1.0 Introduction 

1.1 Problem and Background

In response to the COVID-19 pandemic, governments worldwide have implemented numerous public health measures to suppress transmission, reduce exposure, mitigate mortality and morbidity, and have invested in vaccines, therapeutics, and diagnostics. However, these interventions were implemented with varying degrees of rigor and timing, leading to a wide range of outcomes.

Though the social and cultural milieu can influence how populations accept interventions, the evidence tells a different story. Bangladesh – the most densely populated country in the world – and its neighboring state of West Bengal, India, are culturally very similar with comparable health service structure. Moreover, to date, they have similar numbers of COVID-19 cases and deaths. However, West Bengal has only half of the population of Bangladesh. These differences in managing the pandemic could be explained by institutional, political, organizational, governance (IPOG) factors that affect the public health system’s response and performance.

With the support of the OpenCovid19 grant, the # BDCASESTUDYCOVID19 project will explore the influence of IPOG factors on the choice, implementation, and consequences of public health interventions in Bangladesh and will contribute to improving the public health response to the current pandemic and preparedness for future health crises.

1.2 Solution summary in simple terms

The IPOG factors have dynamic relationships with each other, which are often non-linear and result in cascading effects influencing the policy development and implementation process. To research IPOG factors impact on the choice and implementation of public health interventions and their consequences during the COVID-19 pandemic, our team at the School of Population and Public Health, University of British Columbia (UBC), has developed the IPOG framework and case-study methodology (Figure 1).

Figure 1: Conceptual framework to explore the IPOG factors

The case study methodology allows to synthesize results from both qualitative and quantitative data, including epidemiological information, literature and policy review, and interviews with key informants. In collaboration with the James P. Grant School of Public Health (JPGSPH), BRAC University, Bangladesh, we will adapt the methodology to the context of Bangladesh. The project aims to support public health researchers, practitioners, and policymakers to improve the current response and better prepare the nation for future pandemics.

1.3 Solution summary in technical terms

Each component of the IPOG case study requires a distinctive but interconnected data collection and analysis process. First, the UBC and JPGSPH teams will analyze the epidemiological data on COVID-19 in Bangladesh and develop a timeline of all public health measures implemented in response to COVID-19. These will be used to identify pivotal decisions taken during the pandemic. Simultaneously, the JPGSPH will develop organizational maps of all public health entities and identify key actors involved with the pandemic response and identify key-informants for interview.

Next, we will select two to three decision-points for an in-depth exploration of the plan of response (de jure) and what actually happened (de facto). UBC team will guide these activities by reviewing literature and policy documents to identify the institutional, political, and organizational factors that played critical roles in the policy implementation process. To complement the review, the UBC and JPGSPH team will conduct key-informant interviews with policymakers (identified from the organizational map) to understand the governance processes. Finally, we will compile the case study by comparing the construction data to clarify the informal and formal policy implementation processes. The synthesis of the evidence will aim to inform Bangladesh on future pandemic responses. 

1.4 State of the advancement of the project

The UBC team developed the IPOG framework and the methodology of the case study in August 2020. With a grant from the Peter Wall Institute at UBC, we conducted two roundtables with health policy and systems researchers from nine countries (November to December 2020) to test the framework’s external validity. Currently, the UBC team is implementing the case study in British Columbia, Canada, and with a Canadian Institutes of Health Research (CIHR) grant planning to implement comparative case studies in three more provinces. The #BDCASESTUDYCOVID19 project will give us a unique opportunity to implement the case study in an international setting.

1.5 Project Timeline

Week 1:

·      Organizing data collection strategy (UBC)

·      Workshop 1 - Team development and development of the analytical plan (UBC and JPGSPH)

Week 2:

·      Data acquisition - epidemiological data, list of policy measures and organization (JPGSPH)

·      Analysis of epidemiological events (UBC)

Week 3-4:

·      Development of policy timeline and organizational mapping (UBC and JPGSPH)

Week 5:

·      Workshop 2 – Review of evidence, identification of decision-points and key informants (UBC and JPGSPH)

Week 6-8:

·      Review of literature and policy documents to identify the institutional, political, and organizational factors (JPGSPH)

·      Development of interview guideline (UBC and JPGSPH)

·      Conducting key informant interviews (UBC and JPGSPH)

Week 9-12:

·      Conducting key informant interviews (UBC and JPGSPH)

·      Analysis of the qualitative data (UBC and JPGSPH)

Week 13-14:

·      Synthesis of evidence (UBC and JPGSPH)

·      Development of the case study (UBC and JPGSPH)

Week 15:

·      Workshop 3 – review of the result, formulation of recommendations, and dissemination plan (UBC and JPGSPH)

·      Development of project report (UBC and JPGSPH)

Week 16:

·      Finalizing project report (UBC and JPGSPH)

·      Development of the first draft of the peer-review manuscript (UBC and JPGSPH)

2.0 Project Implementation

2.1 Solution

Solution (Research):

As a collaborative effort of UBC and JPGSPH, we are proposing to develop a case study to explore how IPOG factors shape the decision-making and the choice and implementation of public health interventions to manage COVID-19 in Bangladesh. Our research team consists of a globally experienced team of health policy and systems researchers. The #BDCASESTUDYCOVID19 case study will be led by

Team UBC (BC, Canada): Dr. Md Zabir Hasan with the supervision of Dr. Peter Berman

-       Development of the case study methodology and tool, performing the analysis and dissemination

Team JPGSPH (Dhaka, Bangladesh): Dr. Malabika Sarker

-       Performing data acquisition, collecting qualitative data, and conducting analysis

Hypothesis:

Our general hypothesis is that decision making – the choice and implementation of public health interventions to prevent, detect, treat, and manage COVID-19 and its consequences - is shaped by the institutional, political, organizational, and governance (IPOG) context in which they are developed and implemented.

Background:

Bangladesh, one of the most densely populated nations, is especially vulnerable to the COVID-19 pandemic. After identifying the first confirmed case of COVID-19 on 8th March 2020, the Government of Bangladesh implemented a nationwide lockdown from 26th March 2020 to mitigate the transmission of the virus and allow the healthcare system to prepare itself onslaught of the COVID-19 cases. However, during the lockdown’s initial days, there was a mass exodus of 11 million residents from Dhaka who took this opportunity to wait out the lockdown period in their home districts or villages, which likely only expedited the spread of the disease. On 25th April 2020, the lockdown was partially lifted to restart the economy by allowing workers to return to their station in ready-made garment factories, industries, and private offices. The migrating workforce with limited awareness and opportunity of social distancing and safe, hygienic practices ultimately led to millions of additional viral transmissions. After a series of extensions, the ‘partial lockdown’ was lifted, but cases had already been identified in all 64 districts nationwide. By 18th March 2021, Bangladesh had reached 562,752 confirmed cases of COVID-19, with and 8,624 deaths.

Beyond the difficulties of enforcing the nationwide lockdown and promoting social distancing norms, Bangladesh’s healthcare system was also underprepared to handle such a large-scale pandemic. At the start of the pandemic, only 1,169 Intensive Care Unit beds were available in the entire country, the majority (737 beds) in private hospitals. Besides, there was an insufficient supply of high-quality personal protective equipment, confirmative tests, medications, and logistics. However, dealing with a healthcare emergency of this scale has left much room to examine how the response to the pandemic was organized by the Government and the public health entities.

While the literature on public health interventions and health outcomes has grown, few studies situate findings within their governmental, institutional, and organizational contexts. Research on the public health response to COVID-19 typically focuses on (a) understanding the epidemiology of the infection and its progression to severe illness and mortality; (b) recommending and implementing a menu of interventions that can be implemented in populations, including public health social measures as well as clinical interventions; (c) assessing the impact of these interventions on outcomes.

However, a recent scoping review of existing public health frameworks for evaluating epidemic responses identified that few, if any, frameworks provided a holistic interpretation of the ‘context analysis’, yet this should be undertaken as a first step. We believe that several “upstream” or “contextual” – such as institutional structures, political environment, organizational architectures, and governance processes - determine how well the process of public health response actually works, both in terms of using the science (evidence) to drive action as well as in persuading the population to comply with recommended interventions. We perceive that these factors are poorly characterized, measured, and understood in the context of the COVID-19 pandemic.

Institutional Factors

The higher-level formal and informal “rules of the game” – e.g., the legal and regulatory basis of the authority of the scientists and experts in relation to government action. How do norms for roles and behaviors of key actors and organizations support or constrain effective public health action?

Political Factors

Key political actors and their position in relation to civil service and technical actors. How do politicians and political processes support or constrain effective public health action?

Organizational Factors

The “organogram” for structures whose role is to generate public health knowledge and use it for public health action – structure, lines of authority, complexity, and fragmentation, etc. Who is “at the table” for what decisions and implementation actions? What authorities and accountabilities influence them?

Governance Factors

The processes of decision-making and implementation of actions that enable the Government to carry out its objectives. How were critical decisions reached and action enabled? What role for I/P/O factors driving these processes?

Building on our preparatory work on developing the IPOG framework and initial observation from the British Columbia case study, we are preparing to expand our work internally, first by implementing the IPOG case study in Bangladesh. Though our study will on only one country, Bangladesh being the most densely populated country globally, the lesson from Bangladesh can be applied beyond its border. This study will enhance the knowledge of clinicians, public health researchers, and policymakers regarding the nature of institutional, political, organizational, and governance driving effective change in the global south, which became an epicenter of the pandemic.

2.2 Methodology

We are proposing a two-phase retrospective case study methodology to operationalize our conceptual framework. At the initial stage – we will review the broader context of Bangladesh, which will include exploring the contextual factors such as population demographics and geographical setting using secondary data, government reports, or synthesized documents from global organizations such as the World Health Organization (WHO), World Bank, or Organisation for Economic Co-operation and Development (OECD). Next, bridging the country context with the progression of the COVID-19 infection and the evolution of key policy and decision points and outcomes, epidemiological data will be used to illustrate a timeline of public health and social measures adopted by the Government. This information will provide us an overview of the country’s response and identify key decision points related to public health interventions and their stringencies. We will find and summarizing the measures into one database and plotting them over the epidemiological curve – such as the number of cases, hospitalization, or deaths per week.

Concurrently, to identify relevant public health organizations and key actors involved in the COVID-19 response, we will perform a mapping exercise of the organizational structure. The purpose of the organizational map is to describe and develop visual presentations of the structure of the key organizations who are the actors who determine and implement the public health interventions by the Government in Bangladesh. Generally, formal structures are publicly reported by government agencies representing the “normative” or “de jure” relationships outlined in sources such as laws, regulations, formal standard operating procedures. The organizational map will visually enumerate and identify organizational units, key personnel, and also describe the critical relationship attributes – such as oversight/supervision or authority or coordination – between them.

We expect that from the first three components of the first stage, two to three critical decision-points along the timeline will emerge, which are pivotal for the overall pandemic response for which IPOG factors will be explored. This in-depth exploration aims to understand the “actual” or “de facto” response against COVID-19, which will potentially allow some contrast with the “normative” or “de jure” relationships. The in-depth exploration will start with a concise document review and policy analysis to identify political and institutional factors that might have influenced the COVID-19 public health response and subsequent health outcomes.

As the final step, we will be conducting key-informant interviews (KII) to understand the governance processes surrounding the key decision-point. It will allow us to understand better the processes of decision-making and implementation of actions that enable the Government to carry out its objectives and the role of the institutional, political, and organizational factors driving these processes. The KII will bridge the two stages of the case study by filling the knowledge gaps identified from the timeline and organizational mapping exercise. The rich data from the KII will be narratively synthesized to help us comprehend the governance processes and their interdependencies with the upstream drivers for an effective pandemic response.

2.3 Expected results

In 2019, anticipating potential future pandemic threats, the global health security index (GHSI) was developed to rank all countries for their preparedness against health security events. However, one year later, as the pandemic is ravaging across the world, we have realized that the GHSI has a very weak predictive value regarding the Government’s response and stringency against the COVID-9. This suggests that relying upon simple preparedness indicators and their formal adoption is insufficient to respond to a health emergency.

Thus, it is imperative to understand the governance processes and how the country’s institutional, political, and organizational context influences the pandemic response. The result of this case study will provide us the critical insight from the perspective of a rapidly developing country, Bangladesh. As outputs of the different components of the case study, we are expecting the following evidence :



Institutional analysis: 

Understanding the rule of conduct, institutional norms, legal and regulatory arrangements

Political context analysis: 

Insight into the political structure, leadership, political agenda, and role of politicians/ appointees

Organizational Mapping: 

Understanding the structure, lines of authority, legislative arrangement, and capacity of public health, government, and non-government organizations

Key informant interviews: 

Processes of decision-making about COVID-19 response and the steering of the health system to ensure its continued functioning

The outputs and the results of the Bangladesh case study will be presented as reports, dissemination workshops with policymakers in Bangladesh, educational materials for JPGSPH, which will be used for capacity building for the students and the faculty members in the future.

3.0 Safety, quality assurance, and regulation 

3.1 What steps have you taken to ensure your solution’s safety?

As the research activities associated with the case study primarily utilize publicly available data, we will not require full ethical clearance. We will anonymize the personal information from the qualitative data from KII to maintain the respondents’ privacy and confidentiality. We will apply for an exemption of ethical clearance to the Institutional Review Board of JPGSPH, BRAC University. If necessary, modify the research activity according to the Institutional Review Board’s recommendation.

3.2 Have you planned the conduct of your manufacturing process that ensures quality? What are the steps you have taken?

Not applicable

3.3 Will you need assistance with the regulation system?

Not applicable

3.4 Have you talked to medical staff about the feasibility of your project? What did they say?  

Not applicable

3.5 Have you planned the testing, verification, and validation of your solution? How advanced are you?

We are implementing the case study in British Columbia, Canada, and currently performing the key informant interviews. We have already developed the timeline and organizational maps. Our observation indicates that implementation of the case study is very much feasible. With the active support of Dr. Malabika Sarker from JPGSPH, we believe we will complete the case study within the proposed timeline. 

4.0 Impact, issues, and risks

4.1 What impact do you feel your project could have?

The #BDCASESTUDYCOVID19 project will generate evidence that will act as a nexus of knowledge from where researchers, practitioners, and policymakers will be able to generate specific hypotheses related to the IPOG factors leading to more in-depth epidemiologic, economic, policy, social, and political science research opportunity in the future. The status-quo of health governance failed us during the pandemic, and health systems worldwide have to reinvent themselves. This reflects the immense ingenuity of the human effort, and we need to learn from it. Otherwise, similar tragedies like the COVID-19 pandemic will bound to happen in the future.

4.2 What do you think would make your project a success?

The skillset of the research team, strong collaboration with local partners, and a proven methodology for developing the case study give us confidence that we will be able to execute the research project. The ongoing case study from British Columbia, Canada, supported by Peter Wall Institute and incoming Canada-focused CIHR grant, highlights our success track. However, to expand the case study idea to an international setting, we need seed funding. We believe with the support of the OpenCovid19 grant, and we will be able to launch our study globally.

4.3 Please list the known issues, potential risks, grey areas, etc. in your project

While most of the evidence required for the case study will come from existing secondary data sources, the KIIs are the only primary data we will collect. We acknowledge that respondents – government appointees, prominent public health researchers, and policymakers – may have limited time to engage with us during the interview. However, our local research team from JPGSPH is familiar with Bangladesh’s political and organizational structure and already built robust communication. We believe with their support, we can overcome this issue. 

5.0 Originality

5.1 What other projects on JOGL are like yours? Search for them and Link them!

We have reviewed all the submitted research projects on JOGL and did not find any project which addresses the IPOG factors and their influence on the pandemic response. The only project that partially complements part of our project is #CoronaNetResearchProject

CoronaNet Research Project

Link: https://app.jogl.io/project/456/CoronaNetResearchProject

5.2 Is this an innovative project? What makes this project different if it’s unique on JOGL?

We are proposing #BDCASESTUDYCOVID19 as a research project unlike any other’s submitted to JOGL. Having the case study as an exploratory tool, we will be able to investigate one of the neglected research agendas in the low-and-middle-income countries, health systems, and public health governance. When the “postmortem” on COVID will be done and the government will try to figure out what to do in the future, the result of the #BDCASESTUDYCOVID19 project can be the guiding light to build the resilience of the health sector in Bangladesh.

If successfully implemented in Bangladesh, this project will pave the path of the development of cross-national case studies to compare and contrast the pandemic response. Being part of the JOGL, this project will have the chance to build a collaborative network that will allow us to implement the case study globally.

5.3 Is there already an open-source version of this project?

No

6.0 Team experience

6.1 Please cite your team members and their roles in the project. 

Team UBC (Vancouver, Canada)

Md Zabir Hasan, Ph.D., MPH, MBBS, is a trained physician and currently working as a Postdoctoral Research Fellow in the School of Population and Public Health, University of British Columbia. In this position, he is providing analytical support to several international research projects focusing on primary healthcare integration, performance, and system strengthening. He holds an Associate position in the Department of International Health at Johns Hopkins Bloomberg School of Public Health. Dr. Hasan completed his Ph.D. program from the JPGSPH and his MPH from James P. Grant School of Public Health, BRAC University. Dr. Hasan also worked as the Country Measurement Analyst for the Primary Health Care Performance Initiative at the World Bank. Before starting his doctoral program, he worked as a Senior Research Associate at James P. Grant School of Public Health, where he designed and implemented several research projects on financial risk protection and Universal Health Coverage. Dr. Hasan has over eight years of experience in health system research, monitoring, and evaluation, focusing on the performance of primary health care, health equity, and health care financing in low and middle-income countries. His primary expertise includes data analytics, econometrics and system modeling, implementation science, and mixed methods research.

Peter Berman, M.Sc, Ph.D., is a health economist with forty years of experience in research, policy analysis and development, and training and education in global health. Prof. Berman is a Professor of the School of Population and Public Health, University of British Columbia in Vancouver, Canada, and an Adjunct Professor in Global Health at Harvard T. H. Chan School of Public Health, Harvard University. Prof. Berman’s specific areas of work include analysis of health systems performance and the design of reform strategies; assessment of the supply side of health care delivery and the role of private health care provision in health systems, and development of strategies to improve outcomes through public-private sector collaboration. He pioneered the development and use of national health accounts as a policy and planning tool in developing countries. Prof. Berman has worked extensively on health system reform and health care development issues in a number of countries, including Egypt, India, Colombia, Indonesia, and Poland.

Team JPGSPH (Dhaka, Bangladesh)

Malabika Sarker, Ph.D., MPH, MBBS, is a Professor & Associate Dean of BRAC James P Grant School of Public Health, BRAC University, Bangladesh. In her 30 years public health career, she spent ten years implementing community-based programs at BRAC, the world’s largest NGO. As a mixed-method specialist and implementation researcher, Prof Sarker also oversees the research activity and leads the center of excellence of Science of Implementation & Scale-Up (SISU). Dr. Sarker is a physician with a Master’s in Public Health (MPH) from Harvard University, USA, and a Doctorate in Public Health from the University of Heidelberg, Germany. Prof Sarker was a research faculty at Heidelberg Institute of Global Health (HIGH), Germany, before joining BRACJPGSPH and is continuing teaching as an adjunct faculty. She has published more than 90+ articles in international peer-reviewed journals and authored three book chapters. She is also the international advisory board member of The Lancet Global health, HRH (World Health Organization), MRC UK, NIHR UK, and Metrics for Measurement, USA based non-profit organization.

7.0 Funding and Costs

7.1 Please provide a costing of your project be as detailed as you can

7.2 How is your project being funded so far?

At the conceptualization phase of the case study, we have received a small grant from Peter Wall Institute. For the next phase of Canada-based case study development, we have received a grant from the Canadian Institutes of Health Research (CIHR). During the case study’s preparatory phase, the project lead (Dr. Md Zabir Hasan) is funded by Dr. Peter Berman’s research fund. Besides, Dr. Berman is funded by UBC, and Dr. Malabika Sarker is founded by JPGSPH. However, for the international case study, we did not receive any funding yet.