Maintaining child health interventions in Bangladesh during COVID

Context on the COVID-19 Pandemic

In many countries around the world, the COVID-19 pandemic and responses to it have disrupted the provision of evidence-based interventions (EBIs) for promoting child health and reducing U5M.

According to WHO Global pulse surveys in 2020 and 2021, more than 90 percent of countries reported some form of disruption to essential health services (EHS), particularly to primary-care services.¹

Countries attributed the EBI disruptions they experienced during the early part of the COVID-19 pandemic (March–December 2020) to a variety of demand-side and supply-side factors. The significance of each of these factors varies depending on country and context: not every country studied experienced the same disruptions in the same ways.

To understand Bangladesh’s experience with EBI disruption during the first months of the COVID-19 pandemic, this study builds on earlier efforts to understand the strategies the country has used to reduce U5M. It asks:

• How were EBIs to reduce U5M disrupted or maintained?
• What strategies did Bangladesh’s officials and health care providers use to prevent and respond to these disruptions?
• How did Bangladesh’s previous efforts to reduce U5M affect its ability to weather EBI disruptions and maintain progress on implementing interventions known to improve health outcomes for children under five during the pandemic emergency?

In the early months of the COVID-19 pandemic, Bangladesh experienced some disruptions to the delivery of EBIs for the reduction of U5M. Along with the turmoil caused by the COVID-19 emergency itself, challenging contextual factors such as staff shortages predated the pandemic. Taken together, these factors kept the country’s health system from fully withstanding that initial shock.

Yet Bangladesh’s health care system also displayed characteristics of resiliency, such as the ability to establish collaborative networks and adopt technologies that could be adapted to meet changing service-delivery needs. These helped the country recover from initial EBI disruptions after a few months. Vaccination services were the quickest to recover, bouncing back by June 2020, though they fell off again toward the end of the year; women receiving four antenatal care visits (ANC4), facility-based delivery, postnatal care, and outpatient department attendance took until July or even August to return to prepandemic levels.

Previous work to strengthen Bangladesh’s data systems, especially the DHIS2 data system that covers public health facilities, proved especially crucial to restoring and maintaining EBI delivery. These data systems enabled officials to track disruptions to public care-delivery channels and to respond accordingly.

Maintaining Evidence-based Interventions in Bangladesh During the COVID-19 Pandemic

Bangladesh is one of the world’s most densely populated countries, and COVID-19 spread comparatively quickly there – especially in urban areas and other relatively crowded places. Like many countries around the world, Bangladesh also experienced broad disruptions to EBI delivery during the early phase of the COVID-19 pandemic (between March and December 2020).

Bangladesh had substantial prior experience with effective pandemic response, however. More importantly, for years before the pandemic began, the country had been working to strengthen its health systems, and particularly its primary-care system, to reduce U5M and respond to the everyday health needs of the population. Together, these earlier efforts gave health officials a suite of structures and strategies they could implement and adapt to the COVID-19 context. By the end of the study period (December 2020) they were able to use these tools to mitigate some, but not all, of these disruptions and their impact.

KEY INSIGHTS

Bangladesh’s efforts to strengthen its primary-care system and coordinate its partners accordingly reduced under-five mortality by 56 percent between 2000 and 2015.

Five primary drivers contributed to Bangladesh’s remarkable success in reducing U5M between 2000 and 2015² :

• Emphasis on building a system for community-level delivery of interventions carried out by a large and diverse cadre of community health workers (CHWs)
• Consistent use of data, research, and testing in the implementation of EBIs, plus a willingness to adapt those interventions or implementation strategies in response to new findings
• A focus on equity in the implementation of U5M interventions as seen in the provision of low-cost treatments and in the decision to begin phased rollouts of certain major programs in the highest-need areas of the country
• Strong commitment to addressing a range of contextual factors that influence U5M, especially through initiatives to empower women and improve women’s reproductive health and local adaptations to address cultural or geographic barriers; these contributed to meaningful advances in women’s and children’s health in a society where women still face significant limitations and disadvantages
• High levels of collaboration between the national government and nongovernmental organizations (NGOs), including a well-developed NGO sector in country that played a critical role in research and implementation

The COVID-19 pandemic and the interventions put in place to control it did disrupt EBI maintenance between March and June 2020.

Starting in March 2020, Bangladesh began to adapt and implement many strategies to limit the spread of the COVID-19 pandemic. These included a national lockdown, including the suspension of mass transit and the closure of airports to international travel; social-distancing requirements and the postponement of mass gatherings; screening; strict quarantine; contact tracing; encouragement of mask wearing; and education about hand hygiene.

In part as a result of these interventions, health care workers and officials in Bangladesh did report disruptions in the delivery of EBIs between mid-March and August 2020.^{3, 4} Health management information system data show that pentavalent and measles and rubella (MR) vaccine coverage, outpatient department (OPD) consultations for children under five, and maternal health services – including antenatal care (ANC) visits, facility-based deliveries, and postnatal care – were especially affected.⁵ Indeed, the figures below show the coverage of the aforementioned EBIs in 2020 compared to 2019.

From the below figure, pentavalent first dose and measles rubella first dose immunizations were significantly disrupted from March through May, and then experienced rebound to levels higher than 2019 levels from June through October. However, there was another decline in coverage during November and December.

For outpatient department consultations for children under-five, disruptions occurred starting in March, and coverage gradually increased from May through December. However, coverage never reached 2019 levels, although it came close towards the end of the year.

Lastly, antenatal care, postnatal care, and facility-based delivery saw a drop in coverage from March through May, and experienced a gradual recovery over the remainder of the year.

What did the key informants (KIs) say caused most of these disruptions?

• Lockdowns and movement restrictions kept patients from seeking essential non-COVID health services such as facility deliveries. They also interrupted key community-level health interventions and in-person training and supervision for health care providers.
• Staff shortages in health care facilities and redeployment to pandemic response limited access to non-COVID essential services and undermined their quality.
• Pandemic-related financial strains kept patients from seeking key health services.
• Fear of COVID-19 among health workers and community members limited the supply of key health services and prevented many people from seeking them (such as facility deliveries and OPD consultations for children under five) unless they were severely ill.

Bangladesh adapted some of the strategies it had previously utilized for reducing U5M to mitigate COVID-related drops in EBIs. Given the relative severity of the first year of COVID-19 in Bangladesh, however, there were still disruptions to EBIs.

KIs report that many of the strategies Bangladesh implemented in 2020 to prevent or respond to COVID-related drops in EBI delivery were already in place before the pandemic to reduce U5M; they were adapted in March and subsequent months to suit their new pandemic context.

We have organized these adapted strategies into three main categories: human resources for health, infrastructure, and policy and leadership.

Human Resources for Health

• Leveraging community-based health care delivery

  Health workers restored immunization outreach and services after a period of disruption in March through June of 2020, provided education over the telephone to pregnant women and mothers of children under five, and strengthened community clinics.

• Mentorship, supervision, and training

  Building on existing mentoring programs and processes, health officials implemented online monitoring and feedback sessions and used an electronic tracking system for vaccine programs.

• Strengthening human resources

  Over time, Bangladesh’s government recruited more health care workers and changed the way they were deployed, to provide COVID-19 care as well as maintain the provision of evidence-based interventions for child health.

Infrastructure

• Data use

  Health officials reviewed management information system (MIS) data to track service disruptions, utilization, coverage, and progress. The Directorate General of Health Services (DGHS) organized weekly monitoring meetings to review and respond to this data and provide feedback. Policymakers used real-time data analysis to inform their decision-making.

• Digital platforms and e-health

  Health officials and providers used digital platforms such as Zoom, Skype, and Microsoft Teams for virtual meetings and trainings. Providers also conducted some patient consultations by telephone and used Viber groups, Facebook pages, and YouTube channels for information sharing and communication.

• Leveraging existing systems, capacity, and experience

  Health officials and providers used the experience and capacity they developed in preparation for previous epidemics (such as Ebola and SARS) to maintain EBI delivery in the COVID-19 context.

• Transportation

  Officials provided some transportation to health care workers during lockdowns to ensure that they could reach service-delivery sites. [Note: this was a new strategy implemented during the COVID-19 pandemic.]

Policy/Leadership

• Community engagement and education

  Health officials conducted campaigns to raise public awareness about EBI provision and increase community awareness of facility delivery; initiated outdoor meetings to increase health-seeking behavior, particularly among women who needed ANC; and used digital platforms from satellite television to Facebook to spread community awareness.

• Guideline development for EBI maintenance

  Health officials adapted pre-existing guidelines for maternal, newborn, and child health (MNCH) service delivery for the pandemic context and shared them online with frontline health workers at all levels.

• Donor and partner coordination

  Bangladesh collaborated with implementing partners and donors to strengthen MIS data systems alongside direct COVID-19 response.

• Focus on equity

  Bangladesh’s government focused its EBI maintenance efforts and funding (such as for the Expanded Programme on Immunization) on hard-to-reach areas.

• Redesign of health system to mitigate EBI drop

  To reduce the perceived and actual risk of COVID-19 infection and maintain the delivery of EBIs for the reduction of U5M, health care workers continued to provide newborn care in alignment with COVID prevention measures; developed COVID-specific guidelines for the Kangaroo Mother Care service; encouraged facility deliveries; prepared standard operating procedures for in-person service delivery; and adapted existing health centers, hospitals, and zones to provide non-COVID services such as ANC.

Bangladesh experienced significant COVID-related EBI disruptions through July of 2020. In part because of the aforementioned strategies, available data suggests that the country’s public health system was able to rebound from many of those EBI disruptions in the latter half of the year.

Public-sector data show that while service utilization decreased overall in the spring of 2020, Bangladesh’s COVID-related EBI disruptions began to resolve fairly quickly. Vaccination services resumed more quickly, reaching pre-pandemic levels around June 2020 (although they were further disrupted in November through December of that year). Other services such as ANC4, facility-based delivery, postnatal care visits, and outpatient department consultations for children under five took until August to recover.

The below graphs show this trend, through monthly and cumulative disruption ratios for the aforementioned EBIs. The monthly disruption ratio compares the coverage for a given month in 2020 to that same month in 2019, normalized by the ratio of coverage in January and February of 2020 compared to those months in 2019. A monthly disruption ratio under 1 indicates lower than expected coverage in 2020, with expected levels defined by the level for that month in 2019, adjusted by the ratio of coverage in January and February 2020 compared to those months in 2019. Conversely, a monthly disruption ratio greater than 1 indicates higher than expected coverage, potentially pointing towards catch-up campaigns or efforts in later months in 2020.

The cumulative disruption ratio compares total volume from March to a given month in 2020 to that same period in 2019, again normalized by the comparison of the January and February levels in 2020 versus 2019. This shows a more gradual effect of the disruptions over the course of the year.

As can be seen from the below figure, for pentavalent first dose and measles rubella first dose immunizations, disruptions were most pronounced from March through May, but coverage of these immunizations did recover and even surpass expected levels from June through October. However, there were further disruptions in November and December.

For outpatient department consultations, coverage experienced a sharp reduction from March through May, and then steadily recovered over the remainder of 2020.

Lastly, for antenatal care, postnatal care, and facility-based delivery, disruptions and recovery were more gradual, with disruptions stretching from March through May, and then recovery stretching from June through the end of the year.

We assume that health-service delivery in the private sector experienced similar disruptions – but given the lack of private-sector data, it is hard to accurately tell whether, how much, and when those disruptions resolved. It is also hard to know for sure whether (as some KIs suggested) some of the public-sector downturns were due to some level of patient shift towards care-seeking from private providers and facilities.