Bangladesh’s enabling environment

According to interviews with key informants (KIs), some elements of Bangladesh’s health system that predated the COVID-19 emergency – such as a strong culture of collaboration and a flexible health-system structure – gave the country’s officials and health care providers a toolbox they could adapt and extend to maintain EBI delivery and mitigate drops in EBI coverage early in the pandemic. At the same time, however, other preexisting elements of Bangladesh’s health acted as barriers to EBI maintenance.

Contextual factors that predated the pandemic emergency include:

In Bangladesh, the public sector health system produces and relies on significant amounts of high-quality data for decision-making. The management information system (MIS) at the Directorate General of Health Services (DGHS) and the Directorate General of Family Planning (DGFP) allows the Ministry of Health and Family Welfare to track the coverage of critical health services across the country; the Civil Registration and Vital Statistics system tracks health-related indicators; and the Supply Chain Management Portal provides critical data on the supply chain of medical goods. All of these pre-existing programs assisted the COVID-19 response.

Likewise, public officials, health care providers, and even their partners all use – and share – data to understand the health system’s capacity and track its improvement.

Bangladesh’s health system also has an electronic management information system that collects data from public facilities and community health workers using digital technology to link community and facility data. However, during the COVID-19 pandemic, many health care workers were so overwhelmed that they did not prioritize data collection, which interrupted ongoing activities.

Even before the COVID-19 pandemic, limited data from private health care facilities prevented officials from integrating public and private data and drawing accurate conclusions about service coverage nationwide. The government is pushing private-sector health care providers to share their data, but this will likely take a long time.

Even where solid health data systems exist, their data was sometimes difficult to access and the quality of the data they compile could be poor, which prevented Bangladesh’s policymakers from using data to make informed decisions.

KIs noted that health officials were aware of these limitations and pushing for improvement. The integration of private- and public-sector data is critical for making informed decisions and drawing accurate conclusions.

Bangladesh’s policymakers conducted real-time data analysis to address EBI disruptions early in the COVID-19 pandemic.

Though parts of the health system lack a strong capacity for data analysis, many facilities held data-driven feedback meetings to enable providers to identify service gaps and deliver better care.

Health officials in Bangladesh also learned from the guidelines and recommendations produced by other countries and organizations for pandemic response and EBI maintenance.

Just as Bangladesh’s COVID-19 response built on existing networks of partnership, coordination, and collaboration, so did its efforts to recover from EBI disruptions and maintain high-quality health services of all kinds. For instance, a group of partners created guidelines for breastfeeding for COVID-positive mothers.

KIs also noted that partners working in the field carried out joint tasks such as contact tracing and research.

Bangladesh’s health system includes four directorates under the Ministry of Health and Family Welfare: DGHS, DGFP, the Directorate of Nursing Services, and the Directorate of Drug Administration. These directorates comprise a strong infrastructure for service delivery: for instance, Bangladesh’s immunization program is strong and well structured at all levels, so the country did not face a crisis of vaccine supply during any phase of the COVID-19 pandemic. (Where vaccination services were interrupted, it was because health workers and parents were afraid of contracting COVID-19.)

However, KIs report that Bangladesh’s primary health care system is much less robust. Rates of facility-based delivery, for example, are low.

Some KIs attributed this gap in service provision in part to the country’s shortage of nurses and midwives: available health care workers were already overburdened, and they were forced to multitask in order to meet high demand for their services.¹In fact, critical human-resource shortages are endemic across Bangladesh’s health care system.

According to interviews with KIs, Bangladesh’s existing system of community health workers enabled the rapid expansion of health education and health service delivery at the community level before and during the pandemic. Early in the pandemic, with technical guidance from the Ministry of Health and Family Welfare, Bangladesh’s government initiated different strategies to prevent the spread of the novel coronavirus, including facilitating community-based prevention practices by engaging CHWs to respond to COVID-19 in their communities. (COVID-response activities included educating households on prevention and treatment, contact tracing in their communities, and referring clients to facilities for testing and advanced care.) This task shifting increased the availability of health workers for COVID-19 response and was critical to the quick recovery of evidence-based interventions for child health.

Most KIs did not report any problems with stock outs of essential drugs, equipment, or vaccines for routine immunization or child health services during the early part of the COVID-19 pandemic. Consequently, many reported that their hospitals were able to continue as they had before.

However, other informants pointed to challenges with the procurement of materials needed for COVID-19 response and with logistics in general.

In Bangladesh, leaders at all levels were committed to maintaining the provision of key evidence-based interventions for reducing U5M—ANC, PNC, and other maternal and children’s health services – during the COVID-19 pandemic.

In spite of these facilitating factors in Bangladesh’s enabling environment, however, most of the KIs still reported EBI disruptions during the study period.