key: cord-0888985-ir3l3uky authors: Biswas, Raaj Kishore; Huq, Samin; Afiaz, Awan; Khan, Hafiz T. A. title: A systematic assessment on COVID‐19 preparedness and transition strategy in Bangladesh date: 2020-08-21 journal: J Eval Clin Pract DOI: 10.1111/jep.13467 sha: 065c715ec559d2cf1f8c737a77bcbc3038179090 doc_id: 888985 cord_uid: ir3l3uky RATIONALE, AIMS, AND OBJECTIVES: The COVID‐19 pandemic of 2020 has overpowered the most advanced health systems worldwide with thousands of daily deaths. The current study conducted a situation analysis on the pandemic preparedness of Bangladesh and provided recommendations on the transition to the new reality and gradual restoration of normalcy. METHOD: A complex adaptive system (CAS) framework was theorized based on four structural dimensions obtained from the crisis and complexity theory to help evaluate the health system of Bangladesh. Data sourced from published reports from the government, non‐governmental organizations, and mainstream media up to June 15, 2020 were used to conduct a qualitative analysis and visualize the spatial distribution of countrywide COVID‐19 cases. RESULTS: The findings suggested that Bangladesh severely lacked the preparedness to tackle the spread of COVID‐19 with both short‐ and long‐term implications for health, the economy, and good governance. Absence of planning and coordination, disproportionate resource allocations, challenged infrastructure, adherence to bureaucratic delay, lack of synchronized risk communication, failing leadership of concerned authorities, and incoherent decision‐making have led to a precarious situation that will have dire ramifications causing many uncertainties in the coming days. CONCLUSIONS: Implementation of response protocols addressing the needs of the community and the stakeholders from the central level is urgently needed. The development of mechanisms for dynamic decision‐making based on regular feedback and long‐term planning for a smooth transition between the new reality and normalcy should also be urgently addressed in Bangladesh. (LMICs) such as Bangladesh started to experience the early onslaught of COVID-19 in early March 2020 with severe consequences in the offing. 3 To help address this gap, this study evaluated the health system of Bangladesh and its pandemic preparedness approach by means of a complex adaptive system (CAS) framework. Following the introduction of International Health Regulations (IHR) in 2005 endorsed by 196 countries, national level efforts were called for to strengthen health systems to help prevent the spread of infectious diseases on an international scale without disrupting international traffic and trade. 4 However, in LMICs, political resolve, insufficient resources, and technical limitations have challenged the implementation of these recommendations. 5, 6 Furthermore, the support from high-income countries towards LMICs has not been encouraging. 7, 8 It was also recommended that policy implementation for all LMICs as a single body would not be practical in unprecedented circumstances, as is evident from the ongoing COVID-19 pandemic that demands country specific assessments. 9 Bangladesh is an over-populated LMIC that has seen strong growth over the last decade in its export-based economy and improvements in multiple public health indicators. [10] [11] [12] Despite the goodwill from local and international non-governmental organizations, the existing health system is already stretched with only 7.4 skilled workers per 10 000 population. 13, 14 The dawn of the COVID-19 crisis has positioned the whole system into a unique paradigm by challenging health, the economy, and law and order. There has not been a formal evaluation on the preparedness of the Bangladesh health system for coping with pandemics or substantial analysis on the health system as a whole. A critical assessment is therefore needed in order to better prepare for the ongoing challenge and future pandemics. The objective of this study is to theorize a CAS framework to evaluate the health system during a pandemic and assess the steps taken so far by Bangladesh for tackling the COVID-19 crisis up to June 15, 2020. For the purpose of discussing the preparedness and systematic transmission of Bangladesh during the COVID-19 crisis, the study applied the CAS framework. The parameters of the CAS and sources of data based on relevant theories were detailed in the next section (Methods) followed by a discussion on the agents, internal and external environments that impact the performance of the health system of Bangladesh during the pandemic. Before conclusion, a set of recommendations derived from the quantitative synthesis were listed, which would assist policymakers and relevant institutions to conduct a better transition from current crisis to normalcy. The CAS framework was used to assess the health system preparedness of Bangladesh since the performance is based on multiple dimensions of crisis theory and complexity theory. Crisis theory characterizes the idea that unresolved or inevitable conflict will change the existing paradigm and typical problem-solving mechanisms would not be efficient. 15, 16 Due to the resulting disorganization from the crisis, interventions are applied to help the system to adapt and recover in the shortest possible time. 17 This theory was applied to explain the management of a recent country-specific epidemic such as SARS in Singapore. 18 Complexity theory was proposed to explore the individual, organizational and systemic behaviours of a social phenomenon. 19, 20 Using complexity theory, complex and emerging health issues such as pandemics or epidemics can be elucidated. 21 Health systems can be non-linear and often unpredictable during a pandemic 22 and since complexity theory has been used in the literature for disease outbreaks, 23 several aspects of this theory were applicable in the context of COVID-19. Four major dimensions were extracted from the crisis and complexity theories to encompass the preparedness of the Bangladesh health system for COVID-19 ( Figure 1 ) and, based on these four dimensions, the CAS framework was assembled. The CAS framework is a continuing self-organization that uses a bottom-up approach based on multiple agents of a system to emerge a whole pattern based on both internal and external environment. 24, 25 The CAS is regularly applied to explain the interdependencies among health system agents and their consequences in multiple spheres (macro, meso, micro, and nano). 26 In this study, each of the four dimensions was explored using the four concepts of the CAS framework: agents, emergence, internal, and external environments, to elucidate the of healthcare workers being infected due to occupational exposure and demonstrate the importance of timely sharing of accurate information and proactive collaboration in generating an effective response. 27 Reinforcement of the IHR guidelines 28 has allowed effective management of crises through evaluation of risk communication strategies using information from risk assessments minimizing mass anarchy. 29 Coordination and accountability are vital elements in forming an effective response to events such as COVID-19. Therefore, such mechanisms need to channel the implementation of evidence-based decision-making at central level for its contextualization to the needs at local level. Coordination also requires the incorporation of feedback from communities addressing their concerns that may be causing emotional distress and the development of effective relationships at local level. 18 As part of its COVID-19 response, Bangladesh has established a number of committees at all levels comprising of decision-makers, administration, law and order, information, local and international organizations, and various components of the health system. 30 A technical committee was formed at central level comprising healthcare stakeholders for the purpose of evaluating activities in the plan through a review process and for recommending resource mobilization. The role of committees at local level is limited to the implementation of the plan devised at central level. According to Stacey (2003) 20 on the understanding of complex systems, the committee failed to include sector specialists (including public health experts) focusing on the respective service and information delivery relevant to the COVID-19 response. Such a scenario can contribute to a lower rate of information flow as well as prompt limited impact due to a lower level of diversity and differentials in risk perceptiveness between the various levels. The status quo differentials between local and national interests might also affect the generation of any response due to the unavailability of feedback loops among the parts of the system based on these committees. 31 The differentials between local and national levels can affect the degree of accountability in these systems that are not specified in measured terms regarding the trend of the disease spread. 36 These indicate that community transmission is observed in Bangladesh and is shown in Figure 2 . Although a protocol has been designed, 30 its implementation and accuracy require assessment. Reports from WHO dated April 20, 2020 suggest that the discrepancy between the reported number of tests and the number of people tested indicates multiple testing of the same patient. 34 There is no available data on the quality control around the handling of the samples and is therefore another issue to explore in addition to the diagnostic characteristics of the tests available for the identification of the disease. other key personnel leading to an inadequate proportion of available healthcare workers, disorganization, and increased exposure. As of June 15, 2020, a total of 1.3 million PPEs, 3.14 million mask, 562 439 gloves have stocked. 38 There is a huge shortage of supplies in those facilities located in areas with a higher case burden, especially the N-95 masks. These masks are being highly distributed in districts like Dinajpur (354) and Moulvibazar (388) but Narayanganj had only 10 of the N-95 masks despite having a much higher case burden (last update: . 38 The quality of the supplied resources has been extensively questioned. News reports indicate a debacle with the quality of 20 600 of the N-95 masks where the supplier organization has sought exemption from punishment for providing below quality masks after packaging them with N-95 marking. 39 These inadequacies played a part in the lead up to the health facility lockdowns as health workers were infected, and services were halted as a result. 40 oped. 64 In recent times, the health system has struggled to deal with a recurring seasonal dengue outbreak that has been occurring regularly and increasing in severity since the turn of the century. 65 This is fundamental to the process of strategising an effective call-toaction in any epidemic or pandemic requiring on the spot decisions and informed actions including effective mobilization of resources. 73 Bangladesh had time to prepare for the pandemic with the country's first case identified on March 8, 2020, over a month after WHO's declaration of a public health emergency of international concern. 74 Unfortunately, the authority's reluctance from the outset and persistence with typical bureaucratic procedures yielded weak preparedness. It is expected that preparation of the health system would contextualize the new demands in the existing framework. Part of these preparations would involve setting up testing centres, dedicating diseasespecific specialized health facilities and engaging with the contextspecific needs of professional bodies. All these are possible in Bangladesh but the capabilities of the test centres/health facilities during this crisis and the goodwill of the highly politicized professional associations could be questionable. 75 The Infectious Disease Act 85 should, on paper, have served the purpose of enabling appropriate dissemination of information and controlling any panic. However, emergency measures were. delayed as lack of transparency at the Health ministry led to confusion. 86, 87 Panic was further fuelled when the government accused healthcare workers of negligence in discharging their duties, that they had a weak mentality and claimed they would be replaced by foreign workers. 88 All these presented mixed messages to the community, where infection of COVID-19 was equated to confirming death in rural areas. Consequently, people were averse to testing and many fled from quarantine risking greater community transmission. 89 Any pandemic provides a unique scenario with intricate and rapid mechanisms. The current organizational approach that focuses on maximizing outputs often fails to recognize the interactivity between the components of a complex system. 90 It is to be expected that the health department would make prompt decisions efficiently during public emergencies. Often new ideas and fresh energy are required if the typical system fails. For example, China changed leadership in Hubei Province during the Wuhan outbreak, 98 and the Netherlands made an opposition leader the temporary health minister to cover the crisis. 99 These moves were intended to restore public confidence and display political goodwill. Bangladesh was ill-prepared for COVID-19. The same system that failed to meet regular healthcare demands was put to a sterner test. This resulted in utilization of only one test centre in the first 3 weeks of the crisis (March 8-25, 2020) that was only able to test 0.3% of those who raised a concern over their status. 3 Even the expansion of the test centres was sluggish indicating an inadequate laboratory infrastructure and slow dissemination of test kits. 100 The current situation with COVID-19 will make it difficult to resume normal service in the country straight away. The increased transmission risk of COVID-19 in any congested working space minimizes opportunities for social distancing. Capacity building and legislature mechanism need to be the building blocks for preparing the health system for resumption of normal services in a progressive way. Bangladesh, however, is not showing signs of deviating from its traditional infrastructure development process despite the pandemic. A meagre increment of 0.63% of the total budget is to be allocated to the health sector that is aimed at building a 1000-bed super specialized ward, a one-point check-up centre and a cancer building at Bangabandhu Sheikh Mujib Medical University. 104 A private-public partnership was used to set up testing kiosks in Dhaka in April, but these low-quality facilities could actually put health workers at increased risk. 47 Economic growth is expected to be a trade-off for the lockdown to contain the ongoing spread. The cancellation of orders for the RMG sector amounted to USD 3 billion, as of April 3, 2020. 105 It has been reported an estimated loss of BDT 33 billion every day during the shutdown. 106 Restricted movements can contribute to the economic cycle affecting those with limited earnings as well as large industries dependent on day labourers. In order to address the impact on the economy, the government has rolled out an incentive package of around BDT 950 billion. Around USD 589 million are allocated with a 2% service charge for the payment of all RMG workers for a duration of 3 months. 105 The Ministry of Health along with partners have planned a project of more than 30 million USD for a 9-month duration in order to address the bottlenecks of the health system. 30 Although the initial transition in Bangladesh was disjointed, lessons from that time can be used for cautioned opening. A second wave or more of the COVID-19 pandemic might not be affordable for the already hit economy. 107 Positive steps were taken to keep the economy going such as mobilizing community efforts for Boro-rice cultivation that not only addressed concerns due to an early flash flood, but also contributed towards temporary employment opportunities along with food shortages. A constant monitoring of these small-scale gatherings would provide indicators for the transition steps. 108 In order to implement the response mechanism effectively, more tests would be required and meticulous contact tracing system should be developed along with testing infrastructures that would utilize existing university laboratories. It is expected that population-based risk assessments will be conducted routinely in order to isolate those at higher risk of contracting the virus. Classification of disease risk in terms of infection spread and exposure level covering all population groups will facilitate the issue of accountability and data-driven decision-making. 109 The availability of newer quarantine centres through conversion of existing facilities would need to be functional for some time in the event of any transition to normal services. Leadership and effective governance through coordination between the societal building blocks is pivotal for ensuring a smooth transition. A protocol should be put in place for a smoother and sustainable transition between the lockdown period and normality. A predefined procedure on steps from lockdown to cautioned opening should be documented and followed. For example, New Zealand has set a four-level risk assessment system or United Kingdom implemented five levels corona virus alert, which are allowing them to gradually return to normalcy. 110 A robust information system providing access to disease prognosis harnessing the power of informatics and telemedicine can be utilized to ensure adequate follow up and risk assessment on the diagnosed cases. 111 The summary of the recommendations is listed in Table 1 . Feedback mechanisms at the local level should be developed for a better understanding of priorities and be needs specific to the local context. The practice of social distancing needs to be strictly followed until the emergence of vaccines, and extensive monitoring on inflation and control over artificial crises on trade and resources are required. 106 Meticulous understanding of the available evidence base is necessary to dispel the spread of misinformation and thus creating a cohesive environment for developing contextual and widespread evidence-based sustainable decision making. The aim of this study was to evaluate the existing health structure in Bangladesh and its response in the early periods of the COVID-19 pandemic (March-June 2020). The results show that Bangladesh is not COVID ready due to complacency from its leaders at the beginning coupled with inadequate testing that has led to a scenario where decisions are not evidence-based but rather dependent on intuition and experience. 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All authors read the final manuscript and approved it. Publicly available data from Bangladesh Government were used in this study. They would be made available upon requesting the authors. The full data set is available upon request from the corresponding author.