It took about a year for Alive & Thrive technical experts, working closely with partners in Bangladesh including the government and NGOs, to develop and support the implementation of a standardized package of interventions to improve maternal, infant, and young child nutrition (MIYCN) outcomes in urban Dhaka. But COVID-19 effectively disrupted that work in a matter of days.
“I remember, we were in training at that moment,” said Dr. Mohsin Ali, an urban health specialist with Alive & Thrive, recalling the date in March 2020 when the government imposed restrictions on movement and social distancing measures to prevent further spread of the coronavirus. “We were supposed to do the initial training and then go into service delivery. But right at the midpoint of that training, the lockdowns were imposed.”
The program aimed to integrate MIYCN services and counseling into health facilities and services provided by two NGO partners, Marie Stopes Bangladesh and Radda.
However, the timing of the strict measures imposed proved fortuitous for implementation research that IFPRI, an Alive & Thrive partner had initiated: Researchers had completed baseline data collection just before COVID-19 required significant changes to the interventions. Consequently, data collected after the government imposed the measures could be used to analyze changes in service delivery and food security due to the measures themselves.
While it may have been apparent that social distancing, restrictions on movement, and other measures would affect the health system significantly, being able to obtain data regarding those effects has provided unique insights that will help health system stakeholders better understand the impacts of the pandemic in Bangladesh.
Bangladesh was not unique – similar research in India had also included collecting baseline data before the World Health Organization declared the pandemic in March 2020. So, researchers could compare the changes between the two countries. The comparison is the focus of a brief available now.
Service delivery for pregnant women and mothers, however, was the immediate issue for Alive & Thrive’s Bangladesh NGO partners, who were delivering services in urban health facilities and through community outreach programs when the government announced social distancing measures, Dr. Mohsin said.
Everyone was sent home and the impacts on the services, more than a year in the making, were immediate. NGO services were disrupted, as well as the A&T-supported effort to integrate maternal and infant young child nutrition into these services. Household visits were suspended and MIYCN counselors and community health workers experienced family pressure to resign over fears of infection, causing high staff turnover. Health center visits declined dramatically for the same reason.
“We totally stopped, but for two weeks only - during the initial shock,” Dr. Mohsin recalled. “Many of the NGO partner staff got sick, many left the job. It was a shock. Of course, they did not want to work in this pandemic situation. Later, we had to recoup and retrain them.
“It was a difficult situation. Half of the staff left the job over the course of several months.”
But while the pandemic could have completely undone the program, thanks to flexibility, ingenuity, and technology, it has led to something new and different – an example of resilience. The chaos of staff departure, the uncertainty regarding their personal safety, and the constraints on their ability to move and meet in person did not stop the team developing it.
“We had to redesign the whole thing,” Dr. Mohsin explained. “The in-person training became a distance training. Originally, we had facility-based and community-based aspects for service delivery. But we had to modify that for the safety of clients and health workers.
“We reoriented the whole system. It was not just our interventions - it was also the service delivery mechanism for our partners.”
The modifications extended to the evaluation baseline that had been initiated before the pandemic. The researchers interviewed subjects with new questions after measures to mitigate the spread of coronavirus had been implemented, obtaining valuable data on how the measures were affecting access to services and household food security.
At the onset of the lockdowns, the situation became dire, Dr. Mohsin said. But the team quickly turned to problem-solving and, thanks to determination and technology, developed new service delivery options.
“Communicating over telephone with household members and workers was possible but we had to develop that as part of the service delivery,” he said. “That was a totally new approach – with our NGO partners we had to develop content, modes of operation, everything. NGO partners introduced a monitoring system – and had to figure out how do that over the phone, too.”
NGO partners had client names and telephone numbers. Each worker now keeps in touch with about average 25 clients daily via telephone, which, though not as effective as in-person counseling, does have a positive aspect, he said.
“The calls are not counseling – they are simply contact,” he said. “But they are effective. Sometimes clients feel honored that someone is actually interested in their well-being. They get some necessary information and they can ask questions. The worker can give them some tips and invite them” to the facility.
“The pandemic has revealed new ways to work with clients. We had to stop some things, but we found some alternative ways.”
Other alternative ways resorted to were remote weekly/bi-weekly review meeting with managers/supervisors, regular orientation of service providers as continuing education, and a refresher training for managers and service providers remotely. Further, services were promoted through meetings with pregnant women and community workers in satellite ante-natal clinics, where workers invited women to facilities for counseling services and contacted referrers (pharmacists, small clinics and diagnostics) requesting client referral.
The team obtained appropriate communication equipment and developed protocols for its use.
“We had to develop an alternative mechanism of supportive supervision and we had to redesign all of this remotely.”
The uncertainty of the pandemic’s evolution prevented the team from ever establishing a sense of being on firm ground – a reality that persists to this day and may for many days, weeks, and months to come.
“The pandemic comes in waves,” he explained. “After the initial shock, we recovered. Movement had been sharply reduced due to the coronavirus – clients had stopped visiting. But then it resumed and actually increased.
“Then the second wave came and it decreased. And when we were preparing to go back to the original modality, another wave came. And when we were about to resume all of our services, then a third wave came.”
Given that the vaccination program in Bangladesh as of July 2021 had reached just 3% of the country’s estimated 160 million people, the pandemic’s impact looks unlikely to abate in the near term.
“We thought we were recovering but I think we are in a difficult situation,” Mohsin said. “In May and June, we recovered a lot, but in July it has been trouble. However, the NGOs are more resilient in service delivery than any time with our support.”