How to flatten the virus curve? Budget should focus on wider healthcare access

The country's healthcare system leaves out most of its citizens, especially those who are economically marginalised and live far from cities and towns, making the fight against Covid-19 even more difficult at present.

The public health system has four layers, beginning with 13,779 community clinics at the bottom. Then there are 2,000 primary healthcare facilities or upazila health complexes, and finally, 254 secondary and tertiary-level hospitals combined.

But this wide network still fails to serve rural areas where more than 60 percent of the population live.

There are many anomalies playing in the background of this non-functioning system: new hospitals built where posts of healthcare providers are left vacant for years; facilities without any diagnostic equipment; equipment and machinery installed without anyone to operate them; and 100-bed hospitals turned into 250-bed ones overnight without increasing the numbers of doctors, nurses and technologists.

The pattern of such poorly thought-out investment has been replicated year after year, depriving the public of healthcare. Now, the people in rural areas deprived of adequate healthcare are the mode of spreading the infection from one to another across communities and different parts of the nation.

This mistake cannot be made again. Not when resources are limited against a raging pandemic, and when no matter how much money the government puts into the broken healthcare system, it will not be enough.

In terms of budget, the health sector has remained one of the most neglected ones. Its annual funding has been hovering around 4-5 percent of the total budget since 2016. The money was equivalent to no more than 0.9 percent of the GDP – far from the 5 percent target set by the World Health Organisation (WHO).

This time around, however, the health budget is expected to get a boost. Public health should get the highest priority because it will help revive the economy as well. The budgetary allocation for strengthening the backbone of the system should ensure everyone's access to medical services to the best interest of tackling the coronavirus pandemic.

But while setting priorities, the government has to move away from its traditional approach.

The health allocations over the years reflect the authorities' fixation with infrastructure and procurement of medical equipment. In the budget for 2019-20 fiscal year, 25 percent of the Tk25,733 crore health budget was allocated for infrastructure and medical equipment, after the highest allocation of 33 percent for wages and salaries.

Still, the lack of healthcare is always blamed on a lack of infrastructure.

The reason is that the development has hardly established wider access to healthcare. But wide accessibility is what is needed to flatten the curve of the virus transmission through identification and isolation of every infected case.

Recently, projects have been taken up to open intensive care units (ICUs) at district or secondary hospitals and equip them with ventilators. Doctors at district hospitals said many facilities do not have anaesthetists and other specialised physicians to run ICUs.

Most of the investment in terms of infrastructure, equipment and manpower have so far been made in the capital, followed by divisional headquarters. District and upazila-level hospitals and community clinics have skeleton infrastructures sitting on the ground without manpower and the logistics to run them.

Even the Kurmitola General Hospital and the Kuwait Bangladesh Friendship Government Hospital – two of the initial six hospitals dedicated to treating Covid-19 in the capital – could not expand their ICU operations because of a dearth of skilled manpower and equipment. They have 10 ICU beds each, with respective plans to add another 12 and 16 beds that have been shelved for months.

Meanwhile, the queue of patients waiting for ICU beds keeps getting longer because of a shortage of oxygen supply in the wards. 

Fitch Solutions in April said, "With a continuation of weak economic growth, compounded by the Covid-19 outbreak requiring a budget surplus, public funding for healthcare services and pharmaceuticals will remain insufficient."

In this situation, the return from an investment has to be calculated wisely.

Activating a referral system

According to the WHO, 40 percent of Covid-19 cases are mild and another 40 percent are moderate. About 15 percent develop severe illness and require oxygen support, while 5 percent suffer from complications such as respiratory failure and multi-organ failure.

The WHO emphasises on preventive medical interventions to keep transmission low rather than treatment as the disease has no proven cure. It highlights the need for community engagement and "a Covid-19 referral pathway" to ease pressure on healthcare facilities.

"Our primary healthcare should get priority," said Mushtaque Chowdhury, founding dean of the Brac James P Grant School of Public Health.

He added that community healthcare workers should be engaged in raising awareness in villages, identifying those with cough, fever or other Covid-19 symptoms, and then contact tracing them in efforts to contain the transmission in communities.

These healthcare providers, well-connected to almost every rural household, can then follow up on the suspected or confirmed Covid-19 patients, advise them and their families on social distancing and nutrition, and refer the patients to the nearest facilities for treatment depending on the severity of illness.

To make that happen, they should be trained and encouraged with incentives.

Without primary healthcare, infected people with mild to moderate symptoms in the communities remain undiagnosed and expose others to the infection.

One is also prompted to go straight to tertiary hospitals, bypassing the facilities in the first and second tiers, when health condition worsens, thus overburdening the tertiary hospitals.

The virus spreads in the meantime, leading to higher infections and higher cases of severity.

Setting up ICUs and installing ventilators are important to save critical patients, but what is more important is to check community transmission so that the vulnerable people do not get infected in the first place. If virus transmission goes unabated, ensuring access to ICU facilities and ventilators for the increasing number of critical patients will be an unrealistic feat to achieve.

Dr Kamrul Azad of the Barguna District Hospital said adequate oxygen supply at upazila and district hospitals might save the majority of the 15 percent severely-ill patients. 

If an effective referral system were put in place, the tertiary hospitals would have to treat only critically-ill patients, he added.  

The referral system that the WHO and Dr Kamrul advocate for depends on optimum usage of resources, which will also play a role in post-Covid-19 universal health coverage.

"This budget [for fiscal year 2020-21] should be the budget to fight against the coronavirus. Healthcare should be made affordable, accessible and available," said Prof Muzaherul Huq, former adviser of WHO's Southeast Asia region.

He added that enough skilled manpower should be deployed in healthcare facilities – be it in cities or rural areas.