EBI coverage in Bangladesh during the first year of COVID

Bangladesh experienced broad disruptions in EBI coverage early in the COVID-19 pandemic.

Key informants reported disruptions to the following services during the initial months of the pandemic:

• Pentavalent and measles and rubella (MR) vaccine coverage
• Outpatient department consultations for children under five
• Women receiving four antenatal care (ANC4) visits
• Facility-based deliveries
• Postnatal care visits

According to interviews with key informants (KIs), various supply- and demand-side barriers to EBI delivery contributed to these disruptions. Some of these barriers, such as the fear of contracting COVID-19 on the part of health workers and community members, were caused by the spread of the virus itself. Others were the result of interventions implemented to control the pandemic, such as lockdowns and movement restrictions.

Lockdowns and movement restrictions

Officials in Bangladesh implemented the country’s first lockdown in March 2020, and KIs report that it presented a significant barrier to EBI maintenance. For example, on the demand side, movement restrictions kept mothers at home, resulting in a decrease in facility-based deliveries. On the supply side, lockdowns interrupted field-level maternal and child health interventions for several months, and health care workers struggled to get to and from health facilities. The prohibition of large gatherings also prevented in-person trainings for health care workers as well as mass vaccination events in the spring of 2020.

Staff shortages in health care facilities and redeployment to pandemic response

In Bangladesh, even before the pandemic, staff shortages often interfered with EBI delivery: one KI estimated that 30 percent of posts in the immunization program were vacant. The rapid spread of COVID-19 put an additional burden on overstretched health care workers, most of whom had to focus their attention on pandemic response. Access to other essential services was limited, as was the quality of those services when they could be delivered.

KIs also reported that health care providers did not have essential supplies they needed at the outset of the pandemic, such as PPE and masks.

Pandemic-related financial strains

Poverty has been endemic in parts of Bangladesh for generations, but – as it did in many other places around the world – the COVID-19 pandemic made its challenges starker and more visible. In the absence of social safety nets, health-seeking behavior – which requires money for travel, services, and medicines if necessary – declined. Some KIs also reported worse health outcomes in poorer, harder-to-reach regions such as Sylhet and Chattogram.

Fear of COVID-19

In Bangladesh, KIs cited community fear of COVID-19 as a significant barrier to health-seeking behavior during the pandemic. For instance, patients worried that if they went to health facilities for any reason, they would contract the virus from sick patients or health care workers. This was especially true for pregnant women, many of whom refused to give birth in facilities because they worried that they or their babies would get sick. Mothers were likewise wary of bringing their children to a facility for nonemergency but essential health care, such as when they had a cough or cold; as a result, delivery rates for those services fell drastically. Immunization outreach services were interrupted because community members were afraid to let health care workers into their homes. According to KIs, patients did continue to visit more familiar – but informal, uncertified, and untrained – “quack” health providers in their local communities for medical advice.

Health care workers, too, feared contracting COVID-19. This fear was reasonable: the infection and death rate among health care workers in Bangladesh was high.¹ (Key informants explained that this was partly because some had not been trained on COVID-specific infection prevention control protocols.)

Over time, health care workers grew more familiar with the COVID-19 virus and protocols for managing it, and supplies such as PPE, glass barriers in health care facilities, and antigen tests became more widely available. As a result, health workers’ fear of COVID-19 diminished.

Though limited private-sector data prevents us from knowing the full extent of the challenges Bangladesh faced during the early months of the COVID-19 pandemic (for example, some KIs suggested an unspecified level of shift in care-seeking from public- to private-sector facilities), findings from the public sector suggest that the country experienced broad EBI disruptions between March and June 2020. (The lack of data covering the private sector also means that the extent of COVID-related disruptions to service utilization in that sector is unknown.)