Infrastructure or social behavioral science?
What has been the most effective instruction for combating Covid-19? Millions of global citizens, including us, would emphasize three key messages: 1) Keep safe distance from other people, 2) wash your hands as necessary, and 3) wear a mask to stop the spread.
Now, if we ask you to put a monetary value on spreading these messages widely, the number that you might come up with would be so negligible that it would not affect any country, not even Bangladesh, to come up with a budgetary allocation that would have any extra impact in keeping people clean and healthy with appropriate behavioral interventions.
The finance minister unveiled a Tk568,000 crore budget for financial year 2020-21 of which Tk29,247cr has been allocated for the corona-shattered health sector. An additional Tk10,000cr has been kept aside for dealing with emergency requirements of the battle against the coronavirus.
Unfortunately, this large amount, which is mostly known as “thok boraddo” in Bengali, does not have a specific expenditure plan, which makes us skeptical about its proper utilization. At the end of the year, when the ministries engage in a rat-race to burn out their allocation for pleasing the top management, showing how efficient they have been, the money might end up being allocated for buying elements which are not necessary or do not have any realistic need as assessed by the health workers.
Sometimes the money “left alone” is used for buying expensive medical equipment at a much higher price than the market price without recruiting skilled people who actually can operate them.
If we analyze the previous four years’ budget, the proportion of allocated amount for the health sector ranged from 4.9% to 5.2%. The proposed TK29,247cr budget for the health sector in the coming fiscal year is a 23% increase from last fiscal year.
However, a significant portion of this allocation will be spent on “additional allocation,” incentives, and compensations, as stated by the finance minister, which might be useful in encouraging the frontline workers combating Covid-19; however, the absence of specific attention given to public health human resources indicates that this sector is not properly prioritized by the government yet.
The Covid-19 pandemic has reechoed the old mantra that “prevention is better than cure.” Until we get a specific solution for the disease, ie pharmacological management/vaccine, the whole paradigm of controlling the disease is to prevent it through practising physical distancing, wearing facial masks, and maintaining personal hygiene.
All these are public health interventions, invented and practiced for years by frontline health workers of Bangladesh while working in the water, sanitation, and hygiene sectors without foreign prescriptions or specific attention given by our respective governments. Bangladesh has glorious experiences of attaining mentionable success in achieving almost 100% sanitation coverage, combating diarrheal diseases, meeting EPI targets through its own intercessions with limited resources, and extensive social and behavioral innovations at field levels.
In addition to behavioral aspects, we are currently observing a dearth in ICU beds and facilities in the tertiary hospitals of Bangladesh. Currently, Bangladesh has an acute shortage of health care workers along with an inappropriate skill mix (physician to nurse ratio: 0.4) and inequitable distribution.
The country has 1,169 intensive care units (0.72 beds per 100,000 people) and only 550 ventilators (0.34 per 100,000 people). We have seen how the lack of personal protective equipment has put the frontline health workers at risk of battling Covid-19.
Efficient human resources trained in health administration can help us get rid of this situation and, for this, we need to invest in our public health infrastructure. It should be noted that, despite the big and fancy hospitals we have in Dhaka city, thousands of patients suffering either from Covid-19 or otherwise, died without having access to proper health facilities.
On the other hand, countries that have been successful in combating Covid-19 managed to establish temporary field hospitals within a short span and pack them up after dealing with the crisis. Increasing the budget and allocating money for building expensive hospitals might not be the only solution for improving our overall health sector in the coming days.
Bangladesh is an example of public health success. The country has successfully implemented and scaled up many public health interventions including an oral rehydration therapy program, a family planning program, and the Expanded Program on Immunization. It is home to leading public health institutions like the International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) and Brac James P Grant School of Public Health (Brac JPGSPH).
It should be noted that recently, the Canadian government announced $1.1 billion for Covid-19 research and the development of a vaccine, as well as treatments.
Dr Timothy Evans, the former dean and currently a faculty member of Brac JPGSPH, is one of the core members of this research and development taskforce.
Dr Evans has been training public health professionals in Bangladesh for the last 10 years. The existing public health workforce of Bangladesh cannot be properly utilized due to inadequate government support for research and development.
So, government investment in public health research and development should be increased. Nevertheless, the role of public health schools in Bangladesh is not satisfactory either.
When John Hopkins, the University of Toronto, and Oxford University are leading their research and innovations during the coronavirus pandemic, we have seen no such activities from any of the public health schools in Bangladesh; rather, some of them produced misleading research with horrific predictions which scared the people without encouraging them to be more engaged and prepared.
While budgetary allocation is an important factor, not investing in research and development, universal health coverage, or in social and behavioral health sciences may keep us unprepared for any pandemic or epidemic in the years to come.
Shamim Ahmed is a doctoral researcher at the University of Toronto, and a Social and Behavioral Health Scientist and Rajat Das Gupta is a doctoral research candidate at the University of South Carolina and a public health expert. They can be reached at: [email protected]