Budget should empower existing health facilities, increase tests to fight Covid: health experts

It has been more than two months since the first Covid-19 infection was detected in Bangladesh. Thousands have since tested positive and more than 500 have died. Besides the ever-increasing infection rate, people are curious about what the country's healthcare sector should be like to tackle such a pandemic situation. How much ready is our system for such battles? What should be our priority for investing and improving?

Institute of Epidemiology Disease Control and Research (IEDCR) Consultant Dr Mohammad Mushtuq Husain, ex-vice chairman of Brac Prof Dr Mushtaque Chowdhury, and former regional adviser (South Asia) for World Health Organisation (WHO) Prof Dr Muzaherul Huq discuss all these issues in the fourth session of The Business Standard video conference on the ongoing Covid-19 situation.

Opened by The Business Standard Executive Editor Sharier Khan, the discussion was moderated by Executive Director of the Centre for Policy Dialogue Dr Fahmida Khatun.

Sharier Khan: Welcome to the fourth session of The Business Standard's videoconference. Now I am requesting Fahmida Khatun to start the discussion regarding the current Covid-19 situation and how it has reached a critical point.

I believe that by discussing the issue in this session, we will be able to bring out some important agenda in front of our viewers and the nation.

Fahmida Khatun: Thank you Sharier Khan for inviting me to moderate such an important session and for holding a discussion on the issue with experts who have been working in the sector for years.

We hold frequent discussions regarding the health sector. Discussions about the challenges and weaknesses of the sector have been held many times, along with discussions on whether we are able to provide health care for everyone and the quality of health care being provided.

Such discussions are being held regularly. However, under the coronavirus pandemic situation, these discussions are now in the spotlight. Because health risk is the primary risk posed by the coronavirus, and then comes the economic, social, cultural and other risks.

I want to say this at the beginning that as we discuss the health sector and its weaknesses, we need to know some information. We have made advancement in the sector since the Liberation War.

If we look at various health sector indicators of the past 48 years, such as curbing the mortality rate of mothers and children, Bangladesh is far ahead of other least developed countries, and South Asian and African nations.

We have performed well in achieving the Millennium Development Goals.

If we look at the issue in an infrastructural way – we will discuss the qualitative issue later – Bangladesh is not far behind any third world country. The major factor is receiving the service and quality of that service.

Whether we are able to keep costs within our financial capacity, and how we are spending the money – such matters will be discussed in this session today. We have three special guests with us today.

We will begin with IEDCR Consultant Dr Mushtuq Husain. We are witnessing a number of different pictures amid the coronavirus situation. The health sector is being discussed every day.

We have witnessed that when cases were beginning to get identified in Bangladesh, not everyone were able to get tested, and there was a lack of adequate testing kits and other necessary equipment, too.

What is our current situation? We have been under a lockdown for the past two months, but the number of tests and the death toll have been going up. From March till the present, how much progress have we made regarding the situation, and is it enough?

Give us your evaluation of the situation.

Dr Mushtuq Husain: Thank you Fahmida Khatun. Many people are a bit confused about the testing. When a new epidemic strikes the World Health Organisation (WHO) designated institute IEDCR gets tasked with the first batch of testing.

The procedure is necessary for understanding the nature of the pandemic, details about the new virus and establishing a surveillance mechanism in the country. When the disease begins to spread and get a bit timeworn, commercial kits become available in the market.

The IEDCR has collaboration with the WHO and the Centers for Disease Control and Prevention of the USA. These organisations do not allow the involvement of the private sector in the matter for a set period of time.

During the influenza pandemic, it took six months for the primers to be given to other laboratories.

Under the circumstances, the IEDRC has been saying since the beginning that the test results of the other laboratories will not be accepted by the WHO, and the quality of testing will be compromised. They wanted us to delay the matter.

However, the reality is, when the number of coronavirus patients started to increase, the doctors and healthcare workers started getting exposed to Covid-19 patients, as there was no scope for testing that time.

Many of them faced elevated risk of becoming infected, and many got infected. They also faced a shortage of personal protective equipment (PPE). When we started the preparations (to tackle the pandemic), the health ministry wanted to import PPE from China and Korea.

But China and Korea (at that time) were suffering the worst of the pandemic, and we were having difficulties in importing PPE from anywhere else. This was a weakness.

The testing may have been enough for epidemiological investigation, but the IEDCR could not shoulder the pressure (of providing adequate testing facilities for) treatment of patients at hospitals or ensure screening.

Despite unwillingness from the IEDCR, the health ministry quickly took the right decision to increase testing facilities at hospitals. Testing facility is indispensable for treating (Covid-19) patients at hospitals.

Besides, as the pandemic has entered the community transmission stage and spreading everywhere, the pressure of testing has increased. It is vital to identify Covid-19 patients in communities to isolate and treat them properly in a bid to curb the rising spread of this virus.

Fahmida Khatun: Please pardon me for the interruption. But if we compare Bangladesh to any other country, the impact is still quite low so far. The rates of infection and death are low if we consider the fact that we are a populous nation.

Is it happening because fewer people are being identified as fewer tests are being carried out?

Besides, are we maintaining an accurate record of deaths? The developed countries are keeping records of every death (related to Covid-19). Is the death toll low because of this issue?

Do we have correct information?

Dr Mushtuq Husain: The entire number of current (Covid-19) patients cannot be determined through just the surveillance data. We have to make estimation. A few days ago, I made a comment to the media and it caused quite a stir.

I said that the surveillance data was the tip of the iceberg and it gives us the basis for estimation. At least 10 times the current number of patients can be found outside.

I even estimated that it could be a maximum 30-40 times the current number, based on the experience of the influenza pandemic.

However, it is not possible to hide the number of deaths in Bangladesh.

Those with mild symptoms may be roaming around in the communities, those who live from hand to mouth may not have been giving it much importance, and some may not have any clue about the disease.

So, the number of infections might be greater, but you cannot hide the death toll.

Fahmida Khatun: But we do not know the reason behind the issue. We will return to Dr Mushtuq Husain again. But now we are turning to Prof Dr Muzaherul Huq.

Dr Muzaherul Huq, you have worked for the WHO for a long time. The WHO is playing a very important role at the time of this pandemic. Drawing on your experience of different countries, how would you evaluate the situation in Bangladesh?

Dr Mushtuq Husain has ready discussed about our preparations. But we have heard scientists tell us that the virus will be with us for a long time. This is a type of pandemic that will not go away suddenly.

In the past, we have seen that the Spanish flu took two-three years to get fully under control. Is our health sector ready, both for immediate and mid-terms, to tackle the increasing number of patients and provide them with health care?

What is the plan of the WHO in this regard? And what plan would you suggest for Bangladesh?

Dr Muzaherul Huq: Thank you, Fahmida Khatun. I am dividing your question into two parts. The issue is our preparation, and the two sides related to it.

On one side, did we have adequate preparations to combat such a pandemic? And another is, whether our health sector is prepared to deal with the matter – in present times and in the aftermath.

Let me first discuss the first side. If I draw a few examples from several Southeast Asian countries, we must admit the shortcomings we had during the preparation phase.

For example, when infections started spreading in Wuhan, the first thing the Maldives did was to procure test kits from China. The Maldives did it in February when that country and even Bangladesh had no infections.

They had already collected test kits.

In the Southeast Asian region, two countries – the Maldives and Bhutan – are performing the most tests (for Covid-19). Meanwhile, in the same region, the number of tests being carried out in Bangladesh is even fewer than Afghanistan's.

It is calculated in lakhs, and we are (testing) around 90 people per lakh.

The point I am trying to make is when such a pandemic was heading our way, our preparation should have been more strategic. We must first set a strategy to tackle the pandemic.

Were we prepared in terms of this issue?

I have already given an example about it. We did not take any preparation during the key time. The difficulties we faced at the beginning are somewhat similar to "killing the cat on the first night."

We should have tackled the coronavirus outbreak right from the beginning. For example, Sri Lanka had announced a nationwide curfew for one and half months in the beginning of the outbreak.

By enforcing the curfew, Sri Lanka avoided the elevated risk arising from community transmission situation we are facing now. We could have avoided this issue. Following the curfew, Sri Lanka is now enforcing an alternative to lockdown and slowly reopening everything.

In Colombo, almost everything is gradually being reopened. They will also reopen schools in the near future. However, our lockdown implementation was a bit chaotic. People were a bit confused whether it was a general holiday or a lockdown.

Fahmida Khatun: Yes, there were confusions about whether it was a lockdown or holiday. However, will we be able to recover from the financial losses suffered due to the lockdown?

Many are discussing the conflict between life and livelihood. But both are equally important. Life cannot be replaced vis-à-vis livelihood.

So, we had a continuous lockdown for nearly two months now. Why was it not effective?

Dr Muzaherul Huq: You are saying that there was a lockdown, but the government says they did not implement such a thing.

Instead, a sporadic lockdown was enforced. A building in Tolarbagh was locked down, an area under the jurisdiction of a police station was locked down, a district was locked down.

Somewhere, a deputy commissioner announced a lockdown, and somewhere else, an officer-in-charge (of a police station) announced it. Lockdown was not enforced by many countries in such a way.

The WHO had given some guidelines regarding the lockdown. Then there is the matter of easing and withdrawing the lockdown. The financial impact cannot be ignored. It is not possible for us to stay under lockdown for a long time.

Look at Sri Lanka – their lock was announced for one and a half months, and it was enforced for that period only. Meanwhile, other countries in Southeast Asia did not even have a lockdown.

If you talk about Vietnam, they did not enforce a lockdown. The country prepared for three things – tests, tracing and treatment. If you check them now, you will see that they are not currently under lockdown, and their financial activities have resumed as usual.

They have been carrying out financial activities since the beginning (of the pandemic) without a lockdown. They meticulously performed tests and tracing. They did not leave out people who got infected.

We must set our strategy in this area.

Fahmida Khatun: So, you are saying that we lacked coordination and could not take the right step at the right time. But we still have time. Many are echoing your opinion, stating that we cannot have this lockdown for a long time.

When the restrictions are lifted, we must get involved in testing, tracing and tracking in the future.

We will get back to you. Now we are turning to Prof Dr Mushtaque Chowdhury.

Under the context of the lockdown, you have done a lot of work in the health sector and with the Health Watch. You have also written a few articles, and I have read several of them.

There are talks of lifting the lockdown, but we want to place the same question before you, what are the next steps in our lives?

We are currently living with the coronavirus. How will we cope with the situation?

Another matter related to the issue is, does our healthcare system – which I will discuss in detail in the next segment – have the capacity to bear the burden of the situation for a long time?

Bangladesh is a populous nation of around 17 crore people.

Dr Mushtaque Chowdhury: Thank you The Business Standard for organising this session. We have gone through around 11-12 weeks since the first case was found in Bangladesh. We thought that during mid-May we will reach a peak (in Covid-19 cases), but we have not witnessed it as yet.

I believe that no one can tell for certain as to when we will see the peak.

If we consider the global scenario, we will realise that we will have to live with the coronavirus for a long time, at least for the next two-three years.

We also had a discussion about the Spanish flu. The flu started in 1918 and ended in 1920. The flu struck in three waves. When discussing the Covid-19 scenario, many believe that the disease will hit in several waves.

Many are also saying that the next wave will be even more dangerous than the current one.

So, we must understand the current situation very clearly, and in addition, we must prepare to face the next waves. For this preparation, we need to learn where we stand regarding the situation.

Unfortunately, because of the number of testing being carried out, we are having difficulties understanding the situation clearly. It is hard to say what stage we are currently in.

But we must move forward regardless of the situation.

Fahmida Khatun: What do you want to blame for this issue? We are not getting a clearer picture of the situation, but this limitation is nothing new. We discussed it at the beginning of this session.

What is your suggestion for overcoming this issue? And what is the major reason behind this?

Dr Mushtaque Chowdhury: I can speak of a few reasons. When we started working on the matter in Bangladesh, it was a government issue.

If we want to solve an important crisis such as the coronavirus outbreak, we must employ the whole-of-the-society approach.

However, we have seen that the involvement of the civil society, the NGOs and other sectors is not as deep as it should be. Their engagement is quite low.

In Bangladesh, we faced a number of disasters, and NGOs and the civil society played a large role at those times. But this time, we are witnessing fewer instances of this phenomenon.

One of the reasons behind the issue is that the government – since the beginning – has not involved the civil society in this matter. I do not know the reason behind it.

Besides, the government formed various committees, such as the national committee and coordination committee, but none of them has any representatives from the civil society.

Fahmida Khatun: To find an answer to this question, I am turning to Dr Mushtuq Husain. You are working for the IEDCR as a consultant. This is the time of a severe crisis that needs a concerted effort from every sector, from providing health care to distributing relief and in overall management. Without the involvement of everyone, it will not be possible for us to tackle the crisis.

We all understand this. So, what is the reason behind the reluctance?

Dr Mushtuq Husain: This is not reluctance. May be the people put in charge by the government believed that the crisis will be over in a short time. Many among them, not all, thought it will never arrive in Bangladesh.

They thought that our country is warm and rain is frequent. The virus has weakened. This was a wishful thinking.

So, as few people as possible, from the health ministry and the directorate, got involved. When the strain increased, other ministries got involved too.

One of the first to respond the crisis was the Bangladesh Armed Forces. They told us that they have seen such crises in other countries during peace missions. They also said a large approach is needed to tackle the situation.

They said that they will be able to turn the Army Stadium or the Ijtema grounds into a field hospital. Those are a few examples.

So, the escalating situation caused the people put in charge by the government to deal with the situation to take various initiatives.

Regarding the rush of people centring Eid, we should not blame them. Considering our social structure and our environment, we failed to make the marginalised people of our country understand that if the disease spreads, the disaster could be severe.

For this task, only the involvement of the ruling party is not enough. Dr Mushtaque Chowdhury was right about the issue.

If we cannot ensure the involvement of all social components, including the civil society, the government, non-government and voluntary organisations, if we cannot make people understand the gravity of the situation, if people become careless, if the number of infections increases manifold, people will blame the government.

Fahmida Khatun: So, the government's goodwill is one of the important matters. The other matter is the possible existence of other groups or circles that could influence the government.

When we discuss the overall health care, we see that a group has formed centring the whole system.

As I said at the beginning of this session, the healthcare infrastructure is not too bad in Bangladesh. We have upazila health complexes and community clinics. But if we take a closer look, we will see that many might not have the adequate number of doctors, nurses, technicians and anaesthetics.

Many might not have the necessary equipment, or proper manpower to operate them.

Besides, a few days ago a journalist said an upazila health complex, which was built in 1994, was being run by only a few staff members. The facility received the permission to hire full staff in 2014.

Such scenario shows us a picture of mismanagement, and there is also a certain quarter with vested interests. Any type of procurement is an important issue. To buy something, the tendering process alone takes a significant amount of time.

Pricing is also a factor. Sometimes, a thing costing Tk400 is procured at Tk10,000-12,000.

Such instances of mismanagement are prevalent among us.

Dr Mushtaque Chowdhury, what will you say about the coronavirus crisis, and the healthcare sector as a whole? When will we overcome such issues?

Dr Mushtaque Chowdhury: Before answering your question, I just want to discuss two other points based on your previous question.

The indecision or the ambiguity shown by our government is still prevalent, particularly while enforcing various containment measures – for example the difference between a holiday and a lockdown.

Recently, the government declared that Eid prayers will not be held at Eidgahs, it will be held at mosques. It should have been the opposite.

Because mosques have little room and transmission will be higher there. Meanwhile, if the congregations are held in open spaces, the risk of transmission goes down.

We have another term in the epidemiology called "zoning," which refers to different areas where the number of cases is higher or lower. Steps are taken considering this factor.

Instead of opening up the whole country, we should first open up areas where the infection is lower. This way the whole situation will remain under control. We still have time to follow the zoning method.

I was having a discussion the other day regarding opening of schools in the country. All schools were shut down due to the pandemic, and all will be opened simultaneously.

However, instead of doing this, if we can find 10 districts where the number of cases is low, and open up schools there, we will get clearer picture on how to maintain social or physical distancing there.

And on the basis of that, when we open up larger portions of the country, we could then move forward more confidently.

Fahmida Khatun: I am turning to Dr Muzaherul Huq for an answer to the same question. We will have to live with the coronavirus for the next two-three years. Diseases are unending, if one goes, another will take its place. It is a part of our lives.

What is your suggestion for overcoming the problems and weaknesses of the overall healthcare system?

Please share your recommendations on the basis of your work in the sector for years.

Dr Muzaherul Huq:  Thank you Fahmida Khatun. No country was prepared, not even America.

We know that our healthcare system was also not prepared to tackle the coronavirus. As we were not prepared, it is up to us to prepare now for the coronavirus and its aftermath.

We cannot make a prediction on how many years we will have to live with the coronavirus. If we do have to live with the virus, we need to make appropriate preparations.

However, we are certain that the coronavirus is spreading rapidly across Bangladesh, and containing the decease should be the government's only priority for now.

If we fail to achieve this, the coronavirus will cause the current healthcare system in Bangladesh to collapse. If this happens, the number of deaths due to the pandemic will be beyond anything we can imagine now.

Our first objective should be the containment of the outbreak, and we must do everything to achieve this objective. Dr Mushtaque Chowdhury earlier gave us a suggestion about zoning.

I have also given similar recommendations on multiple occasions. If a zone has more than 300 cases, make it a red zone, below 300 but above 100 cases should be declared a yellow zone and fewer than 100 cases should be declared a green zone.

In the green zones, identify, isolate and treat patients in areas where the number of patients is high. Use contact tracing to track down people who came into contact with the Covid-19 patients and take them to institutional quarantine.

Then open those districts to all financial and other normal activities. This should be our only strategy for now. Besides, the WHO has a guideline on easing and lifting the lockdown.

The organisation has six points for every country to fulfil.

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Our upazila health complexes are not functional. Their lower tiers are not properly functional too. What we see is that infection is rising among those who are being tested only. But we cannot say the exact number of cases outside the tested ones. So, we can assume that the infection is spreading.

We are treating patients and isolating them but the contact tracing is not taking place that much. Contact tracing and separating every single Covid-19 patient is highly necessary for Bangladesh. We will never be able to eradicate the coronavirus from the country unless we do this work.

We have Communicable Diseases (Prevention, Control and Eradication) Act 2018 that has specific sections on how to control a contagious disease under the responsibility of the district civil surgeon. We have divided all districts into red, green and yellow zones. The civil surgeon should be given the responsibility of setting separate strategies for these zones while the deputy commissioner and the superintendent of police should assist him.

Dr Fahmida Khatun: I want to come to Dr Mushtuq Husain's point. We have noticed a few incidents in Dhaka. Many non-Covid patients too are in critical conditions. For an example, an additional secretary died recently. His daughter herself is a doctor, and she moved to 14 hospitals with her sick father but no hospital agreed to admit him before a confirmation whether he contracted the coronavirus.

But how can a non-Covid patient have the test when his condition is critical?

Even a few days back, a pregnant mother who came to Dhaka from Gazipur to get her baby delivered also did not get any treatment. She was sitting on the road until a microbus saw her and took her back to Gazipur where the dying mother gave birth to a child.

The hospitals which are supposed to give general health services are not doing that. Where is the problem? Aren't they deviating from the path of their motto in medical science – serving the patients?

Dr Mushtuq Husain: Before coming to this point, I would like to continue the thread of the previous discussion.

What we usually understand about the preparations of health system is how many pieces of equipment and how many doctors a hospital has. But the first condition of controlling an epidemic is whether the community has the facility within it to prevent, detect and give first aid for the disease.

The United States has many large hospitals but they do not have the public health infrastructure to prevent the disease. They, as the Europe, thought that no contagious disease would spread in their country. So, their airports did not have the home quarantine facilities nor did they have thermal scanners.

But Bangladesh, India and China had all those. However, the prerequisite to dealing with a public health disaster is how much our community health system is prepared for that. Even though we have the system to some extent in our villages, we do not have the facility in cities at all.

Now coming to Dr Fahmida's point, the hospital authority is primarily responsible for the mismanagement in their facility. The health directorate has issued some instructions. To what extent private hospitals are sincere to follow those directives should be monitored.

Private hospitals where Covid-19 units were opened had some complaints about a limited test facility for indoor patients only and not having enough doctors.

The government has recently deputed 2,000 new doctors from the BCS health cadres for those hospitals and testing outdoor patients has also been approved. Even then, there are mismanagement in private hospitals. However, we hope private hospital authorities will no longer harass any patient.

Dr Fahmida: Yes, a government monitoring or supervisory role on private sector hospitals is necessary because there are questions about the quality of treatment and behaviour with patients even in some expensive hospitals.

I want to come to you, Dr Mushtaque Chowdhury, on the issue of emphasis on a collective effort to deal with Covid-19. I want to ask you how a non-government development agency, which is distributing relief actually, can come to the aid of giving health services.

Dr Mushtaque Chowdhury: The big NGOs have health workers, for example Brac has 50,000 health workers across the country. This big force is being used to increase awareness about the coronavirus among the rural people. They can also be used in virus testing.

However, it is not possible for Bangladesh to test all the people like what China's Wuhan has done. So, we have to find out the alternatives. As these health workers are based in rural areas, they can easily pick who have Covid-19-like symptoms

If we can reach this information to the higher level, i.e. IEDCR, we can easily prepare a second estimate about which areas may have more cases.

Dr Fahmida: Are those health workers of NGOs being given any training on it?

Dr Mushtaque Chowdhury: Different NGOs work in different ways. What I know about Brac is: yes, the health workers have been given training. First, they have been provided personal protective gears. Second, they have been asked to create awareness about social distancing among the rural people.

As a nation, we have great achievements but failed to put adequate focus on investing in the primary healthcare system. If we look at Thailand, they have a huge investment in this sector. There, no one can go to a hospital directly without going primarily to a GP (general practitioner).

Dr Fahmida: So, where is the weakness? Is it about the financial constraints as we know that the allocation for our health sector is only .09 percent of the GDP or below 5 percent of the national budget? Again, we see that the budget allocation cannot be increased too as the already given fund cannot be utilised fully.

Dr Mushtaque Chowdhury: I think both the sides, the health ministry that is taking the fund to spend and the finance ministry that is giving it, have problems. We know releasing money from the finance ministry usually takes up to three quarters of a financial year. As a result, the health ministry falls in a huge pressure to spend it within only one quarter. However, the finance ministry can solve the issue if it wishes to.

Another problem is that most of our outdoor patients – more than 70 percent – come for medicines.

We provide the upazila health complexes with medicines from time to time. When they get medicines, they use them. But there is a large shortage of medicines at these health complexes.

If we can meet this shortage, if we can supply medicines timely, and if we can resolve the relevant issues – developing the human resource such as doctors, nurses etc, for example, and distribution of them properly – if we can do that, we will be able to ensure a universal health care that everybody talks about. Then we can achieve the goal of health care for all and that will benefit all, especially the poor.

Dr Fahmida Khatun: Thank you. Now I want to come to Dr Muzaherul Huq. Dr Mushtaque Chowdhury said a while ago about creating awareness at the rural level. But we see that the educated urban people too lack adequate awareness. When the government allowed the shopping centres to open, urban people flocked to buy new clothes to celebrate Eid. Not only that, they are also visiting their relatives on the occasion of Eid. So, which type of behavioural change is needed for the people?

Dr Muzaherul Huq: Look, our resources are limited. But these are not being used judicially.

Dr Mushtaque said one thing that money is spent the most behind buying drugs. But it is not right. Salaries to our officials and staff take the most money away followed by infrastructure and procurement of equipment where there is a scope of pilferage or corruption.

We should first think how to use the resources judicially.

He also said that it is not possible to test 17-18 crore people. With due respect, I want to say that Covid-19 will spread if one single person with the virus goes undetected. There will be risks until we find out all the people infected with the virus through contact tracing and ensure home quarantine for them.

The decision makers will have to decide whether they will remain busy for years with the virus or will find out the infected people at the quickest possible time.

As a PCR test takes time to detect the virus, why don't you go for an antigen-antibody test that takes only 5-10 minutes?

You said about the 50,000 Brac health workers. Even they can perform it as it is a very easy test.

We usually blame the common people that they are not cooperating. But your very first strategy was a wrong one! When you identified the first coronavirus case on March 8, you should have gone into a one-and-a-half-month lockdown.

Dr Fahmida Khatun: Sorry to interrupt you. Many countries, especially the developed ones, that relaxed their lockdown due to lower infections had to impose it again.

Dr Muzaherul Huq: Yes, you are right. But you will lift the lockdown only when you will be able to contain the infection. It means that those countries have managed to decrease the virus' transmission. Then they went through a second wave.

You know that if a person gets infected in the second wave, he does not transmit the virus. But those who will be infected afresh will spread it. For this reason, I said that the infected ones should be identified quickly and put into home quarantine along with those who came in contact with them.

An indecision about how many days the people will be kept indoors or outdoors has prompted them to go outside. One more thing: how many days will you confine the daily wage-earners indoors? We failed to motivate or involve people in our battle against the virus. Creating awareness among them works little if we cannot motivate or involve them in the process.

Dr Fahmida Khatun: Can you please explain how the people can be involved in the process?

Dr Muzaherul Huq: I will give a small example here. We have wards at the rural level where there are ward councillors. If they assure people, alongside creating awareness, that they, with their volunteer groups, would help the people, reach the government relief to their doorsteps, people would have remained indoors. They should have said: "It is our fight; we will fight it together."

However, we still can do this. Are we doing this? That is called the involvement of the local people.

Sharier Khan: Here, I have a question to you all. Every year, what happens is that different sectors get different incentives from the country's fiscal budget. But now, if we do not bring the health sector above all under control given the gravity of the coronavirus situation, nothing will be meaningful. So, to you, what should health allocation in the upcoming budget focus on, i.e. the type of the budget, the size of the allocation?

Dr Fahmida Khatun: Thank you. First, we are saying that the size of the budget should increase. But at the same time, there are limitations in increasing it as I mentioned earlier. However, focus should be placed, like what Dr Muzaherul Huq said, on performing coronavirus test on every single citizen and tracking the Covid-19 patients.

Besides, we should concentrate on making equipment, i.e. ventilators, available for ICUs in hospitals. If there is any procrastination in implementing the suggestions, we have put forward here, there will be no benefit of the increase in the budget allocation. What will be useful is spending the whole money instantly from the allocation.

The finance ministry's duty is to give allocation while the responsibility of the health and other related ministries is to spend the fund entirely.

Dr Mushtaque Chowdhury, please say something in reply to Sharier Khan.

Dr Mushtaque Chowdhury: Yes, I agree with your points. Now, we should think of giving a "big bang" which will come from the prime minister. The "big bang" should be focusing on two issues: how to increase the health allocation to 1.5 percent of the GDP and how to overhaul the entire health sector with the increased fund.

To spend the money, we should create new sectors in the health system along with setting up new health institutions.

If we look at Thailand, they are far ahead in the public health coverage. Back in the 1960s, they established many large health institutions, such as Mahidol, who do research on health and on how to strengthen the health system.

To implement all these, the government should have a commitment to the highest level. Then, we will be able to make a universal health coverage system in Bangladesh.

Dr Fahmida Khatun: Dr Mushtuq Husain, what will you say in reply to this question?

Dr Mushtuq Husain: We do not have the capacity to test all the 15 crore people of the country. Shall we sit idle then? Of course not. We cannot perform massive tests unless the WHO approves rapid test kits for the coronavirus.

Dr Muzaherul Huq: I want say something here. You said about the WHO approval. The WHO never opposed antibody-antigen tests. What they said was that it could not be used as a diagnostic test to treat the patients. Rapid testing kits should be used only as a primary diagnosis or screening of the disease.

Dr Mushtuq Husain: Yes, and a survey is going on to work on the issue, to find out a disease burden through testing the antibody. Now as the whole Bangladesh has turned into a pandemic zone, we should identify each person having a fever and put him or her in isolation either in their home or in a hospital for the treatment. The IEDCR can do this. The epidemiological approach to control the pandemic, put forward by Dr Muzaherul, is very much possible.

Now, I want to come to the issue of the budgetary allocation. Look at Thailand. There, a wave of cases was created and stopped. The waves are also being seen there at times. They took no new measures against it. The name of their ministry is Public Health Ministry, meaning that their first priority is to serve the public health. All their institutes, as mentioned by Dr Mushtaque, are the public health ones.

To set up our ones, we need to spend the budget as well as create appropriate human resources for the public health system. How will the ventilators come to use if there is no appropriate manpower to run them? The planning minister said there is no place to spend the money. The government should ask the health experts, both at public and private levels, to prepare plans and allocate funds five times the present amount if necessary. It is very much possible to improve the country's public health infrastructure and make people aware of what they should do primarily to prevent the disease.

It is right that the increased budget cannot be spent as per the present infrastructure and manpower. But if the people who will plan to make the entire health system solely public-oriented is given the charge, I think, they will fall short of funds even if the allocation is given five times more. Let me give an example. If you provide training on controlling the pandemic to the countrywide health workers, both at government and non-government levels, and organise a 6-month crash programme to give an orientation to the community leaders to engage the whole community, a big amount of money will be spent there. With this increased fund we can also initiate public health institutes to create manpower for the public health. If we do all these things with good governance, the additional funds will be fully utilised.

Dr Fahmida Khatun: Dr Muzaherul Haque, we will conclude the session with your comments on the issue.

Dr Muzaherul Huq: We should keep in mind two points: communication and community engagement, if we really want to control Covid-19. The WHO has been focusing on community engagement from the very beginning.

Now coming to spending of the budget allocation, I previously said one thing: the judicial utilisation of whatever the resources are available. What should we do to ensure that? Look, 64 percent of the population take health care from private hospitals while only 36 percent go to government hospitals. So, I would say the government can easily run the health system with the money it gets.

I would recommend the government prioritise the areas to spend the money. After that, the priority of the priorities should be set. As the Covid-19 impacts will be there in the next five years, should I prioritise setting up new constructions or should I go for ICU beds, ventilators, oxygen, oxygen masks etc which are essential to save a life immediately? Of course, I can go for new institutions. But the already existing ones are not functional. So why go for new ones before making the present ones functional? If they can be made functional, our health care will be improved.

The next important point is: who will drive? That means our skilled healthcare manpower. They should be given quality training on the healthcare. The standard of our medical education is very poor.

Dr Fahmida Khatun: Yes, in Bangladesh, there is a political interference in appointing doctors and posting them. That means there is a severe lack of professionalism here. Dr Huq, all these issues are related to your points too.

Dr Muzaherul Huq: It is the issue of management. What I am focusing on is the optimum utilisation of the resources I have. Then, I should allocate funds by prioritising the areas. We will be able to find a way out from the Covid-19 if we can do these. Thank you.

Dr Fahmida Khatun: Thank you all the three health experts for their valuable views on the Covid-19 issue. However, I want to mention some points from the discussion to draw the curtain on today's session.

First, we have understood that we are not going to be relieved from the Covid-19 crisis any time soon where our focus should be how to prevent, cure and eradicate it. For that, the government should take steps to ensure a coordination among all the related divisions and workers to fight the virus.

Second, only making new infrastructure or buildings and increasing allocation cannot remove the risks from the health sector whatsoever. We should concentrate on, as the discussants said, priorities – ICU beds, ventilators etc – to deal with Covid-19.

We see every year that there is a tax rebate facility offered in the budget proposal in procuring health equipment. Private hospitals take the facility but regrettably they do not spare the people from charging extra on them. We see that the health cost in Bangladesh is higher compared to that in other countries, including our neighbours. So, the government should have an overall management – monitoring, supervision and leadership – on the issue of ensuring cheaper healthcare for people in these hospitals. Our healthcare will not be improved until we can strengthen our public health system.

Covid-19 has given us a food for thought whether we should go for a universal healthcare system for those who live below or slightly over the poverty line. If we can ensure primary healthcare through the universal healthcare system, we will be able to move forward in improving the people's quality of life.

I convey my gratitude to the audience who were with us throughout the session. I also thank The Business Standard for organising a discussion on such an important issue. Now, I am going back to Shahrier.

Shahrier Khan: I want to thank you all for an excellent discussion. In the future too, we hope to sit with you again. Here we announce conclusion of the conversation. Thank you all again.