By observing how the healthcare systems of other countries coped with the outbreak, it may be said that the level of hospital care and intensive care units in Bangladesh are insufficient.
Bangladesh is seeing a rapid increase in COVID 19 cases since the first three were identified on March 8, 2020. Currently, in just over six weeks, the number of confirmed cases is approaching 3,000 and deaths have surpassed 100 people. Although we are seeing a greater proportion of COVID 19 cases in urban areas, standing most cases in Dhaka alone, experiences of other countries suggest that rural areas are soon to be greatly affected. In Bangladesh, over the past weeks, we have seen a number of reports of cases from Narayanganj, Madaripur, and Gazipur, to name a few. Bangladesh’s growth in confirmed cases is behind that of other countries in Europe and in the region. This offers a useful advantage to learn from the experiences of others.
By observing how the healthcare systems of other countries coped with the outbreak, it may be said that the level of hospital care and intensive care units in Bangladesh are insufficient. With around 34 hospital beds for every 10,000 people, Italy is one of the nations which has been massively hit by the coronavirus pandemic. Spain boasts the seventh best healthcare system in the world (with 29.7 beds per 10,000) but still suffered a massive death toll while Bangladesh has four hospital beds for 10,000 people.
Efforts have been undertaken by the government of Bangladesh to reinforce its healthcare system, through the purchase of medicines and ventilators necessary to tackle the spread of the pandemic. Some of these new purchases also include pulse oximeters, and oxygen cylinders, among other necessary equipment. This is an expensive investment for only 15 to 20% of the patients who may require critical services.
Bangladesh has one important advantage that could help tackle this pandemic. Over the past two decades, the nation has invested on a large army of over 50,000 community health workers. They serve from the community clinics, the lowest-level static health facility in Bangladesh. With a small salary, they conduct door-to-door health education through community engagement or at the facilities and health care services to different groups of people, starting from married couples, to pregnant women, the newborn, infants, adolescents, and elderly people. They refer patients with critical symptoms to upazila and district level health facilities for better treatment, which cannot be provided by them.
Over 63% (according to the World Bank) of the population still lives in rural Bangladesh, which demands effective use of existing health resources, such as the community health workers, especially in preventive measures as well as addressing various types of critical communication.
Complementing the government, a number of NGOs such as BRAC employees and thousands of other NGO community health workers support households across the country. They facilitate health check-ups and carry out health awareness and education in their community. With the help of these workers, the primary healthcare system in Bangladesh has a significant position in the world, evident by the achievement of a number of health and hygiene indicators over the decades.
Community health workers, provided with adequate protective equipment, could play a role in the response to Covid19 by providing accurate information to households on prevention, identification and home remedies of non-complicated Covid19 cases. CHWs can emphasize preventive measures to the households they visit, such as hand-washing and physical distancing. They can help identify probable cases of Covid19, if given a simple case definition or algorithm to follow. CHWs can advise people on healthy lifestyle, e.g. giving up smoking, maintaining an exercise regime and eating healthy immune bolstering food. They can give households information on what steps to follow if they have symptoms or someone in the household is diagnosed. CHWs can also address existing myths about Covid19, providing accurate information on the illness and its spread.
Providing essential care services to people confined in their households due to Covid19 infection or risk is also essential. Some examples could include growth monitoring in children, vaccination services and treatment of common illnesses such as diarrhea and coughing, management of diabetes or hypertension for adults and family planning, antenatal and postnatal care for women.
Another way in which CHWs could help is by identifying and monitoring patients at high risk of Covid19 such as the elderly and those with non-communicable diseases (NCDs): defining their location and level of risk and providing them with targeted and accurate information on prevention and care seeking.
Increasing the reach of the surveillance system by reporting probable cases, contact tracing of persons in the community diagnosed with Covid19, and providing guidance on quarantine of affected households is also equally important. This is important in communities with low number of cases before, during and after the outbreak.
Some risks to the adequate implementation of such a program that could be mitigated include:
• The adequate payment of CHWs to take on this increased burden of work, and this could be compensated through incentives for the number of households visited/ informed.
• CHWs might require rapid training on Covid19 to provide adequate information and perhaps provide additional essential health care services or surveillance.
• CHWs will require protective equipment for them to not become infected themselves or become a source of infection for households they visit.
• CHWs will require support from authorities to communicate on their role during the pandemic and ensure households are open to receive their services and support.
The benefits of such an approach would include the continuation of essential health services to populations without crowding of health facilities needed to treat complicated cases, improved and direct communication with households on prevention and management of the illness to ensure adequate information by households, the triage of non-complicated cases away from facilities where they could have potentially infected health workers and patients, the strategic protection of higher risk populations such as elderly or those with NCDs through their identification and strategic communication of preventive measures, and improved community surveillance and faster/proactive community level control.
Community health workers are from the communities they work in and are more trusted by the groups they address. It makes preventive measures such as hand-washing and physical distancing easier to understand by the rural population. CHWs, if adequately trained or guided, can address myths and queries as they will have interactive face-time with the population. Primary care can be provided for the high-risk population which includes the elderly and ones with non-communicable diseases. Since a large urban population has gone back to their rural homes as a result of lockdown, contact tracing can be done more effectively by the CHWs as they have more in-depth knowledge about the community. Although it is not certain how fast the CHWs can be mobilized and what kind of protective gear can be provided for them, but the benefits should outweigh the risk, especially when it comes to ensuring hospital beds for critically ill patients.
Nazme Sabina is a Health System Specialist and consulted for government, research organizations, and development partners in research and policy formulation in Bangladesh.
Dr AM Zakir Hussain is a freelance consultant and was Director, Primary Health Care and Disease Control, Director of IEDCR, Government of Bangladesh, and regional adviser of WHO at SEARO.
Dr Manuela Villar Uribe is a Health System Specialist and works as consultant for international organizations in research and policy formulation across countries in Latin America, Africa, and Asia.