Cookies

We use cookies on our site to analyze traffic, enhance your experience, and provide you with tailored content. For more information, visit our privacy policy. By clicking “accept" or continuing to browse this website without disabling cookies, you consent to the use of cookies.

Health-system resiliency in Bangladesh during the first year of COVID

Available data shows that widespread efforts to address these early supply- and demand-side challenges had an effect, at least in the public sector: starting in June 2020, key indicators began to recover from these initial disruptions. A strong enabling environment – including a strong community health system and existing networks for collaboration – and a catalog of adaptable strategies for boosting EBI coverage helped officials and health care providers respond to the first months of the COVID-19 pandemic while also mitigating disruptions to key child health interventions.

COVID-19 response in Bangladesh

According to interviews with key informants (KIs), Bangladesh’s early response to COVID-19 helped mitigate the impact of the pandemic and kept a surge of infections from overwhelming the health care system. As a result, by August 2020, the system could recover and maintain delivery of essential child health services in this emergency context.

  • Early in 2020, global shortages and supply-chain issues made it difficult to locate sufficient PPE for health workers; but as time passed, officials were able to provide an adequate supply of protective equipment. They also supported the widespread use of infection prevention control (IPC) measures, contact tracing, and isolation training. The Directorate General of Health Services (DGHS) also provided online training on these topics to providers and managers.
  • Government officials made funds available for COVID-19 response, set up separate COVID-19 treatment centers, and allocated special teams of doctors and nurses for pandemic response. Task-shifting likewise increased the emergency availability of health care workers.
  • Rapid antigen tests became available at lower levels of the health system, facilitating patient triage.

“Overall, at the beginning we had inadequate equipment and we panicked. Slowly we overcame the situation. On behalf of the government, gradually we have been able to provide adequate supplies of personal protective equipment and service. Service providers did not suffer from any problems such that they could not provide services.”

- KI

Most of the strategies Bangladesh implemented to prevent or respond to COVID-related drops in EBI coverage were already in place before the pandemic and were adapted to suit their new context. We categorized these interventions into three main categories: infrastructure, policy/leadership, and human resources for health. More detail on these is below:

Data use

Many KIs pointed to Bangladesh’s culture of data use for learning and decision-making. The availability of data from the public sector (through the management information system [MIS] at Directorate General of Health Services [DGHS] and the Directorate General of Family Planning [DGFP]) enabled the Ministry of Health and Family Welfare to track key health indicators and service coverage and respond quickly to the challenges that that data reflected. During the early months of the COVID-19 pandemic, data-driven strategies for decision-making included:

  • Weekly monitoring meetings for the Expanded Programme on Immunization (EPI) program, designed to provide feedback on low-coverage areas to managers
  • The use of public MIS data to track progress, service utilization, and coverage at the district or upazila (subdistrict) level (because private data is not often available for routine use)
  • Predicting the frequency of death using Sample Vital Registration System (SVRS) data
  • Reviews of monthly public data (from the Ministry of Health and Family Welfare along with districts and upazilas) and feedback during in-person and virtual workshops and meetings
  • Reviews of public data for service disruption, including the number of children who missed vaccination, from the Ministry of Health and Family Welfare, districts, and upazilas
  • Reviews of public data from the hospital level, including the number of patients admitted and the number of recoveries
  • The use of disaggregated analysis by geographic area
  • Accumulation of data from the World Health Organization to inform policymakers preparing the country to respond to COVID while maintaining health services for children under five

“Our main focus was data analysis, to see how we adopt policy and take management decisions for operational monitoring. The purpose of the MNCH [maternal, newborn, and child health program] operation plan monitoring service was to monitor the operation and support decision-making.”

- KI

“When we saw that these child health services, for example IMCI [Integrated Management of Childhood Illness program] and all these services, were going down, immediately we had this mechanism to sit with the program people, here at the national level, and they identified the priority actions. We supported them with data because this is the kind of capacity they require. So, we gave that support in terms of data analysis and how to interpret the data. Then looking at the geographical distribution of the disaggregated level data enabled us to look at the services that are going down in terms of not only the national-average data, but also the disaggregated-level data – that means at the district and upazilas level.”

- KI

“We inquired about why essential newborn health care has been reduced, while breastfeeding has been reduced, why Helping Babies Breathe activity reduced; what has happened to infection prevention? This is how we basically tracked these from MIS data. Because it seems clear that the data were up-trend until February [2020], but they fell down from March to April [2020]. Thus, it can be easily understood in which areas service reduction has taken place, by making a chart. Another thing is that we talk a lot about data in our country; unfortunately, all [sources] are public data, not a single one is private data, and you will never get a total picture until the total data system (public and private is) integrated.”

- KI
Digital platforms and e-health

KIs report that even before the COVID-19 pandemic, Bangladesh had implemented digital health services across the public and private sectors to promote and protect public health. These services include telehealth; Skype and other video consultations with health care providers; data collection from remote rural areas via health management information systems; and monitoring, surveillance, and human resource development, including professional development via virtual training and orientation on new and adapted guidelines. Additional COVID-specific e-health services were added in March through July of 2020, including virtual risk communications, online contact tracing and hot-spot identification, and strengthening of pre-existing telemedicine services.

Providers in the public and private sectors alike took advantage of digital-health services such as telemedicine and video consultations to serve patients safely and distantly,1 and Bangladesh developed guidelines for telemedicine for patients, practitioners, and administrators (including trainers) at all levels of the health system in July 2020.2, 3 The public sector used telemedicine services to link patients and providers at different levels of care, including two specialized hospitals, three district hospitals, and three subdistrict hospitals. Using webcams and other videoconferencing platforms, specialists could “see” patients who had been admitted to less-specialized hospitals, eliminating the need for travel and in-person contact.4

“For example, we developed a website from NNHP [National Newborn Health Program] and IMCI. It was in process before, but we developed a website and incorporated a lot of our service-related things there. We created it in a way where one can contact us, or whoever enters into the website will get the name and mobile number of the head of the upazila health complex in that area. We also developed lots of videos on how our services work in the COVID-19 situation. We made an animation. These serve as SBCC [Social and Behavior Change Communication] materials. We put these on our website. And the direct telemedicine service or the emergency telemedicine service was running as usual in our hospitals throughout the COVID-19 situation. Actually, we did not launch any different telemedicine services during this period.”

- KI

“We (at the hospital) have a Viber group. From there we can observe the current hospital condition, in which direction it is going, alright? What is the situation of COVID-19? If any doctor or our director provided new suggestions or any directions, we tried to incorporate them. We had another Viber group with doctors and the Public Service Commission (PSC), which is a separate group. We also kept in touch with that group.”

- KI
Leveraging existing systems, capacity, and experience

Bangladesh utilized its previous experience in epidemic preparedness and response – with dengue fever, Ebola, and SARS – to build capacity for EBI maintenance in the COVID-19 context.

“And we also had the dengue fever in previous years, and we had a threat of Ebola and SARS. So, these are the things – when you go through this kind of regular exercise, responding to health needs or natural calamity, you develop some capacity, and I think that also worked here.”

- KI
Community engagement and education

Because KIs described community fear of contracting COVID-19 as a significant barrier to health seeking during the pandemic, officials and providers used various community engagement and awareness strategies to alleviate fears and ensure the continuity of key health services. For instance, upazila-level health managers advocated to increase community awareness regarding facility delivery; officials from the Institute of Epidemiology and Disease Control Response and elsewhere organized campaigns to raise public awareness about service provision and IPC and advertised services using Facebook, YouTube, and posters; and providers initiated courtyard meetings to increase health-seeking behavior (antenatal care [ANC], for example). Government and nongovernment satellite television channels broadcast public health guidance.

“Our health workers have made household visits. We have about 50,000 health workers. They, along with our other 50,000 field staff of the Bangladesh Rural Advancement Committee (BRAC), conducted household visits and raised awareness about COVID-19.”

- KI
Donor and partner coordination

In Bangladesh, governmental and nongovernmental organizations built on existing coordination networks to maintain EBI delivery during the early months of the COVID crisis. For examples, donors and implementing partners came together to provide technical assistance and guidelines for the continuation of maternal and child health services. Likewise, DGHS coordinated a technical working group, including implementing partners and donors like UNICEF, to develop a priority action plan for COVID-19 response.

“Another big strategy that we took is that we have different partners working in different districts. We had a quality improvement initiative in many of the districts, and it was very useful during the initial phase – very quickly going to the facility in that situation of COVID-19 because there was an overall fear among the service providers. There was a lack of PPE, not sufficient or quality PPE at that time. We had quality improvement initiatives ongoing, we are supporting at the facility level on-site monitoring, and all of these.”

- KI

“COVID-19 gave us that window of opportunity because we have been trying for many years for this, i.e., introducing pulse oximetry, strengthening the oxygen for pneumonia case management . . . we grabbed this opportunity.”

- KI
Focus on equity

Especially during the COVID-19 pandemic, the Government of Bangladesh focused its attention on maintaining EBIs in hilly, hard-to-reach areas such as Sylhet and Chattogram. Staffing health initiatives with local providers can help build a sense of community ownership.

“The Government of Bangladesh ordered giving maximum focus on the targets of maximum programs, and there has to be maximum focus in Sylhet and Chittagong divisions (hard-to-reach divisions and areas where care-seeking pattern due to social taboo is an issue). So, this might improve slowly and gradually by 2020, but the inequality still persists and maybe will persist since the care-seeking pattern in those places will not change overnight. Though the care-seeking pattern is changing, a hard-to-reach area does not become reachable overnight.”

- KI

“Maintaining the cold-chain system will not be a problem because we already have solar power and ice-lined refrigerators (ILR) in the hilly areas, especially in inaccessible, hard-to-reach areas. And we have a special plan for the hard-to-reach areas. We have revised the definition of hard-to-reach areas according to EPI. We brought the civil surgeons of each district to the EPI headquarters and have identified hard-to-reach areas in their respective districts through workshops. We allocate the funds separately for hard-to-reach areas so that there is no problem within the work of their staff.”

- KI
Updated guidelines, protocols, and training for maintaining EBIs in the COVID-19 context new

In the months after the onset of COVID-19 in Bangladesh, Bangladeshi officials also developed COVID response strategies specifically designed to maintain EBIs in the pandemic context. These included new MNCH guidelines for essential service delivery, EPI service delivery guidelines, and guidelines for community clinics, as well as:

  • The continued provision of newborn care following COVID-19 protective measures
  • The development of specific guidelines allowing COVID-infected children to continue to receive Kangaroo Mother Care
  • Provider training on COVID-19 transmission so newborn care can continue (for instance, by assuring mothers that the virus cannot be transmitted via breastmilk)
  • Encouraging facility delivery after checking for COVID-19 infection
  • The preparation of a standard operating procedure for EBI delivery in the COVID-19 context
  • Designating separate queues for ANC so patients do not come into contact with one another
  • Adapting existing centers and hospitals to maintain EHS delivery as well as COVID-19 treatment

Officials provided orientations on these guidelines and strategies to nurses, doctors, paramedics, and other health care providers, reassuring them that they could continue to provide services to mothers, newborns, and children even during the pandemic.

“When COVID-19 started here, by March or April, we started working on our national guideline for MNCH service right away. And from March to May we were able to apply it in the field; it was a quick response.”

- KI

“So, whether it may have been with hard copy or soft copy, there was an arrangement for orienting these guidelines at the local level. These guidelines were very clear, simple, and user friendly.”

- KI

Two KIs also reported some level of transportation support for health care workers during the pandemic period; however, this support was inconsistent and not widespread.

“Yes, transportation was arranged. Since we have doctors or nurse living far, to move amid the lockdown situation, transport facilities were provided. It was off and on.”

- KI

“When it comes to transport, the transport facility may have been provided to HCWs [health care workers] at the city corporation level or at the urban level, but not as much at the upazila level.”

- KI
Leveraging community-based health care delivery

Health officials in Bangladesh implemented some interventions via existing cadres of community health workers. For instance, BRAC built community trust by restoring outreach sessions for immunization; conducting household visits to promote demand for essential health services and raise awareness about COVID-19; providing education to boost health-seeking behavior (including ANC) among pregnant mothers and mothers of young children over the phone; conducting syndromic surveillance in urban areas; and bolstering the capacity of community clinics by helping triage patients and providing PPE, IPC, and data management training to staff.

“Our health workers ensured the health education by communicating with each of their pregnant clients and the mothers of the under-two children by phone until we came back on the field or as long as our online training was ongoing.”

“So this is a strategic approach where we have strengthened our community clinics on how to respond to such crises, and we capacitate them to respond to this crisis. We did this along with the government.”

- KI
Mentorship, supervision, and training and strengthening human resources

According to interviews with KIs, officials provided various virtual trainings in response to initial EBI disruptions early in the COVID-19 pandemic. These included provider training on the transmission of COVID-19 to enable newborn care to continue; Community Nutrition Center trainings; district-level trainings on hypertension (high blood pressure); and training for administrators on updated health guidelines.

“Further, after developing the guideline, we had to inform the service providers about it. Next, we virtually joined our service providers at different levels, from our upazila health administrators to the senior staff nurses, and gave them an orientation about our guideline. Yes, after the orientation they started trying to continue the service according to our guideline and gradually started working.”

- KI

Officials and providers also reimagined processes for regular mentorship and field supervision of health facilities to suit the pandemic context.

“We could not conduct in-person monitoring during COVID-19. So, when we checked the regular data from DHIS2 and when we noticed that this district or this upazila was not performing well, then we immediately set up online meetings with our UH&FPO [Upazila Health & Family Planning officer] of that upazila, the civil surgeon from that district, the divisional director, and in general with the staff and talked to them directly from EPI. We tried to find out their problems and solve them accordingly. And if there were other key tools, I would say the e-tracking system. So by doing this we were able to bring the whole of Moulvibazar district and some parts of Dhaka South City Corporation under our monitoring. And currently we are trying to expand it to 16 districts. So hopefully if it is implemented, we will have another very strong monitoring system besides DHIS2, which is the e-tracking system.”

- KI
  1. 1
    Rahman SMM, Hossain SM, Jahan MUJ. Digital Health During COVID-19 Pandemic and Beyond. Bangladesh Med Res Counc Bull. 2020;46(2):66-7. https://doi.org/10.3329/bmrcb.v46i2.49014
  2. 2
    Bangladesh Medical & Dental Council (BM&DC). Telemedicine Guidelines. Dhaka: BM&DC; 2020. Accessed November 10, 2021. https://www.bmdc.org.bd/docs/BMDC_Telemedicine_Guidelines_July2020.pdf
  3. 3
    Khan MM, Rahman SMT, AnjumIslam ST. The Use of Telemedicine in Bangladesh During COVID-19 Pandemic. E-Health Telecommun Syst Networks. 2021;10(1):1-19. https://doi.org/10.4236/etsn.2021.101001
  4. 4
    Directorate General of Health Services (DGHS). Telemedicine Service. Accessed November 10, 2021. https://old.dghs.gov.bd/index.php/en/home/84-english-root/ehealth-eservice/490-telemedicine-service
Next

Bangladesh’s enabling environment

Sections