Community-based healthcare for COVID response: option or necessity?

By Dr Morseda Chowdhury and Tanjila Mazumder Drishti and Syeda Nafisa Nawal, BRAC

A year into the onset of the pandemic, years of progress in health and nutrition are being upended. A community-driven response is key to delivering undisrupted, essential healthcare services to the most vulnerable across Bangladesh.

When COVID-19 hit a population of 170 million in Bangladesh, the consequences undoubtedly seemed grim. As of 11 March 2021, there are almost 600,000 confirmed cases of infection and 8,489 deaths. Yet transmission control remains a challenge and cases remain underreported, mainly due to the following three factors:

(i) Lack of awareness and COVID-19-compliant behaviour: Afzal, a storekeeper from Rangpur says “COVID-19 is an urban disease. Nobody in my area died of it. I don’t think it is necessary to use a mask.” Afzal’s behaviour is emblematic of the countrywide attitude towards mask wearing. A BRAC study in the Gazipur area found that 50% of the people did not wear masks at all, while 17% were wearing it improperly. This reluctance towards COVID-19-compliant behaviour mainly stems from a lack of community engagement in risk messaging.

Making matters worse, of the population in Bangladesh lacks access to basic sanitation – rendering them unable to wash hands or maintain hygiene properly even if they wish to be COVID-19-compliant.

(ii) Lack of surveillance and case management mechanism at the community level: The absence of a systematic approach for contract tracing and proper surveillance, coupled with the existing stigma around COVID-19 has become a deadly issue. As a result, many cases of infection go unreported and unattended, especially in marginalised communities.

(iii) Lack of testing facilities: Only 113 laboratories in the country perform COVID-19 tests, of which 67 are situated in the capital. The average number of tests per day hovers between 13,500 and 14,000. Most of these are conducted in urban areas. Sample collection facilities are scarce in peripheral cities and rural areas, leaving the COVID-19 situation unassessed. Furthermore, people living in poverty have limited access to testing facilities.

According to the Global Health Security Index 2019, Bangladesh ranked 113 out of 195 countries in terms of health security. Pregnant women were more likely to opt for home deliveries instead of institutional deliveries. Right after lockdown began in the country, institutional deliveries fell by 10%-20% in April 2020, and slowly picked up pace after July 2020. Family planning services were not reaching the target population, while new mothers and children were not getting optimal nutrition and early childhood development support. Experts strongly fear these fallouts will soon translate into increased maternal and child mortality, chronic malnutrition, increased incidence of stunting and wasting, rise in morbidity and delayed or disrupted cognitive development among a whole generation of children.

We need to address the direct impacts of COVID-19, but we also need to prevent our communities from falling into the never ending pit of secondary impacts.

Limited resources, under-equipped healthcare facilities and a large population are some of the main constraints to combat COVID-19. It is more crucial to strengthen community-based healthcare models now in order to build long-term resilience to COVID-19, and prevent its secondary health impacts.

To address this crisis, BRAC’s health, nutrition and population programme, with support from the UK Foreign, Commonwealth and Development Office (FCDO), is implementing a COVID-19 response plan that puts the communities at the front and centre. Currently operating in six districts (Bagerhat, Bhola, Bogura, Kishoreganj, Narayanganj, Sherpur), the project titled “COVID-19 response through community mobilisation and strengthening of community clinics” focuses on the following interventions:

(i) COVID-19 surveillance and service package provision at the household level: Community support teams, each consisting of two community health workers, visit households to check on the families. They also offer maternal and child healthcare service packages from door-to-door to ensure the prevention of any long-term health complications starting from childbirth.

(ii) Creating community ownership: People tend to lean into their communities’ beliefs and behave like their communities do. Thus, the response plan established COVID-19-prevention committees consisting of locally influential figures, in order to sensitise people on the prevention of the virus. It also conducts social audits to ensure that community clinics offer the services properly.

(iii) Strengthening community clinics: Currently, community clinics lack adequate birthing facilities, staff and operational efficiency – leading to limited capacity for service provision. As part of this project, BRAC’s community health workers are deployed to these clinics periodically to provide essential maternal and child healthcare services. Community clinics which do not have functional birthing rooms are also being refurbished to provide better quality of healthcare.

COVID-19 is not the first and may not be the last pandemic we face. To fight future pandemics, it is crucial to put the community at the heart of our health response and build human-centric systems that cater to the actual needs of people in marginalised communities.

Dr Morseda Chowdhury is the Associate Director, Tanjila Mazumder Drishti is a Senior Manager and Syeda Nafisa Nawal is a Manager at BRAC’s Health, Nutrition and Population Programme

This article was previously published on the BRAC website

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