Originally published in undp.org on 3 May 2020
UNDP Bangladesh Research Facility
Since the diagnosis of Patient Zero in Wuhan, China, late last year, the novel coronavirus has spread across 210 countries and territories. As of May 4, there have been 3.53 million confirmed cases, with more than 248,000 deaths.
The Current Covid-19 Scenario in Bangladesh
Bangladesh has been entangled in fighting Covid-19 for two months now. As of May 4, more than 195,000 people are in quarantine and there are 10,143 confirmed cases and 182 deaths. Worryingly, Bangladesh was among the fastest in the world to reach 2000 cases, reaching the figure in just 40 days after its first case on March 8. Globally, only Italy reached this figure faster.
Fig 1: Number of Days to Reach 2,000 Cases in Selected Countries
Source: Dhaka Tribune
The figures for both deaths and infections were initially low. But the number of cases have started to rise very quickly, up from 54 single-day cases on the 8th of April to 641 single-day cases just 20 days later. Due to the low number of tests, these cases have been detected out of a relatively low test sample. IEDCR data shows that citizens in the age range of 21 to 40 are most highly at risk of catching the virus, making up 50% of confirmed cases. Around 70% of deaths have been those aged over 50.
Fig 2: Daily Number of Cases in Bangladesh
Fig 3: Age Distribution of Confirmed Positive Cases.
Bangladesh’s Public Health Sector Response
According to the DGHS’ National Preparedness and Response Plan for Covid-19, Bangladesh’s overall spending on health is around 3% of GDP. However, the government contribution under the current budget is only 1.02%, and more than 70% is out-of-pocket expenditure, the highest in South Asia. According to the Ministry of Finance, the overall allocation for health in the FY 19-20 budget is 4.9% of the total budget, which is one of the lowest in South Asia. It fails to meet World Health Organization (WHO) standards of 15 percent of total budget (or five per cent of the GDP), and has been stagnating since 2015. An overwhelmed healthcare system is almost giving out. But why is Bangladesh faring poorly?
Table 1: Out of Pocket Health Expenditure in South Asia
|Out of Pocket Expenditure (as % of current health expenditure)||73.9||65.1||60.2||49.8||57.8||13.3|
Fig 4: Bangladesh Health Budget as % of Total Budget
Source: Bangladesh Ministry of Finance
Speaking on the issue of Bangladesh’s response to the covid crisis, an eminent health expert in Bangladesh observed that the country had lost valuable time by not shutting down till 25 March, three months after the Wuhan scare. Furthermore, he expressed the view that the government was indecisive, and was not firmly determined on implementing either the lockdown or distancing decisions.
Discussing the same issue, the regional director of a leading NGO opined that Bangladesh’s response suffered from a lack of inter-sectoral coordination. He went on to further state that if Bangladesh had carried out the public health response planning based on a worst-case scenario, it might have started dealing with Covid-19 earlier and more effectively.
Meanwhile, port entries were poorly screened. Testing rates initially stood at 10 samples per million before picking up recently. Enforcing social distancing has also proved to be difficult.
Fig 5: The state of Bangladesh’s Healthcare Facilities
Source : Centre for Policy Dialogue, based on BHFS 2017
Furthermore, there is an acute shortage of medical professionals—doctors, nurses and medical staff members. According to WHO, Bangladesh’s doctor-to-patient ratio is 5.26 per 10,000 people, the second-lowest in South Asia. Only Bhutan, with a ratio of 3.7 per 10,000 citizens, ranks lower. As a comparison, Georgia’s ratio is 50.9 per 10,000 citizens. A leading public health expert also observed that there is a maldistribution of health-sector workers, with 78% of Bangladesh’s population living in rural areas, while 70% of doctors are stationed in urban areas.
Healthcare Workers at Risk
The situation is getting worse with Covid-19: more frontline workers are now testing positive. 25% of doctors and 60% of support staff are yet to receive PPE, with reports of substandard PPEs flooding the market, according to a survey by BRAC’s James P. Grant School of Public Health in select facilities. According to the Bangladesh Doctors Foundation (BDF), doctors now make up 6.5% of total cases.
An example of such a case is the current Upazila Health and Family Planning Officer and DGHS focal point in one of Bangladesh’s Covid-19 hotspots. Even on the day the doctor tested positive, he was working a 17-hour shift, and continued to tend to his patients over the phone while he stayed in isolation. Having recently recovered, he now coordinates a team of six doctors and oversees treatment plans for close to 900 patients. The team uses detailed medical records to decide between home quarantine and hospital admission for patients. The doctor is of the opinion that Bangladesh is past the stage of sample testing, and that anyone with symptoms should immediately be treated as a Covid-19 patient and told to stay home. As a mitigation measure for the virus, the doctor suggested separating groups by area so that they can call a different number for medical advice. He called for ambulances to be sent for critical patients so that no one needs to go out in the open.
Overall, there is a pervading sense of concern among citizens. News reports highlight high infection risks in hospitals, with more and more frontline workers falling ill. In Dhaka’s Mitford Hospital, 42 medical staff, including 23 doctors, tested positive with covid-19 in April, allegedly from a patient who hid information about having contracted the virus. According to data from Bangladesh Doctors Foundation (BDF), intensive care units and general wards of as many as 11 hospitals across Bangladesh had to be closed down after healthcare workers were infected.
How are Non-Covid Patients Coping?
As a result of multiple hospitals closing down, non-covid patients are being denied regular checkup and treatment, thus aggravating their condition. Some functioning hospitals are also reluctant to take in patients fearing that they are contaminated with the virus, as happened a young Bangladeshi returnee from Canada, who died due to gastrointestinal complications after doctors and nurses were reluctant to treat her fearing that she had covid, especially as she had come from outside Bangladesh.
A number of hospitals have been designated specifically for covid and to that extent, the pandemic has crowded out services for other non-covid patients, in a country where the healthcare system was already under huge stress even before the pandemic. With many doctors and nurses also staying away from the hospitals, monitoring medical equipment such as oxygen tubes and ventilators have become a problem, adversely affecting patients suffering from non-covid related illnesses. Because of a fear of catching the virus, non-covid patients are also deciding not to go to the hospitals for appointments.
A young woman, who was interviewed for this article, reported that she went to a private hospital for a regular checkup in March and that although there were sanitizers and masks at the facility, she saw patients not taking precautionary measures, after which she decided not to visit hospitals for follow-up appointments. Instead, she now accesses the telemedicine services when she needs advice for herself and her parents. The lockdown has added to the burden of patients like her and her parents, who now have to worry about getting treatment on time and arranging for transport
Initiatives by the Government and Private Sector
While the overall response has largely been a reactive one, the government has taken some good steps to deal with the crisis through a special insurance and stimulus package for doctors, nurses, and other health professionals. This includes special insurance and incentives for covid-19 frontline fighters, health insurance of Taka 5 lakhs to 10 lakhs (depending on rank), and up to 50 lakh if someone is at higher risk or dies from the virus, and the government has also agreed to bear the cost of treatment if anyone falls sick while on duty. The respective total amounts are Tk. 100 crore for medical staff treating covid patients, and Tk. 750 crore for life insurance of those affected while treating patients. Furthermore, the Bangladesh Public Service Commission has finalized its recommendation to hire 2,000 doctors and 5,000 nurses to deepen the human resources to tackle the virus.
Private entities have also come forward. Bashundhara Group, for example, are using the Bashundhara Convention Centre space to build a 2000-unit hospital which will also have 71 Intensive Care Units (ICU). Likewise, Akij Group has also decided to set up a 301-bed hospital in the Tejgaon area. China Railway Group Limited (Crec), the contractor of the Padma Bridge Rail Link Project, donated Personal Protective Equipment (PPE) and other safety gears to Bangladesh. International private sector partnerships are also adding to the covid response, with Unilever partnering with icddr,b’s covid-19 response by providing by providing cash support and test kits.
Going forward, there are some obvious priorities now. It starts with protecting frontline workers better and ensuring access to safe and immediate healthcare facilities for both Covid and non-Covid patients. In the longer term, Bangladesh’s healthcare system needs an overhaul to build resilience to future disasters such as the ongoing pandemic. Medical professionals need to be available in both rural and urban areas alongside improving governance and management in the healthcare sector. This is even more important now in light of the government’s plan to open up some activities in a planned manner, with attendant risks if mitigating risks are not taken. There is also a need to raise the service quality in the healthcare sector, and greater coordination between the public and private sector to improve healthcare standards.
On the policy side, a few key steps could be taken. Firstly, in the upcoming budget for FY 2020-21, the allocations for the health sector should be increased significantly in view of addressing the health impacts of the pandemic and ensuring safety of workers and citizens. Second, the government should incentivize selected private sector hospitals and clinics to go for dedicated covid-related arrangements. Third, while the government has introduced health insurance for medical staff working in covid-related areas, the remit and depth of support may be further increased. Fourth, investment should be made for mass testing and in setting up specialized quarantine facilities as well. After all, Covid-19 is teaching Bangladesh the hard way that its actions now and later put the lives of 160 million people in the balance.
This article is written by the UNDP Bangladesh Research Facility team
In private sector National Hospital also provides treatments for COVID patients.