|POLICY AND PRACTICE
|Year : 2021 | Volume
| Issue : 3 | Page : 93-99
Maintaining essential health services during the pandemic in Bangladesh: the role of primary health care supported by routine health information system
Sangay Wangmo1, Shila Sarkar1, Tasmia Islam1, Md Habibur Rahman2, Mark Landry3
1 World Health Organization, Country Office, Dhaka, Bangladesh
2 Directorate General of Health Services, Ministry of Health and Family Welfare, Dhaka, Bangladesh
3 World Health Organization, South-East Asia Regional Office, Delhi, India
|Date of Web Publication||26-Feb-2021|
Ms Sangay Wangmo
World Health Organization, Country Office, Dhaka
In the initial phase of the coronavirus disease 2019 crisis, Bangladesh’s health systems faced competing demands to respond to the pandemic and concurrently maintain the continuity of essential health service delivery, particularly at the primary care level. Bangladesh’s established network of primary care health facilities, the country’s backbone for delivering essential health services, routinely feed data into the national health information system, the District Health Information Software 2 platform, which provides near real-time data on the utilization of essential health services, visualized through user-friendly integrated dashboards. Trend analyses of these data showed that by April and May 2020 there had been sharp reductions in the utilization of key essential health services across all levels of care.
Early and continuous monitoring and analysis of these data informed public health policy-makers and health facility managers on rapid response strategies to restore the availability and use of essential health services. Through corrective policy measures and targeted interventions, Bangladesh’s primary health care network provided a critical platform for Bangladesh to build back most of its essential health services by October 2020. Bangladesh’s experience highlights the critical role of primary-level health facilities as a touchpoint for monitoring population access to services and as a staging point for implementation of strategies and interventions that rebuild and strengthen health service delivery towards achieving universal health coverage and more resilient health systems.
Keywords: COVID-19, data use, District Health Information Software 2, essential health services, primary health care, routine health information systems
|How to cite this article:|
Wangmo S, Sarkar S, Islam T, Rahman MH, Landry M. Maintaining essential health services during the pandemic in Bangladesh: the role of primary health care supported by routine health information system. WHO South-East Asia J Public Health 2021;10, Suppl S1:93-9
|How to cite this URL:|
Wangmo S, Sarkar S, Islam T, Rahman MH, Landry M. Maintaining essential health services during the pandemic in Bangladesh: the role of primary health care supported by routine health information system. WHO South-East Asia J Public Health [serial online] 2021 [cited 2021 Nov 30];10, Suppl S1:93-9. Available from: http://www.who-seajph.org/text.asp?2021/10/3/93/309884
| Background|| |
COVID-19 and essential health services
The package of essential health services defined by the Government of Bangladesh (GoB) is the cornerstone of the country’s commitment to universal health coverage (UHC), while its established primary health care (PHC) network is the backbone that ensures its implementation. At the onset of the coronavirus disease 2019 (COVID-19) pandemic, Bangladesh’s health system faced competing demands, with a shift in focus towards emergency response while concurrently maintaining the delivery of essential health services. An initial review of service utilization data from the country’s national health information system (NHIS) found that between January and April 2020 outpatient visits and inpatient cases at PHC facilities had decreased substantially and immunization rates had fallen by 50%, challenging the country’s promise to leave no one behind. Bangladesh’s subsequent response to service disruption showcases how a robust health information system (HIS) at the PHC level can strengthen health system resilience in the face of health security threats such as a pandemic.
Primary health care in Bangladesh
Bangladesh has a pluralistic health system: a highly centralized public sector and a private sector mix of for-profit and not-for-profit providers. The GoB is the leading provider of PHC services in the country. The Ministry of Health and Family Welfare (MoHFW) is responsible for overseeing, managing and regulating health services, family planning and nutrition programmes for the country. Under the MoHFW, the Directorate General of Health Services (DGHS) and the Directorate General of Family Planning (DGFP) oversee PHC service delivery, while the Ministry of Local Government, Rural Development and Cooperatives (MoLGRDC) supplements the MoHFW in the provision of PHC services in urban areas, predominantly through nongovernmental organizations (NGOs) and other private providers.
Under the DGHS, PHC services are administered through the established upazila health system, which encompasses the three lower tiers of health service delivery [Figure 1]. These include an extensive network of community clinics at the ward level, health facilities at the union level and upazila health complexes (UpHCs) at the upazila level. UpHCs are the first referral facilities in the health system, offering outpatient and inpatient services (31–50 beds) with basic operative care [Figure 1]., Community clinics are supported by the MoHFW and managed by leaders and members of the communities that they serve, which promotes community ownership of their constituents’ health. UpHCs alone account for 31% of public sector service delivery and, with over 13 000 community clinics, the entire PHC network accounts for a major portion of the country’s service delivery health information.
|Figure 1: Bangladesh’s public health service delivery structure and NHIS DHIS2|
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Bangladesh’s health information system
In 2009, the MoHFW instituted as part of its NHIS the open- source District Health Information Software 2 (DHIS2), a modular web-based platform for the collection, validation, analysis and presentation of individual-level and aggregated health data for all levels of the health system. As the largest deployer of DHIS2 globally, Bangladesh’s NHIS has come a long way since its deeply fragmented paper-based days.
Across the PHC setting, over 14 000 PHC facilities continuously feed data into the NHIS DHIS2, allowing it to capture near real-time facility and community health data, including on utilization of essential health services [Figure 1]. At the central DGHS level, through an interoperable and standardized framework, the NHIS DHIS2 brings together in one data warehouse previously siloed health information from multiple public health programmes and units, incorporating routine health and health systems data as well as data from historical health surveys.,
In addition to its comprehensiveness, one of the useful features of the NHIS DHIS2 is its rich data-mining functions and enhanced accessibility through a user-friendly, integrated dashboard that synthesizes data from the multiple databases for in-depth analysis and visualization., The DHIS2 dashboard has facilitated health managers’ ownership of and accountability for their health data. Since 2016, weekly videoconferences have been held between the Director General of Health Services and the country’s 8 divisional and 64 district health managers to discuss their dashboard data and any required follow-up; the same forum exists for UpHC health managers through monthly meetings.
| Assessing the disruption of essential health services during COVID-19|| |
The assessment included trend analyses of the utilization of key essential health services between January and October for both 2019 and 2020. It used NHIS DHIS2 routine data from 503 facilities across all 3 levels of health care – 424 UpHCs (primary), 62 district hospitals (secondary) and 17 medical college hospitals (tertiary) – and did not include data from union facilities, community clinics or specialized hospitals. The number of outpatient appointments, inpatient admissions, first antenatal care visits (ANC-1) and institutional normal vaginal deliveries (NVD), as well as the percentage of children fully immunized by the Expanded Programme on Immunization (EPI), were assessed for each month and level of health facility, as proxies for essential health services utilization.
The analysis was presented to country stakeholders during an informal dissemination workshop in July 2020, followed by formal dissemination to divisional-level health managers in October 2020 and to policy-makers at the central level in December 2020. Feedback from these dissemination workshops validated the assessment findings and provided qualitative inputs on the reasons for the observed trends and response measures to restore service utilization.
Utilization of key essential health services before and during the COVID-19 pandemic
The GoB’s response to the COVID-19 pandemic started in early March 2020, when the first confirmed COVID-19 cases were detected. Shortly afterwards, the GoB declared a strict lockdown, suspending road transport and closing all non-essential organizations, businesses and educational institutions, with only medical services, pharmacies and grocery stores remaining open. The lockdown extended from 25 March until 30 May 2020, after which restrictions were lifted.
[Figure 2] presents the 2019 (pre-COVID-19) and 2020 (during COVID-19) trend analyses for four of the essential health service utilization indicators across three levels of care. In 2020, overall trends in utilization followed a similar pattern for all indicators and across all facility levels. Until March 2020, the utilization of outpatient, inpatient, ANC-1 and NVD services was consistent with utilization in the corresponding months of 2019. However, from March onwards, the trends fluctuated greatly, with utilization starting to fall in March 2020, decreasing sharply and substantially in April and May, and then increasing incrementally between June and October 2020. In contrast, the pre-COVID-19 utilization trends show minor fluctuations after March. The changes in 2020 utilization were concurrent with the timing of the lockdown, suggesting that the onset of the COVID-19 pandemic and its associated country responses in March 2020 may have contributed to the disruption of these essential services during the first 2 months of the pandemic.
|Figure 2: Trends in utilization of outpatient, inpatient, ANC-1 and NVD services in 503 facilities across 3 levels of service delivery between January and October in 2019 and 2020, Bangladesh|
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The magnitude of utilization disruption and the time frame for recovery to pre-COVID-19 values vary across the services, and in some cases across facility levels. For example, outpatient and inpatient services experienced the greatest percentage reductions in utilization between January (pre-COVID-19) and April 2020 (during the COVID-19 lockdown). Outpatient service utilization fell by 72%, 78% and 76% in UpHCs, secondary hospitals and tertiary hospitals, respectively. The outpatient and inpatient indicators did not include service delivery with respect to confirmed COVID-19 cases, as these data are reported to a separate national COVID-19 surveillance system.
In contrast, institutional NVDs were the least affected service between January and April, falling by 41%, 52% and 56% in UpHCs, secondary hospitals and tertiary hospitals, respectively. The trends in NVDs are consistent with findings from a study that analysed 2019 and 2020 trends using a different data source, DGFP data on utilization of maternal health services.
Utilization of outpatient services, inpatient services and ANC-1s was 50% or more lower in April 2020 than in April 2019. Although an upward trend in utilization of all four services across all three facility levels is observed starting in June 2020, utilization does not quite reach the corresponding 2019 levels, even by October 2020. Interestingly, for all four services, recovery to pre-COVID-19 utilization was faster at the UpHC level than for the higher-level facilities, suggesting a positive shift in responses to address essential health service delivery at the primary level. For example, by September 2020, normal institutional deliveries in UpHCs had increased to just over 90% of the September 2019 value, while even by October 2020 deliveries in tertiary-level hospitals were at only 68% of 2019 values.
Between January and May 2020, 380 000 children missed their first dose of the measles and rubella vaccine and over 360 000 children missed their third dose of pentavalent vaccine (data not shown). [Figure 3] presents the 2019 and 2020 trend analyses for the number of fully immunized children (EPI coverage) between January and October. Trends in EPI coverage for 2020 initially show a similar pattern to those of the other service utilization indicators, with 2020 and 2019 immunization coverage consistent until March 2020, and coverage then dropping sharply and substantially, by 46%, in April 2020. However, unlike the other essential health service utilization indicators, EPI coverage experienced an equally sharp increase in June 2020, to levels above those observed in 2019, and levels of coverage remained high until October 2020. These findings suggest that the onset of the COVID-19 pandemic may have disrupted immunization services in April and part of May 2020 but that health system responses, supported by robust monitoring and surveillance of the country’s EPI, contributed to quickly building back better with regard to immunization services.
|Figure 3: Trends in numbers of fully immunized children between January and October, 2019 and 2020|
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Completeness of data reporting can affect the results of service delivery utilization analysis. The completeness of ANC-1, outpatient, inpatient and NVD data reported into the NHIS DHIS2 in 2020 was 95% in March, dropping to 88% in April and rising back to 94% by October. For EPI coverage, data completeness was 100% throughout 2020. Overall, data completeness is high, and the 7% decrease in April’s data completeness would not contribute substantially to the major decreases in utilization observed at the onset of the COVID-19 pandemic.
Factors influencing disruption of and response measures to restore essential health services
Through leveraging existing weekly and monthly videoconferences with the DGHS, health managers and policy-makers regularly reviewed health service utilization and related data through the NHIS DHIS2 dashboards to monitor potential disruptions and discuss associated factors. Towards the end of April, dramatic drops in utilization were observed and multiple supply-side and demand-side factors identified. During the initial days of the pandemic in April 2020, the government had shortened outpatient visiting hours, repurposed frontline health workers to respond to COVID-19 and imposed travel restrictions, affecting the physical accessibility of essential services in facilities. Fear and anxiety about the pandemic among communities also adversely affected utilization of essential health services. Based on these collective reviews, the GoB prioritized the timely restoration of essential services through corrective policy measures and targeted interventions across all levels of service delivery, and integrated these into the country’s official COVID-19 preparedness and response plan. Details of identified factors that influenced the disruption and enabled rapid and timely restoration of essential health services in Bangladesh are presented in [Table 1].
|Table 1: Policy-level and operational-level factors influencing disruption and enabling recovery of essential health services|
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During the October 2020 dissemination workshop, division health managers highlighted that the effects of COVID-19 on service utilization were not uniform across the country or even within their divisions. Divisional and district health managers continuously assessed their situations, adapting measures to their own contexts. For example, in the Mymensingh division, 32% of health workers were designated for the COVID-19 response, creating a major human resource gap. In response, the division adopted innovative local-level strategies prioritizing telemedicine and mobile phone consultations for non-emergency services, including screening for COVID-19. Frequent virtual supervisory “visits” and meetings with primary- level staff provided additional guidance and support to facilities. In addition, to minimize exposure and maximize efficient flow of patients, separate emergency services were created for COVID-19 and non-COVID-19 cases, with separate entrance and exit pathways.
| Optimizing the national HIS and PHC network to strengthen health system resilience|| |
The COVID-19 pandemic experience in Bangladesh demonstrates the importance of resilient health systems to ensure continuity of essential health services during a pandemic. Countries should focus on strengthening their PHC systems’ readiness to ensure the continuity of essential health services and to respond effectively to health emergencies. Despite Bangladesh’s immense progress on PHC, challenges in its provision of quality PHC services remain. The country’s PHC structure spans two government ministries, the MoHFW and the MoLGRDC, and implementation is intersectoral, covering both the public and private health sectors. Coverage of public PHC services is not extensive in urban areas compared with coverage in rural areas. The MoLGRDC supplements the MoHFW to cover the PHC services for urban populations. Furthermore, there are substantial human resource constraints at the primary level, including a shortage of physicians and nurses. A 2019 assessment of physician and nurse workload in UpHCs found high levels of workload pressure, especially for nurses., Moving forward, Bangladesh’s PHC can reach its full potential by addressing the extent of its existing resource gaps.
The shared responsibility for PHC service delivery across different sectors and agencies – the public sector, the private sector and NGOs – may extend into issues of interoperability in the NHIS. For example, most urban populations seek PHC services from the private sector through out-of-pocket payments, and these data are not yet integrated into NHIS DHIS2. The country has a national vision for an integrated digital health system and the capacity of the NHIS DHIS2 platform to realize this vision. A national digital health strategy is being drafted, and Bangladesh will continue to integrate siloed aspects of routine health information into the NHIS DHIS2 to capture the full picture of utilization of essential health services. With respect to data quality, data verification exercises take place as part of routine supervision and monitoring, and facilities are scored on the completeness of their data, which should lead to progressive improvements in data quality.
Bangladesh’s network of PHC facilities routinely feeding data into the NHIS DHIS2 has enabled the GoB and health managers to monitor, in near real time, the utilization of essential health services. During the pandemic, this steady stream of data from the most primary level of health service delivery enabled public health decision-makers to quickly assess the effects of the pandemic and respond. While all levels of the health system contributed towards the initial emergency response to strengthen health service coverage and utilization, the network of PHC facilities provided a critical platform for many of the response strategies to restore essential services, including deployment of additional providers, distribution of personal protective equipment, mass training in IPC, provision of telemedicine and community awareness-building.
Bangladesh’s evidence on disruption in utilization of essential health services in the early phase of the pandemic highlights the need for rapid policy and strategic responses, and a resilient health system, to restore essential health services at all levels. The positive trend up to October 2020 highlights the need to sustain such recovery and build back better to accelerate the advancement of UHC. Bangladesh’s experience highlights the critical role of primary-level health facilities as a touchpoint for monitoring population access to services and as a staging point for the implementation of strategies and interventions that rebuild and strengthen health service delivery with the aim of achieving UHC.
Disclaimer: The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.
Acknowledgements: The authors wish to thank the Management Information Systems, DGHS, under the MoHFW, and the field health managers of eight divisions for their kind contributions and support.
Source of support: None.
Conflict of interest: None declared.
Authorship: SW conceptualized the manuscript and produced the first draft; SW, SS and TI conducted the literature search and data analysis. All authors commented on, revised, finalized and approved the article.
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[Figure 1], [Figure 2], [Figure 3]