Prudent spending needed for an efficient public health system: Analysts

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. Given the inadequacy of our healthcare system to cope with the pandemic, there has been much talk about how the sector can be improved to cope with such situations in the future.

Institute of Epidemiology Disease Control and Research (IEDCR) Consultant Dr Mohammad Mushtuq Husain, Founding Dean of the BRAC James P Grant School of Public Health 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. This is an extract of the discussion held on Friday, May 22, 2020. The full discussion is available on the website.

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 are turning to Prof Dr Mushtaque Chowdhury.

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 several 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.

Dr Fahmida: Dr Mushtaque Chowdhury, I want to ask you how a non-government development agency, which is distributing relief, 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 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: 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 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.

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.

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.