COVID-19: How prepared is Bangladesh?

Following the detection of the first few COVID-19 cases in early March, Bangladesh has stepped up its efforts to strengthen the capacity of the healthcare system to avert a crisis in the event of a surge in the number of cases. This analysis sheds light on the preparedness of the healthcare system in terms of the spatial distribution of number of isolation beds, availability of ICU beds and the availability of frontline healthcare workers to combat the pandemic.

If one takes into account the population at risk, the prevalence of infection appears to be highest in Dhaka followed by Narayanganj, Gazipur, Kishoreganj, Narsingdi, and Munshiganj. These regions may therefore be flagged as the COVID-19 hotspots in Bangladesh. Among the eight divisions, prevalence is highest in Dhaka division followed by Mymensingh. Yet Dhaka division has the lowest number of isolation beds per million of its population.

A similar situation is seen in Mymensingh division which also has high prevalence of the disease but a comparatively small number of isolation beds per million. On a finer resolution, district-wise comparisons reveal that the epicenter, Dhaka district, with 300 to 349 cases per million has one of the lowest, that is, between 11 to 20 isolation beds per million. Narayanganj, which is the major hotspot with 250 to 299 cases per million has only 31 to 40 isolation beds per million. The third hotspot is Gazipur with 80 to 99 cases per million and less than 10 isolation beds per million, which is the lowest among all the districts.

Munshiganj, which is the fourth largest hotspot also has a small number of isolation beds relative to the number of cases per million of its population. These figures indicate that there is an elevated risk of the healthcare system becoming overwhelmed in the major hotspots in Bangladesh.

On the positive side, the hilly district Rangamati has the highest number of isolation beds but few cases (as of May 8) per million in Bangladesh.

With regard to availability of healthcare resource persons, the analysis finds that physicians form the largest proportion of healthcare staff in Bangladesh in five of the eight divisions. The proportions of physicians and nurses are nearly equal in Khulna and Sylhet divisions. Rajshahi division appears to be an outlier with the proportion of physicians being less than both the proportion of nurses and the proportion of other healthcare staff.

An alarming finding is the very high ratio of COVID-19 patients to physicians in Dhaka division. Mymensingh division also has a disproportionately small number of physicians available to treat COVID-19 patients (nearly 10% of the number of COVID-19 patients). Barishal division, which has the lowest number of cases, appears to have nearly a quarter but the ratio could easily increase if the number of cases rises and more physicians cannot be provided to treat these cases. A similar situation exists in Chittagong Division as well.

On the other hand, Sylhet, Khulna, and Rangpur have smaller ratios and therefore appear to be in a better position to handle the crisis. Rajshahi division is in the best position to handle the crisis.

The capacity of the healthcare system in Bangladesh has been evolving over the years. We analysed the number of hospital beds per 1000 people and the number of physicians per 1000 people for the period 1970-2015 [World Bank source]. It is seen that there was an increasing trend in the number of hospital beds per 1000 people from 1970 to 1991 during which the ratio increased from 0.1551 to 0.3081. Over the next 11 years the ratio remained relatively steady and then increased sharply after 2005 reaching a value of 0.8 per 1000 people in 2015. Thus, there has been a 167% increase in the number of hospital beds per 1000 people during 2005-2015 indicating significant improvements in healthcare infrastructure in the country.

There has been a slow exponential growth in the number of physicians per 1000 people during the 45 year period. Both curves are seen to converge in 2005 during which the number of hospital beds per 1000 people and the number of doctors per 1000 people were equal. Both ratios were equal to 0.3 meaning that for every 10,000 individuals in the population, there were 3 hospital beds and 3 physicians. Over the next ten years, the number of physicians per 1000 people increased by about 57% to a value of 0.472 in 2015. Overall, there has been growth in the healthcare sector but in a densely populated and developing country like Bangladesh, this growth may not be sufficient to fight a global pandemic.

Hospitals in Bangladesh have 1,169 ICU beds in this year, 2020. Most of the ICU beds are in the capital Dhaka. Government hospitals have nearly 40% of these beds i.e. 432 while the remaining 737 are in the private hospitals. According to various projections, Bangladesh might have more than 20, 000 infections by mid of May and that leads the requirement of ICU beds 1200 (6% of all cases). If all 1169 ICU beds are used for COVID-19 patients then Bangladesh will run out of ICU beds soon after 15 May 2020. These findings sound the alarm that the healthcare system may not have the capacity to handle critical COVID-19 patients due to insufficient number of ICU beds.

The analysis has revealed that the numbers of isolation beds and physicians available to treat COVID-19 patients are worryingly low in the major hotspots in Bangladesh. This finding has important implications for policy. In a densely populated country like Bangladesh where the majority of the people are poor, it is difficult to effectively enforce social distancing and other preventive measures. Thus, there is a fear that the number of cases could flare up at any time during the course of the pandemic. In these circumstances, the healthcare system must be adequately prepared to face the looming crisis by creating excess capacity and mobilising resources to the most affected areas.

Based on the analysis, it is recommended that the number of isolation beds in Dhaka district as well as Gazipur district be more than tripled so as to be on par with the number of cases. In Narayanganj district the number of isolation beds should at least be doubled.

Projections indicate that there is a risk of a deficit in the number of ICU beds for critical patients. Thus, increasing the number of ICU units should also be a priority. Strategies for increasing capacity could include freeing up more beds for COVID-19 patients in hospitals, increasing the number of COVID-19 designated healthcare facilities by roping in private hospitals and clinics, and repurposing government buildings and setting up camps as an emergency measure should the outbreak go out of hand.

With the number of physicians available to treat COVID-19 patients being dangerously low in Dhaka Division, it is recommended increasing the number of physicians by several folds. This could be done by recruiting new physicians in hospitals including final year medical students and calling retired physicians back to work in addition to recruit from special BSC.

There have been reports that some physicians avoid work due to fear of contracting the virus due to lack of PPE. As a result, both COVID-19 patients as well as patients with other medical conditions may not receive adequate medical care. Lack of PPE may therefore be identified as one of the leading causes of shortages in medical personnel.

It is recommended that in addition to offering attractive incentives to frontline healthcare workers, the government must by all means ensure that medical personnel on duty receive PPE and training on how to use these. This is one of several measures that need to be taken to ensure the safety of healthcare workers and their families so as to maximise their participation in the fight against the pandemic. COVID-19 preparedness in Bangladesh must include an effective and feasible plan of action in which guidance on resource management and communication and coordination between national health stakeholders are of utmost importance.

If preparations are taken in a pragmatic way, Bangladesh will win the COVID-19 war with fewer fatalities since it has a strong network of community health workers, a history of success in public-private partnerships during emergencies like floods and cyclones, and people with incredible levels of resilience.

Dr Hasinur Rahaman Khan is associate professor, Applied Statistics, ISRT, University of Dhaka

Dr Tamanna Howlader is professor, Applied Statistics, ISRT, University of Dhaka

Mazharul Islam is lecturer, Bangladesh Institute of Governance and Management