Health sector reforms are overdue. That must begin with budget

Prevention is better than cure, an old adage popular among health practitioners, has largely been unacknowledged by Bangladesh in dealing with the pandemic.

And here we are more than a year after the first three cases of Covid infection sent out a chilling message across the masses, watching the government devise one plan after another to check the virus transmission and secure treatment of the infected.

The pandemic year of 2020, marked by fear, shock and loss, seems to be repeating itself in 2021. But the public fatigued over the prolonged health crisis and its economic fallout no longer wants to obey movement restrictions. They want back their joy of living and livelihoods.

On the other hand, the challenge to immunise enough people so that the virus does not get too many hosts to keep replicating and circulating – a point when the country can claim to have achieved herd immunity – appears to be much larger than expected.

In a scenario like this, the public health that is so intertwined with everything else – from education, poverty to economy – should get the highest priority. The health system should be strengthened and streamlined to find how it can provide treatment for all diseases – physical and psychological – while continuing preventive measures against the coronavirus and other pathogens.

Finance Minister AHM Mustafa Kamal will propose a budget for the fiscal 2021-22, substantially emphasising the healthcare sector. And he will do so when the call to increase the number of Covid hospital beds, oxygen supply and intensive care is getting louder.

Experts think non-pharmaceutical interventions to keep the virus from rampaging through the country is more rational than seeking solutions through vaccination depending on foreign sources or through the means of treatment and cure with limited resources.

And the preventive measures, such as testing, masking, contact tracing, isolation and quarantine, should be based on data and evidence to make sure they are more effective and render a minimum economic toll.

Movement restrictions can be imposed in Dhaka, Chattogram, Narayanganj and Gazipur, where most of the infected cases have been detected, to keep the virus from spreading to other areas, instead of a nationwide lockdown, said Prof Sayedur Rahman, chairman of the Department of Pharmacology at the Bangabandhu Sheikh Mujib Medical University.

Still, a lockdown that is disrupting lives by taking away income opportunities cannot last long.

The capital itself has the highest number of infections, registering more than 57% of all official Covid deaths.

Bringing down infections in Dhaka alone will cut the overall virus transmission to a great extent. In doing so, teams of health professionals and volunteers have to go from door to door for mass symptom screening and sample collection for Covid tests, said Dr Be-Nazir Ahmed, member of the National Immunisation Technical Advisory Groups. And positive results should be followed by contact tracing, isolation of the infected and quarantine of the household contacts of them.

A report published in The Lancet in November last year based on a study in South Africa says upfront expenditures reduce downstream costs by preventing infections, hospital admissions, and use of additional resources.

This is May and the last few months brought about realities that made us hopeful and hopeless at the same time. While the rollout of vaccines has made it possible to lower mortality and morbidity, stronger and mutant strains of the coronavirus have increased our vulnerabilities.

As the New York Times says, low- and middle-income countries are combating new surges in infection when rich countries are opening up businesses like restaurants and bars having contained the virus through mass vaccination – the UK and the US, for example.

Most of the population in Bangladesh are yet out of the purview of the inoculation drive with an uncertainty over vaccine availability. This is the context, in which we are at a greater risk of helping the virus replicate in us and mutate as it moves from one to another among us moving around without health safety measures and social distancing.

Even if we get vaccines, delivering doses to as many adults as needed in a short span of time to achieve herd immunity will not be possible, given the logistics and manpower we have. By the time the government covers a significant number of citizens, vaccine effectiveness and immunity grown from the disease in many of them may expire.

That is why countries like Bangladesh are feared to get trapped in a cycle of rising infections when the developed world is planning about booster doses of vaccines.

The notion among analysts is that we may have to live with the virus and so have to learn how to do it. One thing that can light up the path is research.

The time passing by has led to another realisation that nothing can be put on hold any longer for the pandemic – be it treatment for non-communicable diseases or addressing psychological impacts of Covid on adults and children who have stayed away from school.

The government needs to lay out its own pandemic plan, keeping in mind what we have and what we do not, to deal with it comprehensively and steer the nation onto a recovery path, not only for the next fiscal year but as part of a long-term goal.

Reforms have become imperative. Though increasing budgetary allocation for health is necessary, a greater concern remaining is how to boost the capacity of the health sector to spend money and spend it wisely.

Between July and April, the government's expenditure in the Annual Development Programme was Tk3,083 crore, whereas the revised budget was Tk13.865 crore.
Part of the reform should be establishing a strong foundation of primary health care, on which the entire hierarchy should stand – firmly, accompanied by a well set-up health management and a referral system.

The health system is bound to collapse and fail if people living in unions come to Dhaka for not getting treatment in community health clinics, upazila health complexes and district hospitals. All must have their roles defined to help the system function seamlessly.

Covid has made it more apparent than it ever was.

As The Lancet says, community health workers in low- and middle-income countries could be leveraged to control the spread of Covid-19 in an economically efficient manner.