|
 
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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 1
| Issue : 2 | Page : 49-58 |
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Impact of COVID-19 on essential health services in Bangladesh: A rapid assessment
Sharmin Parveen1, Nasreen Nahar2, Md Shahriar Mahbub2, Kazi Abu Mohammad Morshed3, Abu Said Md Juel Miah4
1 Department of Health Informatics, Bangladesh University of Health Sciences, Mirpur, Dhaka, Bangladesh
2 Department of Reproductive and Child Health, Bangladesh University of Health Sciences, Mirpur, Dhaka, Bangladesh
3 Advocacy, Innovation and Migration, BRAC, Mohakhali, Dhaka, Bangladesh
4 Advocacy for Social Change, BRAC, Mohakhali, Dhaka, Bangladesh
| Date of Submission | 09-Aug-2022 |
| Date of Decision | 29-Nov-2022 |
| Date of Acceptance | 10-Dec-2022 |
| Date of Web Publication | 20-Feb-2023 |
Correspondence Address:
Dr. Md Shahriar Mahbub
Department of Reproductive and Child Health, Bangladesh University of Health Sciences, Mirpur, Dhaka
Bangladesh
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/JIMPH.JIMPH_6_22
BACKGROUND: The COVID-19 pandemic, one of the greatest public health challenges, has unleashed damage to human health as well as socioeconomic disruptions on an unprecedented scale. The study looked into the experiences of the people seeking essential healthcare services during COVID-19 and the short-term and long-term consequences of the denial of getting these services during the pandemic. MATERIALS AND METHODS: This rapid assessment collected data from 2,483 randomly selected households having an average family size of 4.89 people residing in 16 districts of 8 divisions during the reference period of April 2020 to August 2020. RESULTS: A decline of around 10% in the recommended number of antenatal check-ups (4 or more) was observed. Fear of infection, economic fallout, and absence/redeployment of medical staff to pandemic management are the primary reasons many pregnant women avoided seeking necessary healthcare. Only 1 in 5 (21%) of surveyed households received the family planning services that they required. Around a quarter of all newborn children missed the BCG vaccination. More than half (56.3%) of the families with members having chronic diseases opted for self-exclusion from healthcare services. The healthcare cost increased while the average income decreased by a third of the pre-pandemic level. The inability to express problems adequately to a physician was the commonest difficulty faced by the respondents while using telemedicine—a useful tool during a health crisis. CONCLUSION: Measures need to be taken based on the assessment to mitigate any potential long-term impact on people surviving the COVID-19 pandemic. Keywords: Bangladesh, COVID-19, essential health service, impact
How to cite this article:
Parveen S, Nahar N, Mahbub MS, Morshed KA, Miah AM. Impact of COVID-19 on essential health services in Bangladesh: A rapid assessment. J Integr Med Public Health 2022;1:49-58 |
How to cite this URL:
Parveen S, Nahar N, Mahbub MS, Morshed KA, Miah AM. Impact of COVID-19 on essential health services in Bangladesh: A rapid assessment. J Integr Med Public Health [serial online] 2022 [cited 2023 Mar 27];1:49-58. Available from: http://www.jimph.org/text.asp?2022/1/2/49/370077 |
| Introduction | |  |
First detected in Wuhan City in China in late 2019, COVID-19 continues to distress 216 countries, areas, and territories around the world. This deadliest disease has infected over 574 million people globally and claimed 6.3 million lives till the end of July 2022.[1] Bangladesh reported its first confirmed COVID-19 case on March 8, 2020 and recorded the first death of COVID-19 on March 18, 2020. As of August 7, 2022, the death toll stands at 29,302 and total infections jump to more than 2 million in Bangladesh.[2] To limit the spread of COVID-19, the government of Bangladesh declared general holidays in late March and the lockdown continued until May 30, 2020. Regardless of the increasing trend of COVID-19 infection and death rates, the strict lockdown was lifted afterward for the sake of reviving economic activities and thus regularizing the livelihood opportunities of the people.
Health systems around the world are in jeopardy with the accumulative demand for care of people with COVID-19, intensified by stigma, misperception, and restrictions on movement. In this context, the weaknesses of the healthcare sector have been exposed to a great extent. Bangladesh is no exception in this respect. The ongoing health pandemic triggered by COVID-19 has challenged the country’s overall healthcare system resulting in mobilization of health-specific resources and diverting to combat the COVID-19-affected patients.
Bangladesh has grave deficiencies in doctors, nurses, and medical staff members. According to World Health Organization (WHO), Bangladesh’s doctor-to-patient ratio is 5.26 per 10,000 people, the second-lowest in South Asia.[3] The COVID-19 pandemic has also exposed these deficiencies. Most hospitals, initially, ceased normal operation leaving the non-COVID-19 patients without regular check-ups and treatment. Some running hospitals were also unwilling to take in-patients with the panic that they might be contaminated with the virus. The uptake of maternal and newborn health services was also reduced by approximately 19%. Essential maternal health services such as antenatal care visits and postnatal check-ups in health facilities declined extensively, and deliveries in facilities declined by 21% from January to March 2020, compared with October to December 2019.[4]
Given the situation, the government of Bangladesh has taken some measures that many analysts felt were insufficient. As a result, a noticeable disruption of essential healthcare services is reported. The Ministry of Health and Family Welfare (MoHFW) issued a circular in May 2020 with instructions for all public and private hospitals to provide healthcare services to non-COVID-19 patients.[5]
According to the National Preparedness and Response Plan for COVID-19, Bangladesh spends around 3% of its gross domestic product on health. However, the government contribution under the current budget is only 1.02%, and more than 70% is out-of-pocket expenditure. The total allocation for health and family welfare translates to just 1.3% of the gross domestic product, which is much lower, compared to WHO standards (5% of the gross domestic product).[3]
The study is crucial for several reasons. First, evidence needs to be generated through research so that the weaknesses and challenges of healthcare-providing institutions alongside the sufferings of health service-seeking people can be figured out. Second, relevant stakeholders will get ideas of where they should intervene to create a sustainable, resilient healthcare system to withstand any emergency such as present COVID-19. Third, it will also help to advocate for taking some concrete measures for mending the health-related impacts on people. This study might help provide some evidence-based policy recommendations on these issues.
Health systems of Bangladesh
MoHFW is the key decision-maker and is responsible for health policy design and planning. A network of hospitals and health centers provides health services starting from community levels to national levels. The population at the community level is served by community clinics, union sub-centers, and Upazila (sub-district) health complexes (UHCs). The 424 UHCs are the first-level referral center where inpatient and outpatient services are available. The 64 district hospitals at the secondary level refer patients to 17 Government Medical College Hospitals and 11 specialized hospitals at the tertiary level.
Scope of the assessment
The WHO has circulated a guideline to provide some operational solutions on how to maintain essential health services during COVID-19. According to the guideline, the high-priority categories of essential health services include:
Essential prevention and treatment services for communicable diseases, including immunizations;
Services related to reproductive health, including during pregnancy and childbirth;
Core services for vulnerable populations, such as infants and older adults;
Provision of medications, supplies, and support from healthcare workers for the ongoing management of chronic diseases, including mental health conditions;
Critical facility-based therapies;
Management of emergency health conditions and common acute presentations that require time-sensitive intervention; and
Auxiliary services, such as basic diagnostic imaging, laboratory, and blood bank services.
| Materials and Methods | | |
The locations of the study were chosen from both high COVID-19-affected areas and less COVID-19-affected areas—with a combination of rural and urban locations. The study covered all administrative divisions—two districts were chosen from each of the divisions. One district was chosen from the high-hit districts and another from the low-hit districts of each division. Simple random sampling procedures were applied in the selection of districts. One municipality (City Corporation in applicable district) and one Upazila (sub-district) were chosen from each of the selected districts for data collection. The ratio of urban–rural respondents was 41:59. A total of 2,483 households were randomly selected for the sample survey. The average number of family members in the households was 4.89, which means that this study represents a total of 12,142 from 16 selected districts from all 8 divisions.
A survey method using a semi-structured questionnaire was carried out for primary data collection from the respondents. Face-to-face interviews were conducted by maintaining social distancing and taking protective measures. At the very outset of the interviews, the consent of the respondents was pursued from the respondents, and it was conveyed that full confidentiality of personal data would be strictly maintained. The survey data were analyzed by using MS Excel (Redmond, Washington, United States) and IBM SPSS (Armonk, New York, United States). An analytical framework was used, consisting of dependent, independent, and intervening variables.
Ethical consideration
The research was approved by the Ethical Review Committee of the relevant institution. Verbal consent was obtained from study participants. As data collection was done with the help of an online tool (Kobo toolbox), written consent could not be recorded.
| Results | | |
Background characteristics
A total of 2,483 households were randomly selected for the sample survey. The average number of family members in the households was 4.89, which means that this study represents a total of 12,142 population from 16 selected districts from all 8 divisions. The average number of female members of the selected households is 2.40 and the average male members are 2.48 [Table 1].
Change in the financial condition during the pandemic
During the pandemic, the economic conditions of households changed dramatically. Around a quarter of the surveyed households entered into the lower category of income threshold [Figure 1]. Average income decreased by 37.3% in April 2020, compared to January, increasing slightly in July. Households headed by a male member who did not complete secondary school education, who were involved in small business or unskilled labor, and located in rural areas showed uneven financial recovery.
Experience taking regular healthcare services during the pandemic
Among all the respondents, about 60.8% reported that they or their family members fell into sickness at least once from April to August. One in ten households (9.9%) faced problems accessing general healthcare services. The problems include a lack of sufficient doctors (70.2%), nurses (39.6%), medical equipment (38.8%), medicine, beds, higher fees of doctors, the unwillingness of doctors (23.3%), and hospitals (20.0%) to provide treatment and bribery. People from rural areas complained more about the lack of doctors (75.0% vs. 63.8%) and nurses (42.9% vs. 35.2%) than urban areas. More than a quarter of the respondents (28.6%) stated that their clinical costs increased during the COVID situation compared to the pre-pandemic situation.
Experience in sexual and reproductive health service
Family planning services
One in five households (21.3% rural and 19.9% urban) sought family planning services. Households with comparatively higher incomes and higher education sought more services. Contraception (85.6%) and planned conception (16.1%) were the two common reasons to obtain these services.
The risk of coronavirus infection coupled with financial stress had the highest impact on these services followed by the closure of the nearest family planning clinics (25.85%), unavailability of doctors (19.49%), distance of clinics (9.75%), transportation problem (8.90%), etc., which were more common in rural areas.
Pregnancy-related health services
A total of 167 pregnant women (rural: 69%, urban: 31%) were identified in the surveyed households wherein 10.8% of these women did not take regular healthcare services during the lockdown. In general, public health facilities were preferred by them [Figure 2]. | Figure 2: Place of healthcare support for the surveyed pregnant women during the pandemic (Multiple responses)
Click here to view |
Around 70% of pregnant women needed healthcare support more than three times during their pregnancy period. However, 54% of pregnant women could not get the services according to their needs. They went to the hospitals for regular check-ups (76.5%) and laboratory tests (61.7%), vaccination (43.0%), and emergency service (23.5%). More than 37% of pregnant women received ANC service four or more times (rural 30.3% vs. urban 52.0%).
Around 55% of pregnant women reported no family planning or health workers paid a visit while less than one in five was visited once in three months during the study period.
More than a quarter of all babies were delivered at home during this period. Institution-based delivery was higher in private clinics than in government health facilities [Figure 3]. Only 7.2% of pregnant women received maternity allowance during the survey period.
Of all deliveries, 18% were attended by untrained birth attendants (UBA) at home, mostly in rural areas. Financial difficulties, the closure of the nearest health facilities, and the risk of contracting coronavirus were common reasons behind opting for home delivery and/or involving UBA. More than 40% of deliveries by UBA resulted in the development of complications.
Postnatal care services
Around one-third of the new mothers, mostly from rural areas, did not take postnatal care from any healthcare center. Private entities were given preference while trained health workers also played an important role here [Figure 4]. | Figure 4: Places of postnatal care during the pandemic (percentage) (n = 50) (Multiple responses)
Click here to view |
Newborn care
Among the surveyed households, 24.5% of the newborn babies (age 0-28 days) did not get the BCG or oral polio vaccine within seven days, usually given at birth or the first visit to a health worker. Vaccination in under-5 children was less affected (5.91% unvaccinated). These events were more common in rural areas (rural 69.4% vs.urban 30.6%). The reasons include a lack of information regarding the schedule of vaccination appointments in the health centers, and vaccination points not installed at the usual place [Figure 5]. In the surveyed households, 14.3% of newborn babies were not taken to hospitals despite serious sickness. | Figure 5: Stated reasons for missing vaccination of under 5 children during the pandemic (n = 47) (Multiple responses)
Click here to view |
Experience with adolescent health services
A total of 785 households have at least one adolescent member (10–19 years). More than a quarter of the adolescents (26.5%) received health services during the pandemic. Sexual and reproductive health (SRH) issues were common in about 40% of this age group. In more than half of the cases, care for the accident was the leading cause for consultation.
Experience in health services for chronic diseases
More people from urban areas obtained to care for chronic diseases (overall 22.1%), mainly for regular check-ups, laboratory tests, and emergency care related to chronic diseases. The remaining patients with chronic diseases sought healthcare services including therapy, surgery, postoperative check-up, etc. [Figure 6]. | Figure 6: Types of treatment sought by the patients of chronic diseases during the pandemic (n = 548) (Multiple responses)
Click here to view |
Female and male (54.3% vs. 37.7%) aged between 20 and 60 years were most affected by these conditions followed by the elderly (60+). Urban people (70.5%) were more dependent on private health facilities compared to their rural counterparts (64.9%).
While responding about self-exclusion from taking healthcare services, 56.32% cited risks of contracting coronavirus. Other reasons including the financial crisis (62.5% rural vs. 45.2% urban), unavailability of doctors, and closure of nearest hospitals influenced the decision for self-exclusion.
Experience in mental health services
Only 1.5% of households reported obtaining mental health-related services during the pandemic—slightly more in the urban-level households than the rural ones (1.7% vs. 1.4%). The most common services include regular counseling (48.6%), psychotherapy (35.1%), telemedicine treatment (29.7%), etc.
Experience in telemedicine services
Nearly 6% of households obtained telemedicine services during the pandemic (urban 6.5% vs. rural 5.3%). The range of telemedicine services includes first-aid (52.8%), regular check-ups (35.4%), advice on COVID-19-related symptoms (25%), family planning (15.3%), pregnancy-related treatment, postnatal service, treatment for special children, etc.
More than 1 in 10 households encountered difficulty and half of the users expressed their dissatisfaction while getting telemedicine services. Respondents from rural areas were more dissatisfied with this service. Interestingly, 72.9% of the respondents wish to use telemedicine services in the future.
| Discussion | | |
Worldwide, COVID-19 has created disruption to essential health services resulting in a decline in service delivery as well as uptake by the general population. The most affected service areas include immunization, facility-based services, non-communicable diseases, and family planning services.[6] Response to this ongoing emergency forced the focus of healthcare service delivery toward containing COVID-19 by shifting the health workforce, reducing available clinical service hours for other emergencies, and closing healthcare centers.
In a recent study, loss of livelihood was observed in an overwhelming majority among a group of the low-income population in Bangladesh.[7] During the pandemic, a further 16 million people have been pushed under the poverty line.[8] This echoes the loss of jobs occurring worldwide and dependency on government support.
As most of the health expenditure in Bangladesh is spent from own pocket, there is a significant impact of changes in household financial condition on the capacity to bear health expenses. Treatment of COVID-19 is free in public hospitals in Bangladesh where less than 1% population is under the coverage of a health insurance scheme in Bangladesh.[9] Observation from a pilot health insurance scheme for the low-income group revealed a preference for private health practitioners or private health facilities.[10]
Reluctance or refusal to admit suspected COVID-19 patients in the hospital was an important issue at least during the early part of the pandemic. A debate may be raised about whether this is an ethical issue or professional right in absence of proper protection for healthcare workers.[11] Healthcare providers in developing countries are facing multiple challenges in providing care for these patients either due to lockdowns or patients’ unwillingness to visit health centers due to the fear of getting infected with the severe acute respiratory syndrome coronavirus 2.[12]
According to UNFPA, an estimated 12 million women in 115 low-and-medium income countries faced difficulties and disruptions in accessing essential family planning services in 2020.[13] This could potentially translate into additional 4 million unintended pregnancies before the services gradually resumed. An emergency event like the pandemic can stress the health system and create long-term consequences, for example, unsafe abortions. Mitigation efforts for the continuation of services likely had a moderate impact during the first six months of the pandemic.[14]
Women, in general, often are faced with inequalities regarding accessing health services. Care before, during, or after pregnancy is often available and accessible for women on a limited scale due to social, gender, and financial discrimination.[15] In South Asia, child mortality could increase by an estimated 18%–40% and maternal mortality by 14%–52% in 2021 due to the ongoing pandemic.[16] Similarly, an estimated 11,000 maternal deaths could be due to COVID-19. In Bangladesh, an estimated increase in child mortality (1.4%), stillbirth (3.4%), and maternal mortality (1.7%) are expected during 2020.[16]
Facility-based birth was disrupted worldwide due to COVID-19. In a survey by WHO, one-third of 103 countries reported disruption in this critical maternal care service.[7] Lockdowns in different time periods may have contributed to this situation. Skilled birth attendants continued to provide services in these difficult times.[17] It has been suggested that birth attendants, trained in infection prevention and control, can continue to provide services during the pandemic at the community level when access to health centers is limited.[18]
A decline in postnatal care globally was projected during the early days of the pandemic.[19] Steps like increasing outreach to new mothers through home visits, and utilization of telemedicine services, were suggested where facility-based postnatal care was disrupted.[18] South Asian countries adapted to the situation by suspending facility-based care (e.g. Nepal), continuing home-based service (e.g. Bangladesh), or taking advantage of technology-based solutions.[20]
The Expanded Program on Immunization is a priority program for the government of Bangladesh. A WHO survey reported interruption of vaccination, both at the facility level (61%) and in the community (70%), during the pandemic across many countries.[6] Sustaining vaccination program during the pandemic is expected to reduce utilization of healthcare services already stretched in managing COVID-19 cases.[21]
Newborn care is a core component of child health. Any degree of delay or difficulty in accessing essential newborn care may result in higher neonatal morbidity and mortality.[22] A global survey concluded that disruption in seeking newborn care, continuing kangaroo mother care, and follow-up of the sick newborn were common in many low-and-middle-income countries during the pandemic.[23] The WHO recommends using digital tools for identifying and screening danger signs of sick newborns during pandemic.[18] This can help in prioritizing care for high-risk newborns by following a targeted outreach strategy where community health workers can play an important role.
The need for adolescent health services is greater during a health crisis situation due to the closure of schools, lack of physical access to health centers, increased potential of adolescent pregnancy, and mental health issues, for example.[24] Decreasing household income coupled with an uptick in gender-based violence may also lead to child marriage and adolescent pregnancy.[25] Thus, SRH services for adolescents bear more importance during the pandemic.
Non-communicable diseases are characterized by prolonged duration and the need for repeated interactions with healthcare providers. Any disruption can affect services like diagnostic and therapeutic procedures, essential drugs, rehabilitation services, etc. The effects are amplified when the health system is mobilized toward managing a health emergency by redistributing staff and other resources.[26] Evidence is accumulating that morbidity and mortality from common non-communicable diseases (NCDs) are likely to increase due to limited access to essential emergency care as well as deterioration in the clinical outcome in the long term.[27],[28]
COVID-19 has produced unprecedented effects on daily life. The movement restrictions associated with “lockdown,” financial uncertainty, losing touch with family and friends, and balancing between working from home and child care have exerted huge stress on mental well-being.[29] As an immediate impact of lockdown measures, mental health issues like anxiety and depression were found to be common in the adult population in Bangladesh.[30] Anticipating an increasing need for this type of service, developed countries have expanded access to mental health services through telemedicine more than developing countries (80% vs. 50%).[31]
Telemedicine has assumed an important role in continuing to provide healthcare for patients while minimizing the risk for everyone involved.[32] For physicians who suspended providing consultation due to fear of the coronavirus, telemedicine opened up an avenue to remain available for their patients. There are widely perceived barriers to the more widespread use of telemedicine including lack of ubiquitous internet access, low-digital literacy, lack of confidence, and poor infrastructure for digital health solutions.[32]
Strengths and limitations of the study
SRH, NCDs, and mental health are potentially the most impactful ones affected during the pandemic considering the fact that cross-cutting health conditions can affect more than one area of health. This will also help to get a wider view of the effects on health services.
The survey questionnaire was designed to minimize bias through techniques like logical construction of questions, careful data validation during analysis, etc. However, post-survey adjustment techniques like weighting-class adjustments were not applied which are known to reduce bias in a survey but not eliminate it completely.
| Conclusion | | |
The COVID-19 pandemic has impacted healthcare across the whole spectrum of the health service delivery system. Without any intervention, the community is likely to be deprived of key healthcare provisions necessary to maintain a healthy and functional society. Ensuring the availability of a health workforce trained on infection prevention and control, effective coordination regarding providing COVID-19-positive and non-COVID-19 patients with essential healthcare, use of technology-based healthcare solutions, increased funding to reduce out-of-pocket expenditure can be considered as short-term and long-term steps to decrease the pressure on the already stretched healthcare system.
Acknowledgement
We express our acknowledgement to the Directorate General Health Services, Ministry of Health and Family Welfare, Bangladesh. We would like to thank Nourin Rahman, Ezzat Tanzila Evana, and Nazia Islam (Advocacy for Social Change, BRAC, Mohakhali, Dhaka, Bangladesh) for their extensive help in carrying out this survey.
Ethical approval
The research was approved by the Ethical Review Committee of the Bangladesh University of Health Sciences (BUHS/ERC/EA/20/28).
Financial support and sponsorship
BRAC Health, Nutrition and Population Programme (HNPP) (Grant Reference Number: 03.09.0000. 662.68.053.17-368).
Conflicts of interest
None.
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| 32. | PAHO. Covid-19 and Telemedicine. Pan American Health Organization. 2020 July. Available from: https://www.paho.org/ish/index.php/en/telemedicine. [Last accessed on 07 June 2022]. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1]
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