Stories from the field: Special series on the COVID-19 response – Bangladesh
Bangladesh has instituted an ambitious public health intervention, providing a community clinic for every 6,000 people. The Government has been able to establish more than 13,200 of these clinics all over the country, covering the whole population. They have become the people’s first point of contact for essential health services in rural areas and means that everyone can access the services they need, closer to their homes, through community health clinics. With the COVID-19 pandemic, the system was put under severe pressure, and people naturally experienced fear and anxiety about the virus. But community health workers made significant contributions in sharing information and advice on staying protected, while ensuring that essential health services continued.
Learn how Bangladesh is playing its part in building a fairer, healthier world.
Community health workers in Bangladesh have played a crucial role during the COVID-19 response. They have ensured the continued delivery of essential health services, health promotion and prevention, including behavioural communication activities.
WHY IT MATTERS
As the backbone of the primary health care system of Bangladesh, community health workers are key to driving progress towards universal health coverage and ensure health system resilience. Rural communities can access health services close to home, including during the pandemic.
If everyone can access essential health services including during the COVID-19 pandemic, the Bangladeshi population as a whole will experience improved overall health and better socio-economic status.
WHO has worked closely with the Government to build and strengthen the capacities of community health workers for decades. This included the provision of technical assistance for training and the development of guidelines and protocols for community health workers during COVID-19.
THE LONG READ
Archana Rani was worried when her 3-year-old son, Subol, developed a high fever, but she knew exactly where to take him. The Borogoan Community Clinic in Bochagani District is just a 5-minute walk from where she lives, and she trusts the community health care provider, Mr Harish Chandra Devshorma, to conduct a proper check-up and give the right advice. She also knew that if her son needed any medication, it would be provided free of charge.
“The community clinic is a blessing to us. We do not need to go to the town for essential medical care. It saves our time and money. We are economically poor as we have to work hard every day for our livelihood,” said Archana.
Local community clinics operate across Bangladesh, providing primary health care services to rural and often marginalized populations. Each clinic has a full-time community health care provider, who is assisted by 2 other community health workers who serve part-time in the clinic and part-time visiting households in the community catchment area. These community health workers provide antenatal and postnatal care, conduct diabetes and blood pressure checks, look out for signs of fever, diarrhoea and cough. They also support family planning and safe delivery, provide advice on nutrition, adolescent health and hygiene, among other services. They are regarded as the backbone of the primary health care system of Bangladesh and they have been making a major contribution to the delivery of essential health services to rural populations throughout the COVID-19 pandemic.
Community health clinics
One of the most pioneering health efforts in Bangladesh was the introduction of a community-based health care programme in the 1970s. Since then, the programme has gone from strength to strength with a growing cadre of community health workers playing a critical role in improving the overall health and the socio-economic status of the Bangladeshi population.
Bangladesh has a pluralistic health system where both public and private sector providers play important roles. According to a study in 2021, the country has about 148,000 community health workers of which about 60,000 are supported by the Government; the rest being in BRAC and other non-government organizations. They are respected as very important assets of the health system.
In 1998, Bangladesh instituted an ambitious new public health intervention: a community clinic for every 6,000 people. The Government has been able to establish more than 13,200 of these clinics all over the country, and they have become people’s first point of contact for essential health services in rural areas. Community clinics have now become the prime strategy of the Government towards achieving universal health coverage (UHC). Bangladesh has built up its community health workforce with a focus on women’s empowerment, sustainability, community mobilization and engagement with community clinics.
The Government of Bangladesh and WHO have established a solid and long-standing partnership to improve the health of the population. WHO has strongly supported the Government’s high priority to provide effective community-based services in a range of ways. WHO has been providing technical support for capacity building since 1998, when community clinics and community health workers programmes started up. WHO also supported the establishment of the first 14 community clinics in rural Bangladesh from 1999-2000 as a pilot project.
Since 2010, the country has received even more intensified support. This has contributed to the development of community health care providers who lead the community clinics and related monitoring and evaluation guidelines. WHO supported development of a 3-month-training manual for community health care providers, and organizes training of trainers for health inspectors and medical officers based at Upazila Health Complexes.
“Community health workers are the indispensable part of the health system. They are the key to primary health care and a major strategic partner to the journey towards achieving universal health coverage in Bangladesh. They are regarded as the first line defenders against any disease, pandemic or local outbreak in the community. We really appreciate WHO’s technical assistance in the development and strengthening of community health workers programmes in Bangladesh. WHO’s support was instrumental to the development of the national community health workers strategy (2019-2030) and capacity development of the community health workers by making them fit-for-purpose,” said Sabina Alam, Joint Secretary, Human Resources, Health Services Division, Ministry of Health and Family Welfare, Bangladesh.
WHO, through the UHC Partnership, also provided catalytic support through an initiative called “Better Health in Bangladesh: Health Systems Strengthening Technical Assistance 2018 – 2022,” which aims at strengthening the health system to accelerate progress towards UHC and health-related Sustainable Development Goals. This has contributed to strengthening the country’s community-based services programme further.
Community health workers respond to COVID-19
Community health workers have been playing an important role in the COVID-19 pandemic response. Since they remain close to the community, they are the first point of contact for people living in rural areas in Bangladesh. When COVID-19 first emerged as a highly transmissible disease in March 2020, people became anxious and curious. Their lives, livelihoods and the existing healthcare system were all threatened. Fear, prejudice and lack of awareness meant that people were not visiting health facilities for essential services, and when COVID-19 vaccines were made available, people were not coming to the vaccination centres either.
So community health workers performed the essential function of working as ambassadors of the public health system.
District health managers asked them to reach out to community members, raise awareness about public health and help revive trust in the health system. Community health workers also conducted contact tracing, facilitated home quarantine, isolation, referral and follow up in the rural and hard-to-reach areas.
“The Government’s community health workers were utilized to create awareness on the implementation of COVID-19 health and hygiene rules and advice, and were engaged with the national vaccination programme. Without their involvement, we cannot make our vaccination programmes successful. […] community health workers are the key gateway to reach the people based in rural communities. They have been with us from the emergence of COVID-19, helping us create public awareness by eliminating the public’s anxieties and fears against the disease,” said Dr Abul Basar Md Sayeduzzaman, Upazila Health and Family Planning Officer, Bochaganj, Dinajpur.
There are of course other challenges. “Masks and hand sanitizers are the most important supplies for healthcare providers as they deal with both COVID-19 and non-COVID-19 patients. They need to change masks every few minutes, but we can’t ensure adequate supplies every day. This really is a big challenge now. Our local leaders and philanthropists may come forward on this, which will really help save the lives of the health workers by preventing them from getting infected,” said Dr Sayeduzzaman.
WHO support to the COVID-19 response
“WHO has been working closely with the Government of Bangladesh to build and strengthen the capacities of community health workers in the country. Since the outbreak of the pandemic in early 2020, WHO has provided technical assistance for training and the development of guidelines and protocols. In addition, WHO also provided medical supplies to the Ministry of Health and Family Welfare, and we will continue doing so in the future,” said Dr Bardan Jung Rana, WHO Representative in Bangladesh.
WHO has been working closely with the central and district health systems of Bangladesh. WHO’s technical officers, including surveillance and immunization medical officers, have supported the capacity building of district and field level medical officers and staff. WHO officials provided training on infection prevention and control; COVID-19 management, including contact tracing, quarantine, isolation, and referral; and evaluation and follow-up based on standard guidelines approved by WHO and Ministry of Health and Family Welfare. As a trusted partner, WHO has been tasked to mobilize resources from different donor agencies to assist the country in COVID-19 management by providing medical goods and products such as quality masks, COVID-19 testing machines, testing kits, personal protective equipment, respirators, oxygen supplies and more human resources.
Primary health care helps maintaining essential services during COVID-19
When the COVID-19 pandemic began, Bangladesh’s health system faced competing demands; with a shift in focus towards emergency response while at the same time maintaining the delivery of essential health services. In April and May 2020, data from Bangladesh’s National Health Information System showed sharp reductions in the use of key essential health services across all levels of care. However, Bangladesh’s primary health care network provided a critical platform for the country to build back most of its essential health services by October 2020. This highlights the critical role of primary-level health facilities to both monitor the population’s access to health services, and to implement strategies and interventions that rebuild and strengthen health service delivery. This in turn supports progress towards universal health coverage and more resilient health systems.
Bangladesh and health security
The Government of Bangladesh has recently demonstrated its commitment to growing and strengthening its pandemic preparedness capabilities. In 2016 the country volunteered for a Joint External Evaluation of its capacities to prevent, detect and respond to health emergencies. The gaps identified during this evaluation were used to develop the Bangladesh National Action Plan for Health Security in 2019. The National Action Plan is a country-owned, multi-year, planning process that is based on One Health for all-hazards, and a whole-of-government approach. Bangladesh also completed a Simulation Exercise in 2018 to further develop, assess and test the functional capabilities of its emergency systems, procedures and mechanisms to be able to respond to outbreaks or public health emergencies.
In addition, the country conducted a bridging workshop on International Health Regulations (IHR) Performance of Veterinary Services in 2019 and developed a roadmap for integrated response activities for zoonotic events. The Government regularly submits the State Party Self-Assessment Annual Reporting Tool (SPAR) through the National on IHR focal point. The country is continuously improving in all 24 indicators under 13 core capacities of IHR 2005 to detect, assess, notify, report and respond to public health risks of domestic and international concern, such as COVID-19.