Perception of Citizens on the Healthcare Services During COVID-19 Pandemic in Bangladesh

Abstract

The COVID-19 pandemic has caused radical changes in the healthcare services infrastructure throughout the world and has reshaped the perception of the citizens on government initiatives to combat this pandemic. The study aims to understand the citizens’ perception of the measures of healthcare service of Bangladesh to combat COVID-19 and to explore the influencing factors that shaped the citizens’ perception. The study is qualitative in nature, followed by multi-method data collection techniques. The primary data and information were collected through 15 in-depth interviews (IDIs) where respondents were either COVID patients or close relatives of patients and 5 key informant interviews (KIIs) who were the public health experts and health practitioners. The study revealed that Bangladesh had huge equipment shortages at the early stage of the pandemic. The significant disparity was seen between the poor and the rich in getting healthcare services during COVID-19; the lower and middle classes suffered the most on many fronts due to the various measures of the government in confronting the pandemic. Inefficient use of limited resources, mismanagement in the health sector, poor governance, undue political influence and inappropriate vaccine management strategy led to trust deficiency among the citizens; social media also played a critical role in shaping the citizens’ perception. Findings of this study will guide concerned policy stakeholders to re-instate citizen trust in the government through undertaking appropriate policy interventions.

Keywords

COVID-19 Bangladesh citizen perception citizen trust healthcare service

Introduction

Citizens’ trust in government is an important indicator of government competency because it encourages citizens to follow government policies during a crisis. A trustworthy government can generate confidence among the citizens to cooperate with government activities (Saechang et al., 2021). The outbreak of the COVID-19 pandemic is such a crisis that governments have responded actively to minimise the harm. It is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV2), which (Johns Hopkins Medicine, 2021) has affected 259.02 million people in 222 countries, with 5.2 million dying (Worldometer, 2021a, 2021b). Due to COVID-19, the world economy has been hampered; global GDP declined by 3.5%, and the World Bank forecasted that remittances would reduce by 14% by 2021 (IMF, 2021a, 2021b; World Bank, 2020). Additionally, 88 million people became extremely poor due to the pandemic situation, and among them, 10 million people are in a critical situation due to increased healthcare spending (UN, 2021). Also, the COVID-19 pandemic has put 90% of the world’s healthcare systems to the test, and most countries have put in place common healthcare measures such as physical distance, individual protection behaviour improvement, community isolation, quarantine, telemedicine, healthcare apps, vaccinations and so on (WHO, 2020a, 2020b, 2020c, Pan American Health Organization, 2020). WHO reported that, among the infected countries, 55% of governments allocated additional financial facilities for healthcare. Among the countries, 70% of the upper-middle- and higher-income countries showed an effective response, while in the middle- and low-income countries, it was only 42% and 41% (WHO, 2020a, 2020b, 2020c, Pan American Health Organization, 2020).

Bangladesh, a country with a stable government system and a strengthening economy, first reported COVID-19 cases in April 2020 (World Bank, 2021). At present, 1,574,948 people have been affected by the coronavirus, and 27,961 have died here (Worldometer, 2021a, 2021b). Due to the pandemic, an additional 24.7 million people became poor, and GDP growth declined from 8.1% in 2019 to 5.2% in 2020 (ADB, 2020; Mottaleb et al., 2020; Khatun, 2021). The government has also taken protective healthcare measures according to the WHO guidelines through the coordination of the Ministry of Health and Family Welfare (MoHFW) with the cooperation of the Directorate General of Health Services (DGHS) (Azad & Mohakhali, 2020). The government also came up with stimulus policy packages of $8 billion for economic survival and $7.5 billion for health insurance and life insurance (KPMG, 2020; IMF, 2021a, 2021b). However, these packages primarily benefited the formal industries, while the people working in the informal sector became deprived. These people make up 52 million of the 61 million employed people in the country and contribute 40% to the national GDP (ILO, 2021; Mujeri, 2020). Due to governmental measures, at least 20 million informal workers will lose their jobs in 2020 (Hossain, 2021). Furthermore, based on social media rumours and a lack of trust in official information, 16% of Bangladeshis refused to be vaccinated (Rafe, 2021).

From the above portrayal, it is evident that there is a contradictory impact of the COVID-19 pandemic on the economic as well as the political conditions of Bangladesh. The objective of the study is to investigate citizens’ perceptions of healthcare services in Bangladesh during the COVID-19 pandemic. Furthermore, the study intends to investigate the political economy underlying citizens’ perceptions of healthcare services in Bangladesh during the COVID-19 pandemic.

Literature Review

Throughout the world, the emergence of COVID-19, a public health issue, has drawn attention. The pandemic has created disruptive physical as well as mental impacts on the livelihood of mankind (Polakovic, 2020). The pandemic has created unprecedented conditions for people, and governments around the world are attempting to deal with the situation by implementing countermeasures. However, the effective implementation of these initiatives is wholly dependent on the perception, trust in government and support of the citizens. According to Alexopoulos and Buckley (2013), citizens’ trust in government is positively correlated with the behaviour of complying with protective attitudes in personal life. The effective implementation of public policy initiatives is also subject to public trust in government. Like this, lower trust can reduce the support of people for government activities (Chanley et al., 2000). The statement also applies to governments’ current efforts to combat the COVID-19 pandemic.

A study conducted by the WHO (2020a), (2020b), (2020c) and Pan American Health Organization (2020) reported that more than 50% of the countries are dissatisfied with the government’s measures for outpatient, inpatient and community healthcare services. On the other hand, in the United Kingdom, only 43% of citizens considered that the government was able to handle the COVID-19 pandemic effectively (Suleman et al., 2021). Studies were also conducted in several countries on the acceptability of healthcare measures like vaccination. Khubchandani et al. (2021) found that 22% of people in the United States are unwilling to take vaccines. Also, 13.9% of the students were reluctant to take vaccines in Italy (Barello et al., 2020). The rate also diversified in Germany, the United Kingdom, Portugal, Denmark and Canada (Neumann-Böhme et al., 2020).

Several studies have been conducted on the perception of people towards healthcare management during the COVID-19 pandemic in Bangladesh. Most of the studies found the perception to be positive, though there was a significant portion that showed negative attitudes (Hossain et al., 2020; Mannan & Farhana, 2020). On the other hand, Wadood et al. (2020) found that about 18.3% of people showed negative attitudes towards healthcare measures like handwashing to contain the infection of the coronavirus. This attitude could lead to problems in the future. Additionally, a study was conducted on the students of Bangladesh, among whom 50% expressed their reluctance towards COVID-19 and that they would not be affected, whereas only a minimal portion was worried about the infection and its impacts. The study also showed these students were distressed about the negative impacts of COVID-19 on their regular life routine, studies, economic conditions, fieldwork and so on (Wadood et al., 2020).

Mannan and Farhana (2020), Islam and Siddika (2020) and Rahman and Sathi (2020) have conducted a significant number of studies regarding the knowledge, attitudes, and perceptions of people towards COVID-19 for understanding the existing condition of the COVID-19 pandemic. Anwar et al. (2020) and Hossain et al. (2020) found that the sector is already overburdened with huge numbers of patients in proportion to hospital beds and doctors, poor healthcare services in hospitals, a lack of critical care and skilled professionals and so on. Joarder et al. (2021) also found similar results supporting this statement. Maswood (2020) stated that the government had spent a lot on the healthcare system during COVID-19, but the result was not as per expectation due to corruption, mismanagement and the poor capacity of the health sector. This deterioration has been blamed on political leaders and public officials (Iftekharuzzaman, 2020). Parvez et al. (2021) found in their study that men are more unwilling to maintain social distance because they think that they are healthy and have a lower chance of infection than women. The satisfaction level regarding government health services was greater among females than males. However, the perception among the young adults was better.

In Bangladesh, a number of studies were conducted to depict the critical public health situation, the government’s policy measures during COVID-19, and the challenges faced by the government in dealing with the pandemic situation. However, whether these measures truly contributed to gaining citizens’ trust remains an open question in academic research. This study is completely focused on citizens’ perception and trust in the healthcare management efforts to confront COVID-19 in Bangladesh and endeavours to explore the influencing factors that shaped people’s perception.

Methodology

For conducting the study, a qualitative study design and exploratory research approach were applied, which facilitated the researchers in gaining deeper insight into the perceptions of citizens of the healthcare management system in Bangladesh during the COVID-19 pandemic. The data collection was conducted between 10 August to 3 November 2021. To collect the required data, both primary and secondary methods of data collection were employed in this study. Under primary data collection, multimethod data collection techniques such as in-depth interview (IDI) and key informant interview (KII) were utilised. Fifteen IDIs of the citizens who themselves or their relatives were affected by the coronavirus, and five KIIs of public health experts and practitioners, were conducted using a purposive sampling technique. The main reason for using this technique is the certainty of getting quality information from a group of respondents who are completely aware of the study issue. By conducting the literature review, themes of trust in governance on public health issues (government health system capacity, responsiveness, skilled manpower number, health infrastructure) were identified. Based on the themes, a semi-structured questionnaire was developed to collect data through interviews. The IDI provides more detailed data to the researcher than surveys, and the KII technique gives quality data to the researcher in a shorter period of time (Marshall, 1996; Ozdemir & Koc, 2012). Due to the government’s lockdown and social distancing policies, all primary data were gathered via telephone interviews. Along with the primary data, secondary data were gathered using online search engines like Google Scholar and PubMed; and from there, recently published journal articles, government reports and national and international NGOs’ reports relevant to the research topic were consulted. To describing the gathered qualitative data, a thematic analysis was performed, which enabled the researchers to ascertain the key theme of the study report (Lochmiller, 2021). The study employed a triangulation of data gathered from primary and secondary sources to generate concrete evidence against the research question. The ethical clearance was taken from the ethics review board of the Department of Public Administration and Governance Studies, Jatiya Kabi Kazi Nazrul Islam University.

Findings and Discussion

The Capacity of Bangladesh Health System to Fight COVID-19 Pandemic

Like all other global leaders (the United States, the United Kingdom, Russia and Italy), the government of Bangladesh has also set forth to fight against COVID-19. However, the responses of the participants expressed the limitations of the capacity of the healthcare system to combat the outrageous impact of the COVID-19 pandemic. The media reports also stated that as the hospitals were not equipped properly, COVID-19-affected people were afraid of getting admitted (Trainee, 2021). The respondents of the study mentioned that the hospitals are not well equipped with N95 masks, personal protective equipment (PPE), ventilators, test kits, oxygen and so on. and the doctors are not trained enough to provide effective treatment to COVID-19 patients.

One of the IDI respondents exclaimed that

13 people had died only because of the shortage of high flow nasal cannula just within 25 hour in Bogra when a nasal cannula costs only 180 takas; is the value of a life is 180 takas? (IDI 10, Personal Communication, 25 September, 2021)

A study by Islam and Siddika (2020) found that in Bangladesh, 86.1% of people considered the health sector of the country not capable to fight against the COVID-19 pandemic. 58% of people are dissatisfied with the taken health measures while 92% suggested increasing testing facilities. World Health Organization (2020) also suggested increasing tests in Bangladesh.

Citizen’s Perception on Healthcare Measures During COVID-19 Pandemic

After the researchers learnt about the capacity of the health sector, they tried to understand the perceptions of citizens on the healthcare measures during the COVID-19 pandemic in Bangladesh. Findings showed that, due to the lockdown, people were puzzled, and the poor and destitute (day labourers, rickshaw pullers, hawkers and homemakers) were the worst sufferers of this policy, as they did not have any savings. Shammi et al. (2020) also argued that the lockdown caused unbearable misery and acute unemployment in their lives. A participant mentioned that

Due to lockdown, a large number of people lost their jobs, and some attempted suicide for not being able to earn money to buy foods for families. Despite the lockdown, poor people go out thinking that death caused by coronavirus is preferable to death by starving. A large number of immigrants have stuck in the airport who could earn a huge amount of remittance. (IDI 7, Personal Communication, 9 October, 2021)

Following that, the findings showed that a stark disparity exists between the rich and poor in terms of healthcare service. One of the respondents expressed that,

I got admitted to Shahid Ziaur Rahman Medical College after 2 days of infection; my lung was infected and was breathing complexity. Doctors and Nurses were responsive enough but the hygiene standards of the hospital was very poor. However, only VIP patients were getting better service. (IDI 5, Personal Communication, 21 September, 2021)

On the other hand, some of the respondents showed dissatisfaction with the services of government hospitals. They stated that the doctors do not want to serve properly and neither do the nurses.

Most interestingly, some of the participants compared the health services of public and private hospitals. They mentioned that the private hospitals are trying to provide quality health services, but their service charge is sky-scraping. An IDI respondent wondered that

Two days on life support at a private hospital cost us 4 lakhs taka, a cruel irony as my brother died anyway. The doctors couldn’t even tell us when he departed. And the final insult? The hospital is holding his body ransom, refusing to release him or provide a certificate until their outrageous bill is settled. This is beyond pathetic; it’s a profound injustice. (IDI 2, Personal Communication, 7 September, 2021)

In the present study, one KII respondent emphasised that in hospital management, the government is doing well in some respect. Opposingly, several respondents opposed this statement and stated that there is a paradox, the public hospitals have a resource crisis and private hospitals are only convenient for rich people. On this issue, an expert said that

I think public hospitals can deliver better healthcare services and are more trustworthy than private hospitals though we mostly believe that public hospitals are ineffective in providing emergency health related services. (KII 3, Personal Communication, 25 October, 2021)

Citizen’s Trust on the Healthcare Management in Bangladesh During COVID-19

Rieger and Wang (2021) observed that the actions taken by the government during the pandemic are the basis of citizens’ trust in the government. Despite the government trying its level best, it failed to gain the trust of the citizens.

In this study, to describe the issue, one respondent complained that

People don’t want to visit the hospitals because of mistrust. Even the elite class goes to foreign countries for treatment. (IDI 6, Personal Communication, 10 October, 2021)

The respondents agreed that the budget for this sector is huge in comparison to others, but incapacity, corruption and mismanagement caused the money to be misused. Hossain et al. (2020) also argued that the preparedness of government for tackling the pandemic was very poor with mismanagement, corruption, resource crisis and inefficiency.

Influencing Factors to Shape the Perception and the Extent of Citizen Trust

The COVID-19 pandemic had devastating effect on the economy of Bangladesh. Production was hampered drastically, and many people start living their lives under the poverty line due to this massive shock in the economy (Karim et al., 2020). Findings also found the economic well-being and political factors shaped the perception of the citizens regarding healthcare management during COVID-19 pandemic.

One of the KII stated that

The poorer section of the people are the worst sufferer due to lockdown by the government. Additionally, the middle-class people were in an embarrassing situation as they couldn’t express their want of food for hesitation and couldn’t bear the suffering at the same time. (KII 1, Personal Communication, 12 October, 2021)

As a result, agitations and mistrust were raised among these people but they were not united enough to raise their voices strongly. The government has put effort with scarce resources to reduce the burden in the health sector but in the wrong way, which led to huge corruption. Hence, some respondents commented that the saviour himself is the destroyer. This has diminished people’s trust in the sector, leading to negative perception.

The respondents also believed that in vaccine management, internal and external political influences and lack of international political foresight from the government were noticed that shape up the perception of the citizens. Two of the respondents said that

Government could handle vaccine trade directly, where they tried to manage it with the help of a third party pharmaceutical company. Additionally, diplomatic channels, large business corporations influences the government to buy vaccines, to do their medical business without proper monitoring, to curve government regulation policy in their favor. (IDI 1 and 3, Personal Communication, 28 September, 2021)

Evidence from the studies of Erfani et al. (2020), Mannan and Farhana (2020) and Karim et al. (2020) showed that in Bangladesh, social media and TV channels are the key sources of COVID-19-related information for the citizens.

On this issue, one KII claimed that

Social Media played a crucial role to shape the perception of citizens through which people both in rural and urban areas learn about the overall condition of pandemic scenario as well as governmental interventions to tackle coronavirus. This helped the citizens to make the decisions their healthcare throughout the lockdown situation. (KII 5, Personal Communication, 26 September, 2021)

All the KIIs admitted that good governance is the key factor of citizens’ trust which is somehow absent in Bangladesh and so, mistrust has emerged among the citizens on public health service quality. Maswood (2020) and Shishir (2020) argued that lack of accountability, poor monitoring, lack of effectiveness and efficiency, corruption is acute in the health sector of Bangladesh, which may reduce citizen’s trust in the government.

Conclusion

The COVID-19 hit the world brutally, and in the earlier period, the Bangladesh government was not very responsive and proactive in taking the necessary health measures for tackling the upcoming storm. Though the Bangladesh government has taken several measures to fight the COVID-19 pandemic, people’s perceptions are not very positive, according to the perceived data. Responses were undertaken to provide healthcare facilities, but due to mismanagement and huge corruption in this sector, people lose trust in taking healthcare services from the hospitals. Social media, in addition to internal and external political influences, influenced citizens’ perceptions. Furthermore, a lack of good governance has been identified as a key factor in increasing citizen mistrust in the health sector.

Government policy responses should be proactive, and proper implementation and monitoring should be done under the supervision of the special committees developed by the health ministry. COVID-19 special hospitals should be made with the proper equipment required for the treatment of COVID-19 patients. To improve reliability, information about COVID-19 should be made available to all. Active collaboration between the public and private hospitals needs to be ensured under the supervision of the health ministry. Additionally, zero tolerance for corruption and political favouritism or nepotism should be introduced in the health sector. Simultaneously, skilled and prudent personnel should be assigned to appropriate positions in order to gain citizens’ trust. Above all, good governance is a pre-requisite element that will play a pivotal role in gaining citizen trust and ensuring sound management in the health sector of Bangladesh.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article

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