Posted on May 3, 2020

Covid-19: A reality check for Bangladesh's

healthcare system
6

Photo source: Observer BD and aljazeera

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

Source:IEDCR
 Fig 3: Age Distribution of Confirmed Positive Cases.

Source: IEDCR

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

Indicator Bangladesh India Pakistan Sri Lanka Nepal Bhutan

Out of Pocket Expenditure (as % of 73.9 65.1 60.2 49.8 57.8 13.3
current health expenditure)

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.

Looking Forward

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

• Filed under:
• Coronavirus COVID-19
• Goal 3 Good health and well-being
• Bangladesh
• Success Stories
• Goal 11 Sustainable cities and communities