especially in urban areas. It may not be possible for government hospitals alone to provide services to a large number of population during such outbreak. However, private hospitals often refuse to admit such patients during outbreak for multiple reasons, such as, fear of transmission among other patients and health professionals, inadequate number of health professionals, lack of skill and equipment/bed/ICU/CCU, and lack of accountability. It is important that the role and accountability of private for-profit hospitals during such emergency is established, and a referral linkage is established, where necessary, from private hospitals and diagnostic centres to government hospitals, or vice-versa. A coordinated approach is required to ensure that the private sector plays effective and complementary role during such emergency. This reminds us about the importance of accreditation, licensing and empanelment of private hospitals. DGHS should consider this as a priority, and coordinate with respective ministries for proper implementation of accreditation and licensing of private-for-profit providers. The 'Public-Private Partnership' strategy of the health sector should look into the role and accountability of private for-profit hospitals during such emergency.
  8. Health workforce
  9. a) This outbreak reminds us once again the importance of having 'public health experts' within the health system to strengthen the preventive measures, such as, promoting vaccination, personal hygiene and sanitation, hand washing, social isolation, healthy diet. This is the time when MOHFW can negotiate with the Ministry of Public Administration and Ministry of Finance to approve the required number of 'posts' at different levels within the health system and recruit public health professions urgently. There can be senior expert(s) at the central level (DGHS) to coordinate the public health initiatives nationwide, and at least one public health expert at district level.
  10. b) Number of medical technologists working under DGHS per 10,000 population is 0.32 (Bangladesh Health Bulletin, 2018). In addition to doctors and nurses, posts of lab technicians/medical technologists need to be created, vacant posts need to be filled-in, and necessary training should be provided to existing and newly recruited lab technicians/medical technologists.
  11. c) We have large workforce of Community Health Care Providers (CHCPs), Health Assistant (HA) and Family Welfare Visitors (FWV) under MOHFW. Thse frontline health workers are already providing health education to a large population. It is important to consider how this community health workers can play role throughout the year and during such emergency.
  12. d) 'Bangladesh Health Workforce Strategy (2016-2021)' has been approved in 2015/16. This needs to be reviewed to ensure that 'service delivery during emergency, epidemic and pandemic' is adequately addressed in the strategy. Proper implementation of the strategy needs to be ensured.
  13. e) MOHFW needs to review the role of Divisional Directors with enhanced delegation of authority for better management and coordination of health service delivery, including the emergency preparedness and management of epidemic.
  14. f) Review and revise the career development plans of doctors, nurses, and other health professionals.
  15. Health information system
  16. a) Evidence informed planning depends on availability of reliable data and expertise to analyse the data for planning and budgeting. This is therefore important to strengthen the capacity of Management Information System (MIS) unit and Institute of Epidemiology, Disease Control and Research (IEDCR) for recording and analysing the data. Greater coordination is required between MIS and IEDCR. It is important to collect and analyse district-level data to assess need for each district.
  17. b) MOHFW and MOLGRD have their own recording and reporting system. This Covid-19 pandemic reminds us once again that it is important to have a single surveillance system for both urban and rural areas, and MOHFW should take the leadership in capturing patient data for both urban and rural areas at district.
  18. c) MOHFW should continue providing information to people through multiple channels about availability of services- preventive, diagnostic and curative care. People should be well informed - what preventive measures should be taken and where to go to get treatment when they are symptomatic. There may need e-health, 24-hours call centres for consultation and referral advice during the lock-down and social isolation. Hence, capacity of the call centres (16263 and 333) under MOHFW needs to be strengthened.
  19. Access to essential medicine
  20. a) Line Directors and Directors need to revisit their plan for the next two years, and do evidence informed planning for procuring medicine, regimens, equipment and other supplies.
  21. b) Appropriate storage and distribution system needs to be in place to provide medicine and supplies to local level as per need.
  22. Health system financing
  23. a) Planning Wing, MOHFW and respective Line Directors needs to review the Operational Plans (OP), and revise the plans as required, to allocate and use resources efficiently for emergency preparedness and communicable diseases control for the next two years under the 4th Health Sector Programme. This includes, but not limited to, procuring PPE, drugs, test kits, regimens, ventilators, equipment for intensive care unit and providing training. As already mentioned, MOHFW should do 'district-level planning' and do the procurement as per local need.
  24. b) MOHFW needs to negotiate with Ministry of Finance (MOF) for increased budgetary allocation to increase coverage of the preventive and curative care. In 2019/20, the budget allocated to MOHFW was 4.9 per cent of the national budget, which is one of the lowest in the South Asia region. Out-of-pocket health expenditure (that is health expenditures directly paid by a patient during time of service use and not reimbursed by any insurance coverage) is still very high in Bangladesh (71.89 per cent of current health expenditure in 2016) compared to global average (approximately 18.96 per cent) and many neighbouring countries (64.58 per cent in India, 55.44 per cent in Nepal, 50.12 per cent in Sri Lanka). Budgetary allocation to MOHFW in upcoming years needs to be enhanced.
  25. c) MOHFW can discuss with development partners and agree about the technical support required for next two years under the 4th Health Sector Plan for coordinated management of such epidemic.
  26. d) Develop a 'Trust Fund' within MOHFW to use during such national crisis
  27. e) MOHFW can prepare a strategy, guideline and legal framework to coordinate, receive and utilise resources available in the private sector including private hospitals, NGOs, civil society organisations, and professional bodies (e.g. Bangladesh Garment Manufacturers and Exporters Association or BGMEA). For example, MOHFW may contract in and/or contract out services from/to the private hospitals, receive donation and support of civil society organisations for procuring PPE, medicine, equipment during such emergency.
  28. f) Adequate resources should be allocated to strengthen Institute of Epidemiology, Disease Control and Research (IEDCR) for research, innovation, screening, diagnosis, and capacity development.
  29. g) Another critical factor is financial authority among different policy makers at the central level, and delegation of authority to local level within MOHFW. MOHFW needs to review their current delegation offinancial authority, and take necessary measures (e.g. negotiate within Ministry of Finance) to make required changes, as needed, for better coordination, harmonisation and management of such pandemic.
  30. Leadership and governance
  31. a) MOHFW should take the leadership role to form a high-level committee, and prepare a national Response Management protocol, as suggested by World Health Organisation, to ensure all the relevant ministries are involved, and a whole-society approach is adopted to contain Covid-19. Such outbreaks require coordination with other ministries. What is the right time to close and re-open education institutes, garment factories? How to ensure required food supply during lock down? How to refer patient when public transport is shut down? When do we need to procure equipment for medical check-up at airport, how to use those equipment? When do we start the vector (e.g. mosquito) control? When and how long to spray disinfectants? What should be the role of media? How the Ministry of Religious Affairs can support MOHFW during such emergency where social distance is required? All these decisions should be taken in a coordinated way, and MOHFW should take a leadership role in the dialogue and decision making. MOHFW should also initiate school-based, mosque-based and community based preventive measures (e.g. personal hygiene, hand washing, sanitation, waste management, healthy diet) through coordinating with respective ministries, private organisations and professional bodies.
  32. b) MOHFW should consider taking the leadership in preparing a population and patient data base to track and monitor movement of the people if needed, in coordination with respective ministries and department, including Immigration and Passport authority, and Election Commission.

These recommendations are not new. These have been discussed for long. But this is the time the MOHFW implemented these actions with the support of other ministries and help the nation grow and achieve its development targets.


Dr. Rumana Huque and S M Abdullah are with Department of Economics, University of Dhaka, Bangladesh. [email protected],

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