Health systems trust in the time of Covid-19 pandemic in Bangladesh: A qualitative exploration

  1. Taufique Joarder
  2. Muhammad Nahian Bin Khaled
  3. Shahaduz Zaman

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Abstract

Background

Lack of trust hinders care seeking, and limits community support for contact tracing, care seeking, information and communication uptake, multisectoral or multi-stakeholder engagement, and community participation. We aimed at exploring how trust might be breached and what implications this may have in Covid-19 pandemic response by the Bangladesh health systems.

Methods

We conducted this qualitative research during the pandemic, through seven online focus group discussions, with purposively selected mixed-gender groups of clinicians and non-clinicians (n=50). Data were analyzed through conventional content analysis method.

Results

The common thread throughout the findings was the pervasive mistrust of the people in Bangladeshi health systems in its management of Covid-19 pandemic. In addition to the existing health systems weaknesses, few others became evident throughout the progression of the pandemic, namely, the lack of coordination challenges during the preparatory phase as well as the advanced stages of the pandemic. This; compounded by the health systems and political leadership failures, lead to opportunistic corruption and lack of regulations; leading to low quality, discriminatory, or no service at all. These have trust implications, manifested in health seeking from unqualified providers, nonadherence to health advices, tension between the service seekers and providers, disapproval of the governance mechanism, misuse of already scarce resources, disinterest in community participation, and eventually loss of life and economy.

Conclusions

Health sector stewards should learn the lessons from other countries, ensure multisectoral engagement involving the community and political forces, and empower the public health experts to organize and consolidate a concerted health systems effort in gaining trust in the short run, and building a resilient and responsive health system in the long.

Key Messages

  • Implications for policy makers

    • The preexisting health systems weaknesses, widely discussed in many literatures on Bangladeshi health systems, need to be addressed first, in consultation with health policy and systems experts.

    • In order to improve the coordination and science-based professional response to Covid-19 pandemic, the relevant experts, instead of administrators or bureaucrats, should be immediately engaged and deployed.

    • In order to facilitate adaptive leadership, health system should ensure transparency in every aspects of its functions, curb corruption and discrimination, regulate private sector for cost and quality of services, and ensure equity and fairness.

    • Politicians in power should engage with other social, cultural and religious forces and formally engage with other political parties in facing the Covid-19 crisis, with a view to fostering multisectoral collaboration and community engagement.

    • The health system actors should ensure a free flow of correct information following evidence based, scientifically oriented social and behavior change communication (SBCC) strategies.

  • Implications for public

    Bangladeshi health system is grappling with the Covid-19 pandemic. The authors believe that a better response was possible. In this research, people themselves expressed their perceptions and views regarding the alleged mishandling of the situation by health systems stewards. Careful addressing of the issues explored in this article may lead to a better pandemic response in the short run, and develop a resilient health system in the long.

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    1. ScreenIT

      SciScore for 10.1101/2020.08.05.20157768: (What is this?)

      Please note, not all rigor criteria are appropriate for all manuscripts.

      Table 1: Rigor

      Institutional Review Board Statementnot detected.
      Randomizationnot detected.
      Blindingnot detected.
      Power Analysisnot detected.
      Sex as a biological variableStudy context: This research was sponsored by United Nations Youth and Students Association of Bangladesh (UNYSAB), which organized a webinar on 19 May 2020, amid the lockdown situation (officially termed as ‘General Holidays’) in Bangladesh, on ‘Trust in the Health System in COVID-19 Pandemic and Beyond.’ Moderated by the first author, the discussants included a public health expert from the not-for-profit private sector (Head of the communicable disease program of a leading non-governmental organization of Bangladesh), a public health expert from the public sector (an Assistant Director of a government health agency of Bangladesh), a health economist (an Associate Professor at a leading Bangladeshi public university), and a female entrepreneur.

      Table 2: Resources

      No key resources detected.

      Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

      Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
      This mistrust arguably stemmed from the existing health systems weaknesses, supplemented, throughout the progression of the pandemic, by, the lack of coordination challenges during the preparatory phase as well as the advanced stages of the pandemic. This; compounded by the health systems and political leadership failures, lead to opportunistic corruption and lack of regulations; leading to low quality, discriminatory, or no service at all. These have trust implications, manifested in health seeking from unqualified providers, nonadherence to health advices, tension between the service seekers and providers, disapproval of the governance mechanism, misuse of already scarce resources, disinterest in community participation, and eventually loss of life and economy. Understanding of these findings is important in reorganizing, restructuring, and revamping Bangladesh’s response towards Covid-19 pandemic. One of the predictors of mistrust in Covid-19 response was the lack of coordinated actions. Many respondents, especially those with a public health background indicated that, this happened, because appropriate experts were not engaged since the early days of the pandemic. This is supported by the news articles and reports from Bangladesh. Bangladesh detected the first Covid-19 case on 8 March and experienced the first death on 18 March, but it formed the 17-member National Technical Advisory Committee (NTAC) On 19 April 2020. Until then, most of the pandemic control efforts were ...

      Results from TrialIdentifier: No clinical trial numbers were referenced.

      Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

      Results from JetFighter: We did not find any issues relating to colormaps.

      Results from rtransparent:
      • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
      • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
      • No protocol registration statement was detected.

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    2. Version published to 10.1101/2020.08.05.20157768v1 on medRxiv