Future of disease control: Bangladesh’s health system needs to be resilient

There is a saying, "There are no mistakes in life, only lessons." The problem arises when we fail to learn from our mistakes or fail to translate those mistakes into an experience. While Bangladesh struggles with the Covid-19 pandemic, the health authorities are tempted to compare themselves with the outliers like the US, UK, Italy, and Spain, which have failed to check the virus's spread. By this, the local authorities feel complacency that they have done very well at pandemic management compared to many powerful countries. Unfortunately, we forget about some other comparable countries that fared remarkably well. Cuba, Vietnam, Nepal, Bhutan, Cambodia, and many African countries have managed the pandemic quite well despite a similar or poorer economic situation.

What did the well-performing countries do right that we did not? These countries have some previous experience. The African countries, particularly the West Africans, experienced Ebola between 2014 and 2016. The South-east Asian countries experienced Severe Acute Respiratory Syndrome (SARS) between 2002 and 2004. Their experience of dealing with an earlier infectious disease epidemic prompted them to revitalize their health system. This experience paid off to tackle the Covid-19 pandemic as well.

When Ebola hit West African countries badly, local health system experts recommended transforming their health system into a resilient one. What does a resilient health system mean? It means the characteristic of returning to its original state despite ongoing challenges. The health system of a country needs to be resilient to tackle pandemics. It should have three characteristics that will make the system resilient. The first one is called 'absorptive' capacity. The second one is 'adaptive' capacity, and the third one is 'transformative' capacity.

Absorptive capacity is when the health system absorbs the shock and returns to its original situation regarding care provisions. It can provide the same or at least similar types of services, even during a crisis. During any pandemic or emergency condition, resources become limited. In such a situation, the health system needs to adapt to low resources. At the same time, it should provide a similar level of services that the system could deliver before the shock. For this, there must be preparation and mindset for adaptive planning. Finally, there would be some services required in a pandemic situation that might not have been needed before. For example, now we need ICU facilities, high-flow nasal cannula, central oxygen supply, pulse oximeter, etc. Hence, our health system needs to be ready and provide the type of services required in a changed situation like a pandemic. This readiness is called transformative capacity.

There is another thing we must consider. It is mostly in a pandemic situation caused by a novel microorganism that things change very rapidly. If there is a cholera outbreak, Bangladesh knows how to deal with it. But when new threats dominate, people don't know how to deal with them. Recent scientific findings and recommendations come up every day—different innovations and medicines surface in the market. Something may work, something may not. This begs prioritization. Adaptive leadership can deal with such situations. The health authorities may say something today and come up with new narratives the next day as per the updated evidence. This is a normal phenomenon and imperative too, but adaptive leadership demands the public's trust in the health systems. The question is, are they trustworthy?  

In Sweden, for example, people have high trust in the government. They have obeyed every changing narrative of the authorities concerned regarding the pandemic. But this could not happen in Bangladesh because the general people and even the health service providers have little trust in the health authorities. For adaptive leadership, we need public health leaders who have a background and expertise in health policy and systems.

Scientific leadership can make effective recommendations based on scientific evidence. But we saw something contrary. The circular made before the last Eid-ul-Azha asked people to say their prayers in mosques, instead of Eidgah. This was unscientific advice because the Covid-19 virus spread more in an indoor environment. If people went to the Eidgah, they would have less chance of getting the virus. 

Who are giving such advice? The health bureaucrats, most of whom, ironically, lack a background, expertise, or experience in public health. The health sector's leadership positions are mostly occupied by unrelated bureaucrats, not the public health experts. But health is a highly scientific field, amenable to technical decision making.

We can refer to a simple example here. For many years, GeneXpert machines have been used in Bangladesh to diagnose tuberculosis. These machines could be programmed to test Covid-19, but our health system leaders did not care using them until the end of June. These machines would not have been left idle when RT-PCR testing facilities were deficient. 

In 2016, the World Health Organization, in its report "Joint External Evaluation of International Health Regulation Core Capacities of the People's Republic of Bangladesh," identified some weaknesses in infectious disease preparedness. These included the quality of laboratory systems, prioritization of public health risk, resources and mapping, operating procedures and planning, case management procedures, coordination among public health and security authorities, providing and receiving medical countermeasures during a public health emergency, etc. The report was published four years ago, but there have been no significant changes because our health leaders barely noticed the message.

We observed a similar situation of indifference during the dengue epidemic of 2019 as well. In February 2019, the British Medical Journal warned about a possible dengue outbreak later that year. The City Corporation, which is ironically responsible for the urban health in Bangladesh, could not realize the importance of that alarm call. Perhaps, they did not have the expertise to translate scientific evidence into preventive measures.

The National Health Policy 2011 called for forming a National Health Council headed by the head of government, involving the leading public health experts. The policy gives priority to preventive measures along with curative services. These progressive recommendations of the health policy have largely been ignored.

There is no specific career track for public health in the health sector of Bangladesh. The Public Service Commission recruits only MBBS degree holders in the health cadre. But health is not just about clinical services. To ensure public health, we need health economists, biostatisticians, health policy analysts, health communication experts, and researchers, to name a few. There must be a public health professional track to deal with health administration, surveillance, policy decision making, research, management of community health, etc.

The Covid-19 pandemic showed us that we need more public health professionals to prevent an outbreak of any disease early on. Suppose we engage only clinicians to do this job. In that case, we will prevent them from performing their actual duties as well as deprive those who require medical services. 

In the interest of Bangladesh's resilient health system and adaptive leadership in the future, I have five recommendations. At first, we need to identify what Essential Public Health Functions are. The next step will be to check what services from that list is already included in the health sector. Next, after finding the gaps, we need to appoint public health professionals to perform those functions. We should develop a distinct but inter-connected career ladder for the public health track. The medical curriculum and higher education in public health also need relevant amendments to promote a system, accommodative of public health graduates. Finally, we need the arrangement to monitor whether the public health career ladder is working correctly or not.       

Dr Taufique Joarder is an executive director of Public Health Foundation, Bangladesh.