Covid-19 silver lining: Prime Minister’s Suborna Sheba for all?

Covid-19 is perhaps the ultimate example of why we need universal health coverage (UHC)—if anyone is left out, it threatens the health security of everyone. Photo: Anisur Rahman

Mushtaque Chowdhury and Robert Yates

The coronavirus rage is showing early signs of slowdown in most parts of Europe and South East Asia. Strict regimes of social distancing are being eased with reopening of schools and selected businesses, not without controversy though. But it is still advancing in the rest of the world and until an effective vaccine is universally available, it remains a threat to us all.

In Bangladesh, the number of identified cases continues to rise every day. The government is taking steps to push social distancing as a new norm but, for understandable reasons, finding it difficult to fully enforce it. The effect of these measures on vulnerable people is devastating and potentially has a greater impact on their lives and wellbeing than the virus itself.

As in many other countries, Covid-19 has revealed the weaknesses in Bangladesh's health systems. These include: inadequate surveillance systems and capacity to track the spread of the virus, shortages of health human resources of all categories, lack of essential facilities and equipment (e.g. functioning primary care centres, hospitals and ICUs), insufficient specialised equipment (ventilators, testing kits and PPEs), and lack of necessary drugs. Bangladesh has successfully faced many natural disasters in the past but in this particular case, we, like others, were overwhelmed. The head of the government firmly took over the helm but others seemed ill-prepared, leading to poor or little coordination among the different arms of the state. Efforts to get citizens on board were tragically missing. It also showed how poverty and vulnerability deterred enforcement of tough actions in protecting citizens' health. Added to this is the inherent crisis of valid, relevant and timely data.

Despite Bangladesh's acclaimed progress towards the MDGs, in terms of improved socio-economic status for its people, the Covid-19 shock will definitely threaten its performance in the SDGs. It is clear that the principle of "leave no one behind" will have to be enormously reinforced if Bangladesh has to move into a "developed country" status in 2041.

The Covid-19 crisis has set the ground for a "new" health system. Bangladesh has about 30-40 million people who are poor by any standard. With rising poverty and unemployment due to the crisis, this number is likely to rise to about 50 million in the next two to three years. They, in addition to the remaining population, will need publicly-financed healthcare. With such a deadly disease ever-present and able to flare up quickly, it is in all our interests that there is truly universal access to a full range of health services needed to tackle the disease and other conditions. Covid-19 is, therefore, perhaps the ultimate example of why we need universal health coverage (UHC)—if anyone is left out, it threatens the health security of everyone.

The government led by Prime Minister Sheikh Hasina has committed itself to achieving UHC for Bangladesh in several international forums, including signing a United Nations General Assembly resolution on UHC in December 2012 and a political resolution on UHC at the High Level Meeting for UHC in New York last September. Unfortunately, this is one of the few commitments made by the highest office which has, until now, remained unimplemented. But perhaps Covid-19 and its aftermath might give the government the impetus it needs to change this and bring universal healthcare to everyone in Bangladesh. In particular, the government can use the opportunity of this major health disaster to garner support for more investment in the health sector.

According to the World Health Organization, Bangladesh spends only 0.4 percent of its GDP through public health spending, the lowest in the world. Our South Asian neighbour Sri Lanka, for example, spends four times as us; 74 percent of our nation's health expenditures are by people from their own pocket, leading 3-4 million people sliding into poverty every year. This will inevitably increase as a result of the Covid-19 fallout. The generous allocation of new resources to meet the pandemic-related challenges gives the conviction that the government, if committed, can make more money available for health. A phased increase of public health spending to 2.5 percent of GDP over the next 2-3 years would give Bangladesh enough resources to accelerate progress towards UHC based on the principles of primary health care, and give the population better protection from future outbreaks of infectious diseases.

The key to achieving UHC is through reforming the health financing system. In particular, it requires switching from a system of private voluntary financing (mostly people paying fees for services) to a compulsory public system. This has happened in every developed country in the world, with the exception of the US, which has famously failed to reach UHC. Many countries at Bangladesh's income level have made tremendous progress towards UHC including Sri Lanka, the Philippines, Vietnam and Morocco. Thailand achieved UHC in 2002 when its GDP per capita was almost exactly the same as Bangladesh's today. UHC is, therefore, perfectly affordable in Bangladesh if there is the political will to implement it.

Because UHC reforms always require significant increases in public financing, they tend to be led by heads of state who have the power to reallocate public budgets. Progressive leaders often take this initiative because UHC reforms are extremely popular. Across the world, politicians that have delivered UHC to their people have become national heroes. This was the case in Germany, UK, France, Australia, Japan, Canada, Korea, Thailand, Brazil, Mexico, and Indonesia. It is also interesting to note how many of these great UHC reforms emerged out of national crises—including the UK, France and Japan after WWII, Thailand in 2001 after the Asian financial crisis, and Rwanda after the genocide in 1994. And yet again, in 2020, we are seeing early signs of some leaders recognising the opportunity that the Covid-19 crisis might give them to launch popular UHC reforms—notably in Ireland and South Africa. Might this crisis even precipitate a change of government in the United States where it is highly likely that the Democrats are going to campaign on a pro-UHC platform?

Prime Minister Sheikh Hasina has the political capital to go for a big push on UHC. Given global trends, it is inevitable that Bangladesh will make the transition to publicly financed UHC at some point in the next 20 years. As there are sufficient resources in the country to achieve this now, there is no reason why the prime minister shouldn't become Bangladesh's national UHC hero and write her name into the history books in the next five years. What a wonderful gift this would be during the Mujib Borsho and on the golden jubilee year of Bangladesh's independence! This new transformative initiative in healthcare could proudly be called "Bangabandhu-Sheba" or "Suborna-Sheba". It will be an essential step in living with the ongoing threat of Covid-19 and achieving the long-term sustainable development goal target of universal health coverage.

Mushtaque Chowdhury is Convener of Bangladesh Health Watch (BHW) and Professor of Population and Family Health at Columbia University and founding Dean of BRAC School of Public Health. 

Robert Yates is Executive Director of Centre for Universal Health at Chatham House, UK.

করোনা-পরবর্তী স্বাস্থ্যব্যবস্থা সর্বজনীন করতে হবে

মোশতাক চৌধুরী ও রবার্ট ইয়েটস

বলা হয়, প্রতি সংকটেরই একটা ইতিবাচক দিক থাকে। ১৯৭১ সালের সশস্ত্র সংগ্রামের ফসল স্বাধীনতা, বাঙালির নতুন করে এগিয়ে যাওয়া। ২০২০ সালে আমরা এক নতুন ধরনের চ্যালেঞ্জের মধ্য দিয়ে যাচ্ছি। পৃথিবীর বিভিন্ন দেশের মতো করোনাভাইরাস আমাদের জাঁকিয়ে বসেছে। প্রতিদিনই অনেক লোক সংক্রমিত হচ্ছে; মৃত্যুর ঘটনাও বাড়ছে। স্বস্তির কথা হলো ইউরোপ ও দক্ষিণ-পূর্ব এশিয়ায় এ মহামারি অনেকাংশে স্তিমিত হয়ে এসেছে। আমাদের দেশেও তাই হবে, তবে সেটা কবে শুরু হবে, তা এখনই বলা যাচ্ছে না। 

কোভিড-১৯ পৃথিবীর বিভিন্ন দেশের স্বাস্থ্যব্যবস্থাকে তছনছ করে দিয়েছে। যেসব দেশ তাদের স্বাস্থ্যব্যবস্থা নিয়ে গর্বিত ছিল, তারাও এখন এর দুর্বলতা দেখে অনেকটা অস্বস্তিতে আছে। আর আমাদের মতো দেশের কথা তো বলাই বাহুল্য। করোনা আমাদের দেশের স্বাস্থ্যব্যবস্থার বিভিন্ন ত্রুটি আবারও চোখে আঙুল দিয়ে দেখিয়ে যাচ্ছে। এগুলোর মধ্যে আছে নতুন রোগের প্রাদুর্ভাব শনাক্তকরণে দুর্বলতা, চিকিৎসক ও অন্যান্য স্বাস্থ্যকর্মীর স্বল্পতা, অতি প্রয়োজনীয় সরঞ্জামাদি ও ওষুধপথ্যের অপ্রতুলতা ইত্যাদি। বাংলাদেশ প্রাকৃতিক দুর্যোগের দেশ, কিন্তু আমরা সেসব দুর্যোগ বারবার সফলভাবে কাটিয়ে পৃথিবীতে একটি রোল মডেল হিসেবে পরিচিত হয়েছি। কিন্তু করোনার ব্যাপারটি পুরোপুরিই আলাদা। পৃথিবীর বিভিন্ন দেশের এই সমস্যা কাটিয়ে উঠতে যারপরনাই বেগ পেতে হচ্ছে। আমরাও এর থেকে আলাদা নই। অনেক দেশের তুলনায় আমরা একটু দেরিতে শুরু করলেও প্রধানমন্ত্রীর নেতৃত্বে আমরা এটা মোকাবিলার দিকে ধীরভাবে এগিয়ে যাচ্ছি। করোনার বর্তমান উপদ্রব কমে আসবে বলে আমাদের বিশ্বাস। যদিও বিশ শতকের প্রথম দিকের স্প্যানিশ ফ্লুর মতো করোনা আবারও ফিরে আসতে পারে, হয়তো আরও ভয়ংকর কোনো রূপ পরিগ্রহ করে।

এমডিজিতে বাংলাদেশের অর্জন অনেক, অনেকের ঈর্ষার কারণ। বলা বাহুল্য, করোনা পরিস্থিতি আমাদের আরও এগিয়ে যাওয়ার গতিকে বাধাগ্রস্ত করবে। আমাদের সামনে রয়েছে এসডিজি, যা ২০৩০ সালের মধ্যে অর্জন করতে আমরা প্রতিশ্রুতিবদ্ধ।

করোনা পরিস্থিতি বাংলাদেশকে তার স্বাস্থ্যব্যবস্থাকে নতুন করে সাজিয়ে তোলার একটা সুযোগ এনে দিয়েছে। বাংলাদেশের প্রায় তিন-চার কোটি লোক দরিদ্র পর্যায়ে পড়ে। করোনা সংকট এই পরিস্থিতিকে আরও জটিল করে তুলবে। মনে করা হচ্ছে আগামী দুই-তিন বছরে দেশের গরিব জনগণের সংখ্যা প্রায় পাঁচ কোটিতে গিয়ে ঠেকবে। এসডিজি তথা ২০৪১ সালের মধ্যে যদি আমরা উন্নত দেশের পর্যায়ে পৌঁছাতে চাই, তাহলে এদের সবাই তথা দেশের প্রত্যেকের জন্য সহজলভ্য উন্নত স্বাস্থ্যব্যবস্থা নিশ্চিত করতে হবে। পৃথিবীর বিভিন্ন দেশের ইতিহাস থেকে আমরা জানি যে এটা শুধু জনগণের সরকারই নিশ্চিত করতে পারে। বাংলাদেশে যে স্বাস্থ্যব্যবস্থা আমরা তৈরি করেছি, তা সব মানুষের কাছে সমানভাবে অভিগম্য নয়। বিভিন্ন ধরনের স্বাস্থ্যজনিত আঘাত বা শক বছরে প্রায় তিরিশ লাখ লোককে গরিবের কাতারে ঠেলে দিচ্ছে। করোনার ফলে এই সংখ্যা আরও বেড়ে যাওয়ারই কথা। আমাদের স্বাস্থ্যব্যবস্থা ‘সর্বজনীন’ বলা হলেও স্বাস্থ্যসংক্রান্ত খরচে সাধারণ মানুষকে প্রায় ৭৪ শতাংশ নিজের পকেট থেকে গুনতে হয়। এটা তো ‘সর্বজনীন’ স্বাস্থ্যব্যবস্থা হলো না। তাই করোনা-পরবর্তী সময়ে স্বাস্থ্যব্যবস্থাকে নতুন করে ঢেলে সাজাতে এবং সেটাকে প্রকৃত অর্থেই সর্বজনীন করতে হবে। নিশ্চিত করতে হবে, দেশের সব নাগরিক যেন নিখরচায় সব ধরনের স্বাস্থ্যসেবা সহজেই পেতে পারে। 

প্রধানমন্ত্রী শেখ হাসিনা সব সময়ই সর্বজনীন স্বাস্থ্য সুরক্ষা বা ইউনিভার্সেল হেলথ কভারেজের (ইউএইচসি) একজন প্রবক্তা। ২০১২ সালে জাতিসংঘ সাধারণ পরিষদের ইউএইচসি–সংক্রান্ত প্রস্তাবে বাংলাদেশ স্বাক্ষরদাতা। গত বছরের সেপ্টেম্বর মাসে নিউইয়র্কে উচ্চপর্যায়ের সভায় ইউএইচসির পক্ষে প্রধানমন্ত্রী স্বাক্ষর দেন। কিন্তু এই প্রতিশ্রুতি রক্ষায় সরকারের কিছুটা গড়িমসি লক্ষ করা যায়। করোনা পরিস্থিতির কারণে সরকারের প্রতিশ্রুতি আবারও নতুন করে উচ্চারিত হচ্ছে।

বাংলাদেশে স্বাস্থ্যক্ষেত্রে সরকারের বিনিয়োগ বিশ্ব স্বাস্থ্য সংস্থার হিসাবমতে সর্বনিম্ন, পৃথিবীর পরিমণ্ডলে সবচেয়ে কম। এই যখন অবস্থা, তখন আমরা আর কতটুকুই আশা করতে পারি। আমরা যদি আরও সামনে এগিয়ে যেতে চাই, তাহলে স্বাস্থ্যক্ষেত্রে বিনিয়োগ বাড়াতেই হবে। করোনা সংকট আমাদের দেখিয়েছে যে সরকার চাইলে স্বাস্থ্য খাতের জন্য বাড়তি জোগান দেওয়া সম্ভব। প্রধানমন্ত্রী সম্প্রতি যেসব প্রণোদনা ঘোষণা করেছেন, তা আমাদের জিডিপির প্রায় ৩ দশমিক ২ শতাংশ। সরকার চাইলে স্বাস্থ্যক্ষেত্রে বর্তমান বিনিয়োগ শূন্য দশমিক ৪ শতাংশ থেকে পর্যায়ক্রমে ২ দশমিক ৫ শতাংশে উন্নীত করতে পারে। কিন্তু অর্থায়নে এই পরিবর্তন আনতে সরকারের সর্বোচ্চ আগ্রহ ও অঙ্গীকার প্রয়োজন। 

করোনা যে পরিস্থিতির সৃষ্টি করেছে তা থেকে উত্তরণে এবং ভবিষ্যতে এগিয়ে চলতে এই অঙ্গীকারের কোনো বিকল্প নেই। দেশ এখন এই পরিবর্তনের জন্য সম্পূর্ণ প্রস্তুত—অর্থনৈতিকভাবেও। প্রয়োজন শুধু সরকারের সদিচ্ছা। সর্বজনীন স্বাস্থ্য সুরক্ষা বা ইউএইচসি বাস্তবায়নের মূল চাবিকাঠি হলো কীভাবে স্বাস্থ্যব্যবস্থা অর্থায়িত হবে। বর্তমানের অবস্থা অনেকটা জগাখিচুড়ির মতো। জনগণ স্বাস্থ্যসেবা পেতে নানাভাবে অর্থ প্রদান করে, যা সব সময়ই গরিব জনগোষ্ঠীর স্বার্থের বিপরীতে যায়। ইউএইচসি হয়ে গেলে সরকারই হবে সব (বা
বেশির ভাগ) খরচের জোগানদাতা। এই ব্যবস্থা যুক্তরাষ্ট্র ছাড়া পৃথিবীর সব উন্নত দেশে রয়েছে। বাংলাদেশ যে এই নতুন ব্যবস্থা গড়ে তুলতে পারে তার প্রমাণ মেলে অনেক দেশের দৃষ্টান্ত থেকে। অর্থনৈতিকভাবে সমগোত্রীয় শ্রীলঙ্কা, ফিলিপাইন, ভিয়েতনাম ও মরক্কো ইউএইচসি বাস্তবায়ন করেছে। থাইল্যান্ড ২০০২ সালে যখন ইউএইচসি বাস্তবায়ন করে, তখন তাদের জাতীয় আয় ছিল বর্তমান বাংলাদেশের সমান। বাংলাদেশ ইউএইচসি বাস্তবায়নে তাই পুরোপুরি উপযুক্ত এবং অর্থনৈতিকভাবে প্রস্তুত। ২০২০ সালে করোনার কারণে বেশ কিছু দেশ ইউএইচসি বাস্তবায়নে তৎপর হচ্ছে, যার মধ্যে আছে আয়ারল্যান্ড ও দক্ষিণ আফ্রিকা। বাংলাদেশও এই তালিকায় আসতে পারে। 

বাংলাদেশে করোনা পরিস্থিতির উন্নতি ঘটবে। প্রধানমন্ত্রী শেখ হাসিনার অনেকটা একক নেতৃত্বে এই পরিস্থিতি সামাল দেওয়ার চেষ্টা চলছে। দেশকে উত্তরোত্তর উন্নয়নের পথে নিয়ে যেতে তাঁর অঙ্গীকার এবং বলিষ্ঠ নেতৃত্বের সঙ্গে সবাই পরিচিত। ২০৪১ সালে যখন আমরা উন্নয়নের পরম পর্যায় তথা উন্নত দেশগুলোর কাতারে নাম লেখাব, তখন স্বাস্থ্যব্যবস্থা একটি নিয়ামক হিসেবে চিহ্নিত হবে। আর এর জন্য প্রস্তুতি দরকার এখনই। করোনা-পরবর্তী এই রূপান্তরকে এগিয়ে নিতে প্রয়োজন বর্তমান প্রধানমন্ত্রীর মতো একটি দূরদর্শী ও বলিষ্ঠ নেতৃত্ব। বৈশ্বিক অবস্থাদৃষ্টে এটা নিশ্চিত বলা যায় যে পরবর্তী ২০ বছরে বাংলাদেশে ইউএইচসি বাস্তবায়িত হবে। যেহেতু দেশ এখনই এই রূপান্তরের জন্য প্রস্তুত, তাই আর অপেক্ষা কেন। ইতিহাসে ‘ইউএইচসি হিরো’ হিসেবে নাম লেখাতে তাই এখনই শেখ হাসিনার দৃঢ়ভাবে এগিয়ে আসা উচিত হবে। বাংলাদেশে এখন আমরা মুজিব বর্ষ উদ্‌যাপন করছি। আগামী বছর ২০২১ সাল আমাদের স্বাধীনতার সুবর্ণজয়ন্তী। তাই আর দেরি না করে এখনই ইউএইচসি বাস্তবায়ন শুরু করা সমীচীন হবে। জাতির পিতার স্মৃতি এবং স্বাধীনতার বিশেষ পূর্তিকে স্মৃতিবহ করতে এই উদ্যোগের নাম হতে পারে বঙ্গবন্ধুসেবা বা সুবর্ণসেবা। এই সুবর্ণ সুযোগ হাতছাড়া করা ঠিক হবে না। 

মোশতাক চৌধুরী বাংলাদেশ হেল্থ ওয়াচ এর  আহ্বায়ক এবং যুক্তরাষ্ট্রের কলম্বিয়া ইউনিভার্সিটির অধ্যাপক ও ব্র্যাক স্কুল অব পাবলিক হেল্থের প্রতিষ্ঠাতা ডিন। 

রবার্ট ইয়েটস যুক্তরাজ্যভিত্তিক চেথাম হাউসের নির্বাহী পরিচালক, ইউনিভার্সেল হেলথ কেয়ার।

Covid-19 and the missing data conundrum

Mushtaque Chowdhury and Farzana Misha

The recent outbreak of Covid-19 is unprecedented. Given the novelty and the rapidly evolving contexts, data gathered from the field is the only path to attaining the true picture of the disease's progress. Unfortunately, we do not have a handle on this yet. To design an evidence-based, feasible and effective response, the true extent of the spread and impact needs to be known, which can only be done through accumulation of accurate and up-to-date statistics. Such data is needed not only on the health sector but also on economics, businesses, education, remittance, social safety nets, etc. A constant flow of new and updated data on the response from different actors including in government, NGOs, healthcare, industry and agriculture are needed to monitor and effectively combat the disease.

Much like the lack in coordination of responses, the same holds true for data generation. Here perhaps, concerns extend well beyond coordination. It is the sheer absence of some relevant state machineries in the game. Let's take the case of two prime public sector agencies vested with the responsibility of generating data, particularly during the emergency situation in which we find ourselves—the Institute of Epidemiology and Disease Control Research (IEDCR) and the Bangladesh Bureau of Statistics (BBS).

The IEDCR was established in 1976 as the country's "disease detectives". Surveillance is an epidemiological practice through which the spread of a disease is predicted, observed and monitored to minimise harm to the populace. Over the years, it has made several important contributions. During 2007–2011, they investigated 76 disease outbreaks including the Nipah virus outbreak (although there is no recent information available on their website). In 2009, when the H1N1 threatened Bangladesh, they instituted screening of incoming passengers through 16 points including three airports, and recommended textbook containment measures such as social distancing, wearing masks, washing hands and isolating patients. An important function the IEDCR has been performing since 1978 is collecting and reporting on nationally notifiable diseases through weekly morbidity reports from upazila levels, and monthly disease profiles from medical college hospitals.

Once Covid-19 hit our shores in early March, IEDCR was designated as the sole source of information for the disease's spread in Bangladesh. The wait for the afternoon update became almost ritualistic. The situation has come a long way since the initial days when the sole testing site for Covid-19 was the IEDCR itself. Testing capacities have been somewhat decentralised now and extended to over 30 locations in Dhaka and the main divisional cities. The fact that this is not enough—which is agreed upon by epidemiologists—is clear given that we have one of the lowest test rates in the region. Our testing rates (per million population) are almost half of those in India or Pakistan. There are limitations to expanding the facilities fast if the quality is to be ensured and IEDCR is being relieved of its responsibilities of carrying out the tests. In the absence of widespread testing and reporting of related deaths, the media regularly reports on the number of deaths from "corona-like symptoms", which gives an alternative but less robust understanding of the spread of the disease. Couldn't this be done by IEDCR itself by using its upazila-based weekly morbidity data? Why have they not used the medical colleges-based disease profile data to give additional estimates? If reported correctly, such data would have been more reliable than any other sources, and, in the interim, could make national preparedness more evidence based.

On the other side of the crisis, the premier agency for demographic and socio-economic data is the Bangladesh Bureau of Statistics (BBS). Conspicuously, they have been eerily quiet in this current crisis. The BBS is unilaterally responsible for running projects of national importance such as the Census, Household Income and Expenditure Survey and the Labour Force Survey. They have also been running a Sample Vital Registration System (SVRS) through which data on vital events are collected and analysed on a periodic basis since 2011. Implemented in 1000 primary sampling units, it gives district-level estimates of births, deaths, marriages, and migration. Data is collected using a dual record system with the help of field registrars and staff of the upazila statistical office. Although there are genuine concerns about its quality, the SVRS has the potential to be a critical source of information in understanding the progress of Covid-19 at the community level, particularly in terms of the number of deaths. BBS could help the national response by recommending how the testing facilities correspond to the needs, not only in medical terms but also other relevant factors such as socioeconomic status of the region and capacity of local health facilities and staff, among others. Given BBS's extensive knowledge of the population and population characteristics, they are well placed to suggest where healthcare is most needed.

The silence on their part likely stems from several reasons. Hamstrung by unyielding bureaucracy, hierarchical modus operandi, and a strong resistance to change stifles the enthusiasm of eager staff from the get-go. Finally, activities of the BBS are typically placed in the non-essential category, to the extent that the recent government closures stopped all BBS activities, including the preparation for Census 2021. Once we put it all together, it paints a vivid picture of why we see no movement on their part.

Given our weak infrastructure, the government needs to ramp up efforts to fill the gap—while far from perfect and much left to be desired, they're beginning to get a better handle on the technical side of the issue, that is, increased testing and supplying protective gear. On the socioeconomic front, we don't know much beyond what has been reported by various universities and think tanks in the country. While there are many ambitious plans to reach aid to those who need it, we have not heard much on how the support will target and reach the intended beneficiaries. Traditional approaches and thinking will unlikely be effective here as we have seen so far. We understand BBS's trepidation and reluctance to engage. But in a world that considers data to be the new oil, we as citizens should demand more from them—especially in the face of resistance when it comes to receiving bad news. The reputation of these organisations is not up for debate in this article, but rather to encourage them to remain relevant in a fast-changing world. The post-coronavirus Bangladesh will demand their data even more.

Mushtaque Chowdhury and Farzana Misha are respectively Adviser and Research Coordinator of BRAC James P Grant School of Public Health, BRAC University. Prof. Chowdhury is also Convener of the Bangladesh Health watch.  

Time to push online learning in higher education

Mohammed Shahidullah and Mushtaque Chowdhury

We have come a long way in teaching and learning using technology. Whatever we call it—online learning, virtual learning, or e-learning—it has made education independent of time and place. Users have access to course materials 24 hours a day, seven days a week. Learning management systems (LMS) make it possible to upload course materials, assignments, and exams as well as to create discussion boards and other communication tools. Online learning has made distance learning an accessible and effective alternative that is traffic-jam free and unaffected by unexpected campus closing because of hartals, strikes, and man-made or natural calamities like the coronavirus pandemic. Online learning makes it possible to not lose a semester or spend extra money for overstays in hostels. As a result, it solves the problem of campus housing, which is always a major problem for university students. This also provides opportunities for stay-at-home mothers and persons who have jobs but would like to advance their degrees.

Online learning has many benefits. These include, among others, flexible schedule and environment; independence of place and time; saving on on-campus housing; independence of transportation hassles and expenses; student-centred learning according to the learner's convenience and timeline; equal opportunities for all students, introverts and extroverts alike; improving technical skills through the use of LMS; freedom from campus buildings or fixed learning resources; access to many free courses like Massive Online Open Courses (MOOCs) and modules from anywhere in the world; access to lectures from world-famous experts in respective disciplines; supplementing in-class learning; finishing a semester strong and on time; and independent learning and time management.

There are a few myths on online learning, including the notions that online learning is less rigorous and promotes "cheating", that it is isolating and lonely, and that the instructors are inferior. These are all unfounded. Because of these myths, unfortunately, there was a strong resistance to implementing online learning in higher education. No new technology or change is readily accepted or welcomed because of its "disruptive" nature. In traditional classroom teaching, students are tested on what they read. In online learning, the emphasis is on authentic learning—learning by doing. Students engage in various ways, such as through experimentation, real-world problem solving, problem-based activities, case studies, and participation in discussion boards and virtual communication. Exams and quizzes are proctored like in the TOEFL and GRE to avoid cheating. Online learning provides a strong networking community for group study, discussion, and sharing ideas and interests, reducing feelings of isolation or loneliness. In universities in the global north, most on-campus instructors also facilitate online courses, and all online instructors are required to go through training on online teaching-learning. Communication with instructors usually takes place through telephone, email, discussion boards, virtual live meetings, and chatrooms.

Online learning requires specific software, hardware, technological know-how, and, of course, high-speed broadband Internet. An LMS is required for uploading courses and related resources on the website. Blackboard, D2L/Brightspace, Canvas, and Moodle are some of the popular LMS platforms. Moodle is a free open-source LMS. Desktops, laptops, tablets, or smartphones are needed to access an LMS. A webcam or built-in HD camera and a high-quality headset help in video conferencing and live classroom sessions using Zoom, Skype for Business, Blackboard Ultra, and WebEx. Virtual live meetings can be treated as traditional classroom sessions from one's residence, and all activities can be recorded for later review or for students who missed a class. These classes provide the students with the opportunity to ask questions and participate in discussion.

Many of the private universities in Bangladesh proactively adopt new technologies to provide contemporary education to their students. These students are able to complete their education on time and will have an added advantage in the job market. Most private-sector employers will prefer candidates who are trained in online learning because most jobs will require such expertise. Unfortunately, most public universities in the country are lagging behind in offering their students an opportunity to complete their education on time by introducing online learning, even in the current lockdown situation. It is slated that the universities will probably remain closed for many months, causing a wastage of precious time for students. 

Some of the private universities in Bangladesh have been delivering their courses online since the onset of the pandemic in March 2020. For example, BRAC University's James P. Grant School of Public Health offers a one-year full-time Masters in Public Health (MPH) programme, with half of its student body coming from abroad. As the lockdown started, BRAC University went online, and most of the courses were offered remotely. In the MPH programme, students have already completed the modular course on epidemiology, which was done with interactive teaching followed by Q&A. Using Google Forms, the School has also successfully conducted exams. According to the course coordinators and School administration, there were some initial hiccups as the students returned home following the lockdown, but since then, it has been running without any significant challenges. The students' attendance in "classes" has also been one hundred percent. Such online teaching was tried for biostatistics in Spring 2006 when the first author was a Fulbright visiting faculty at the School. Moodle was the learning management system used, and the course went successfully.

There is more than one way to train faculty members to teach online within a short period of time. Resources are available to offer free training. Technology companies can help with hardware and software. Policymakers and regulators, such as the University Grants Commission (UGC) of Bangladesh, can play a significant role in developing guidelines and making available the needed resources to incorporate online learning as an integral part of learning in higher education. The public universities must not shy away from this transformation. We believe that this is an important way forward to truly implement Digital Bangladesh.

Mohammed Shahidullah and Mushtaque Chowdhury are respectively Adjunct Faculty at the University of Illinois, Springfield, USA, and President of the Dhaka University Statistics Department Alumni Association (DUSDAA). Dr Chwdhury is also acting as the convener of the Bangladesh Health Watch.

COVID-19 burden and hospital readiness by A M Zakir hussain

PREDICTING the number of cases and deaths from any disease requires some basic information, eg, (i) exposure potential — the probability of people to be exposed to the pathogen; (ii) the infectiousness of the pathogen (transmission capacity of the pathogen from host to host); (iii) the infectivity or capacity of the pathogen to cause the disease; (iv) the susceptibility of the host to infectivity or capability to resist infectivity. In the absence of these information, no model will be able to predict the incidence or outcome of an infection. Possible death – scenario 1: Let us assume that all of the 16 or so crore people in Bangladesh have been exposed and everyone is susceptible to COVID-19 although none of which is practically possible. If this were true, the total number of COVID-19-related mortality in Bangladesh would be as presented in Table 1, based on a direct standardisation method, applying Chinese age-specific mortality data. In Table 1, the total of 11,55,847 in the second but last column includes 4,25,238 deaths among 0–9 years old children, which were not accounted for among the total of 4,77,581 additional deaths from COVID-19, in the last column as there would be no death according to the Chinese estimate in the 0–9 years age group from COVID-19. This is corroborated by the data from European and American countries as well. Up to April 14, in the United States, of the 6,839 deaths, 5,151 had underlying conditions and only 137 were found without any underlying conditions. For another 1,551, this status was unknown. While of the 4,77,581 who might die of COVID-19 in Bangladesh, about 75 per cent, ie, 359,108 people, would be above the age of 60 years, and 1,18,473 people might die between the ages of 10 years to 59 years in Bangladesh (many of who would also have pre-existing medical conditions, especially at younger ages — the 40,239 deaths shown in the last column). These are the numbers above the deaths that would occur even in the absence of COVID-19. But again, the 4,77581 deaths due to COVID-19 will occur only if everybody is susceptible to SARS-CoV-2 and everybody is exposed to it, which, however, is not possible. Again, 70–80 per cent of these 4,77,581 hypothetical deaths would have critical co-morbid conditions. In actuality, therefore, 119,395 people might die in perfect health because of COVID-19 in Bangladesh. These figures are theoretical propositions. Possible cases and deaths – scenario 2: Let us now estimate COVID-19-related figures for Bangladesh more practically, from another perspective, ie using the figures of Wuhan first. The city has a population of 11 million and the number of reported COVID-19 cases was 50,333, of them 3,869 died. This means an infection rate of 4.6 per 1,000 population in the city — a case fatality rate of 7.7 per cent, and a mortality rate of 0.35 per 1,000 population in Wuhan. Applying these rates to the total population of Bangladesh, the total cases of infection would be 777,874; the total number of fatal cases (or mortality) would be 59,794. Let us consider now the scenario of Italy. The total population of Italy is about 60.36 million. It reported by April 16, a total of 178,972 cases of COVID-19, of whom 23,660 died of the diseaset. The infection rate of COVID-19 in Italy is 2.96 per 1,000 population and the case fatality rate is 13.2 per cent. The mortality rate is 0.4 per 1,000 population. If we apply these rates to Bangladesh, the total cases of infection would be 503,200 and the number of dead would be 66,422. The population size in the United States is 328.2 million. The United States by April 16 reported 770,564 COVID-19 cases with 41,114 deaths. The incidence rate of COVID-19 in the United States, therefore, is 2.35 per 1,000 population and the case fatality rate is 5.34. The application of these estimates will give the total number of COVID-19 cases in Bangladesh to be 399,500 and the total fatality from COVID-19 in light of the United States would be 21,316. The population size of the United Kingdom is 66.65 million; the COVID-19 cases reported were 120,067 and death 16,060 by April 16. The incidence rate is 1.8 per 1,000 population and the case fatality rate is 13.38. The application of these rates to Bangladesh would give the total incident cases of 306,000 and the total death would be 40,943. As figures in Table 1 are only a theoretical proposition, under extreme and unsubstantiated conditions and those of city/country-wise estimates given later are experiential, we will consider these later figures for further elaboration. According to the Wuhan estimates, Bangladesh might have a maximum of 777,874 infections of COVID-19 and 59,794 deaths. According to the Italian estimates, Bangladesh might experience incident cases of 503,200, of whom 66,422 might die. The application of US and UK estimates would give lower figures of infection and mortality. The maximum infection we get is 777,874 and the maximum deaths 66,422. As these estimates are based on rates, an increase in absolute numbers will not sway these rates much. The total numbers estimated for incidence and mortality for Bangladesh are, therefore, apt to remain the same. Optimistic estimates – scenario 3: The additional points we need to bear in mind are the effects of the environmental and weather conditions on the viral transmission (sunlight, humidity, atmospheric temperature, etc); genetic pre-disposition of the people of Bangladesh, which will determine people’s susceptibility to the virus to cause disease (manifestation of infectivity); exposure potential which might be controlled through adoption of the preventive measure, eg isolation, lockdown, quarantine; and the infectiousness of the viral strain running through the population; development of immunity, in addition to the comorbidities. Exposure to homologous (similar genes) viruses/pathogens may also give people some partial protection. There is also a possibility that exposure to sunlight would help people develop vitamin D, which also is contemplated to give some resistance in people against SARS-CoV-2. The actual numbers, however, are difficult to estimate as the parameters are unknown. In the United States, at least 50 times more people have been found to develop antibody to the virus already, without any trace, while 20 per cent to 80 per cent people did not show any post-infection clinical features in China. There is no reason why the same phenomenon will not be observed in Bangladesh. This means of the 777,874 cases of infection, actually 518,583 cases may be reported if the asymptomatic cases are estimated to be a third of the total infections. But if the US data are considered, only 15,557 cases will be reported in Bangladesh for 777,874 infections. As the number of deaths in the South Asian countries is markedly low in comparison with those in Europe, we believe that the 66,422 deaths that have been estimated for Bangladesh, may not actually be experienced, because of some or all of the factors mentioned above. Hospital readiness for COVID-19 A DIVISION-WISE hospital based management of COVID-19 cases is suggested below. The number of 777,874 infections and 66,422 deaths, as estimated above theoretically, may be divided by division and cities hypothetically based on the relevant population size. The distribution of the cases of infection and mortality would be as in Table 2. It needs to be noted that, the actual number of incidence and death reported by the government by location is different from what has been estimated in Table 2. This difference may be due to the actual exposure potential and other factors, mentioned above. We only give a theoretical possibility here. Experientially, about 15 per cent of the infected (critical patients) would require hospitalisation; 5 per cent (a third of the critical patients) of whom would require ICUs, ie 38,894, in total. This may be broken down into the eight divisions of the country commensurate with the population size. This would be approximately 11,886; 7,125; 4,632; 3,928; 3,901; 2,851; 2,485; 2,089 ICU beds in Dhaka, Chattogram, Rajshahi, Rangpur, Khulna, Mymensingh, Sylhet and Barishal divisions. The total number of hospitals in Bangladesh is more than 6,500, ie six ICU beds on average per hospital — varying according to the size of hospitals and number of hospital beds, which usually follow the population size by location and are apt to be proportionate to the critical patients by location. This may range between 2–50 ICU beds as per the hospital size. But as may be surmised, we do not need these ICU beds all at a time. The average hospital bed occupancy, as the experience tells us, should not be more than 14 days on average. This means, over the next two months, we would in fact require 2,972; 1,781; 1,158; 982; 975; 713;621; and 522 (9,724 in total) ICU beds in Dhaka, Chattogram, Rajshahi, Rangpur, Khulna, Mymensingh, Sylhet and Barishal divisions. As many COVID-19 patients practically would die within a few days after hospital admission and some would not be able to reach hospitals in time, so about a half of the 9,724 beds might be actually optimal for COVID-19 patients in Bangladesh. This would mean 1,486; 891; 579; 491; 488; 356; 311; 261 ICU beds (4,862 in total) for Dhaka, Chattagram, Rajshahi, Rangpur, Khulna, Mymensingh, Sylhet and Barishal divisions. As the use of mechanical ventilators has found to be rather injurious to COVID-19 critical patients. This has not been considered. It may be of interest to note that the European Union countries have 11.5 ICU beds per 100,000 people, on average, in a normal condition. According to EU standards, we need 19,550 ICUs for Bangladesh under similar conditions. Life expectancy in the European Union is 81 years and in Bangladesh it is about 73 years while 60 per cent of the deaths in Bangladesh occur from non-communicable diseases (eg, heart diseases, diabetes, chronic obstructive pulmonary diseases, cancer and injury). Almost all of these might require ICUs. So, even keeping the near future needs into consideration, we should establish at least 9,724 ICU beds, mentioned above, in the country now. It might be kept in mind also that adequacy of ICUs in Bangladesh could increase the life expectancy of Bangladeshis further. The clinical aspects have not been discussed here as the treatment processes are changing rapidly globally. It is expected that treatment should be commensurate with the pathogenesis of the disease. Ventilators are not considered a panacea any more.

 AM Zakir Hussain is Working Group member of Bangladesh Health Watch. Dr. Hussain is also former director, Primary Health Care and Disease Control; former director, IEDCR, DGHS; former regional adviser of SEARO, WHO and former staff consultant, Asian Development Bank, Bangladesh.

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Bangladesh Health Watch Report 2018-2019