Age, sex, and family income.

The findings revealed that in both Rohingya and host communities, women, adolescent girls and elderly people were dependent on their family members for accessing the healthcare facilities. This was mainly due to their limited mobility driven by their weak physical health in the case of older adult participants, and strong socio-cultural, religious, and gender norms in the case of women and adolescent girls, and financial dependency for all three groups.

During the interviews (April 2020—June 2020), many of elderly participants stressed that due to their weak physical condition, they required their family members to accompany them to their routine healthcare facilities but, due to the fear of contracting COVID-19 in the health facilities, their caregivers refused to accompany them. As elderly participants shared, One 70 years old male Rohingya participant shared,

“When they asked us not to go outside [lockdown], my grandson stopped taking me to see the doctor. He was afraid that he would get sick of the Coronavirus […]. I cannot argue with him because he looks after me” (70 years old male Rohingya). “I asked my son to take me to hospital many times. He said he would not go anywhere during the lockdown. But the lockdown did not seem to end” (68 years old female Rohingya).

Similar incidences were also shared by our younger participants as well, mostly the Rohingya adolescents. However, unlike the elderly Rohingya participants, their dependency on family members was driven mainly by two factors; (a) strong socio-cultural, religious, and gender norms that restricted their mobility to venture outside without their family members, and (b) their financial dependence on their families. As mentioned by Rahima [pseudonym], a 14-year-old Rohingya girl,

“I need medicine for my headache. Usually, I go to the hospital with my brother and get it from nurse Apa. But when the lockdown was enforced, my brother refused to come with me. My father does not allow me to go outside alone. I had to suffer for weeks because of my headache.” (14-year-old girl, unemployed, Rohingya).

Most of the Rohingya girl participants mentioned that they faced difficulties while accessing healthcare facilities that their male siblings did not face as the society did not impose rigid norms on adolescent boys. As a result, many of them admitted seeking help from their male family members whenever they faced any health-related issues or when adolescent girls and women needed the menstrual kit. As was in the case of Shahida (pseudonym), a 16-year-old Rohingya girl, who mentioned

“I had to explain my problems to my father or brother who would go to the drug store and get medicine for me […] You can understand, how is it possible for a girl like me to explain every problem to my father and brother. Not every concern can be shared with men.” (16-year-old girl, Unemployed, Rohingya).

In the Host communities’ context, similar to the Rohingya camps, most elderly participants, regardless of gender, mentioned that their family members refused to accompany them to the health facilities due to fear of contracting COVID-19. As a result, many opted to seek healthcare treatment from the informal providers, “Vaidyas,” (a practitioner of Ayurvedic medicine or folk medicine).

In contrast, many adolescent girls, including young lactating mothers in the host communities, mentioned that their family income had reduced due to the COVID-19 lockdown. As a result, their family members were reluctant to accompany them to the hospitals as that would incur transportation costs. Additionally, the strict socio-cultural, religious, and gender norms restricted females from venturing outside their homes independently. Since they did not earn, they depended on their family members for day-to-day expenses. Therefore, many female adolescent and women participants mentioned seeking health-related advice and services from informal providers in the neighborhood to avoid transportation costs.

Thus, informal providers were perceived as the most viable and accessible source of healthcare, given the existing constraints, now exacerbated by COVID-19. As mentioned by one 17-year-old adolescent girl,

“In the lockdown, my father refused to go with me to the hospital. I wanted to go alone, but […] my family will never allow me to go that far alone […] So, I always take medicine from a nearby pharmacy [local drug store]. […] I tell the Bhaiya there (Salesperson) what my problem is, and he gives me medicine […] It costs some money, but we save the transportation cost”. (17-year-old adolescent girl, unemployed, Host).

Almost all of our participants in the single female household heads’ group from the host communities unanimously agreed that loss of income during the COVID-19 lockdown had impacted their personal lives, leaving them struggling to survive. Some of them mentioned that they had to skip meals so that their children could eat well. As a result, health was at the bottom of the hierarchy of their priorities during the pandemic. In the words of one single mother,

“Since the lockdown was announced, I did not seek any health services even when I was sick. If I go to any hospital, I need money to cover my transportation cost, which was high in the lockdown period. As I could not manage meals for my family, I’ve seen my kids crying for food and forgot about my sickness” (43 years old single female-headed HH, Unemployed, Host).

Knowledge and perception on COVID-19.

The data revealed that participants had varying levels of knowledge and, perceptions regarding COVID-1. Their understanding of the disease and believe influenced their desire to seek care, decisions and selection of providers during the COVID-19 lockdown.

Many of the adult Rohingya participants, mostly elderly, PWDs and some single female household heads perceived COVID-19 as a “Gujob” (rumor), some said, “Allah r Azab” (wrath of God), while a few mentioned, “Allah r porikkha” (God’s test). Driven by those religious believes, most of them found reluctant to follow COVID-19 safety measures recommended by the health providers and camp authorities.

Similarly, many adult participants from the host community, mostly single women, pregnant and lactating women, and some PWDs, attributed COVID-19’s origin and causes to religious punishment same as Rohingyas. At the same time, most of the Hindu women described COVID-19 as “Mondho Bhaggo” (Bad Fate). Some elderly participants in the host community also believed that Muslims won’t be infected by COVID-19 and being a Muslim they were safe from the harmful effects of COVID-19. In both cases, the fatalistic attribution of COVID-19 to religious beliefs made many participants perceive themselves as safe from COVID-19, as it was inevitable that they would be infected if they were ‘sinners.’ As mentioned by a 38-year-old single mother,

“COVID-19 is the result of Mondho Bhaggo (Bad Fate). If your actions are good, you do not need to worry. I am a destitute woman. I have never wronged anyone. How will COVID-19 kill me?” (38-year-old, Single Mother and Homemaker, Host).

Stigma, rumours and mistrust.

Stigma and rumours against the treatment and management of COVID-19 in the Rohingya camps during the lockdown prevented many participants from going to the health facilities. a 22-year-old girl was afraid that she would also be seized and thus stopped visiting the health facilities during the lockdown. In her own words,

“My grandmother told me that if you have cough these days, they [camp officials] will not let you come back from the health posts. They will take you to center [isolation center] where God knows what they will do to you” (22-year-old, PWD, Rohingya).

However, after the lockdown was enforced, in the case of boys, the rumours, fears, and stigma around healthcare facilities were noted as the primary reason for seeking healthcare from alternate sources. A 16-year-old boy scared and sought treatment from a local pharmacy close to his house but not the health facility. In his own words,

“During the lockdown, when I got sick, I was afraid to go to the health post because I thought even if I do not have COVID-19, they [hospital staff] will [either] detain me as suspected COVID-19 patient, or I will catch COVID-19 from them anyway.” (16-year-old, Day Labourer, Rohingya).

Being refugees and already persecuted, there was inherent fear and mistrust of the administration’s agenda and most remained anxious that they would be taken away into ‘isolation’ and would never see their family members again.

Similar stigma was reported by host participants as well. The host community participants also had diverse opinion towards COVID-19 driven by socio-cultural and mistrust. Especially pregnant women, elderly women, and adult participants were unwilling to visit any health facility despite having COVID 19 symptoms due to fear and a lack of adequate information about COVID 19 isolation and social stigma associated with the infection.

Perceived benefit.

Our data suggest a link between participants’ perceived benefit and their health-seeking behavior amid the pandemic. All groups, despite different reasons, mainly had inclined towards informal providers such as traditional healers and/or the medication prescribed by the local drug store salesperson “Oshud Dokaaner Bhaiya,” often perceived as “Village Doctors,”, which were more accessible to them during the COVID-19 lockdown, and they felt comfortable with them. Burmese doctors (informal providers from their country) played a huge role in the lives of these communities as mentioned by our participants. Also the Imam [religious leader] placed a role for general health treatment. People visit them and collect “Panipora” and “Piaj pora” (Recite religious verse and blow in the water) for cold related symptoms, mild fever, Jaundice and stomach ache.

Similarly, one pregnant woman mentioned that a “Vaidya” [Traditional healer; informal provider] had suggested her drink “aadha cha” (Ginger tea) every day as a preventive measure for COVID-19.

Sources of health information.

The study found that the preference and trust on the source of health information influence people’s healthcare seeking behaviour in the both study communities. At this stretch, the individual COVID-19 health-seeking behavior of participants in both communities had been influenced by awareness information from trusted sources for example religious, political, and social leaders, Community health workers, and digital media. However, our data suggest substantial gender differences between the participants’ social networks as sources of health information which also help them to choose health care providers.

In the Rohingya context, male participants perceived their religious leaders as the most reliable source of health information during the COVID-19. However, the female participants expressed their vote towards the community health workers and government officials as the most reliable sources of health information during the COVID-19. Like Rohingya participants in the host community group, most of the male participants expressed an inclination towards religious leaders and local government officials as the most reliable sources of health information. In contrast, the female participants preferred door-to-door meetings with NGO-based community health workers because that allowed for more private space to talk about their day-to-day issues.

Costs of healthcare.

This study found that many MVG participants could not avail themselves of their essential health services during the lockdown due to their inability to afford medicine and pay diagnostic fees. Most of the MVG participants from the Rohingya and host communities mentioned that they lost their only earning source during the COVID-19 lockdown. This directly impacted their family income, which led to economic uncertainty within their lives affecting their ability to spend money on healthcare services, including doctor’s fees, diagnostic tests, and essential medicine.

According to the Rohingya participants, they could avail required medicine free of cost from some of the health posts before the lockdown. However, many MVG participants mentioned that those health posts were closed during the first month of the lockdown, prompting them to go to the local drug shops to buy the medicines. Hence, many elderly and PWD participants who constantly needed regular treatment could not afford their medication. As one elderly female participant narrated,

“I could not survive a day without my medicine. My knee pain did not let me sleep at night. Before the lockdown, I did not require any money for my regular medicine. But the hospital where I used to go to collect this medicine was closed during the first month of the lockdown. Thereby, I had to pay 400 BDT to get my medicine from a local drug store. Hence, I could not continue this medicine for that month. I was left with no other choice but either to beg from my neighbor to collect money for my medicine or discontinue this for one month.” (68-year-old female, Unemployed, Rohingya)

This situation was comparatively worse in the host community than in Rohingya camps. As per most of participants, a few health facilities were open during the lockdown period. Those facilities did not provide any free services, and hence people who lost their job and monthly earnings often could not manage money for their treatment. As a result, some MVG participants skipped their treatment during the pandemic or purchased their medicine from the local drug stores and other informal providers, where medicines could be purchased at time on credit.

Distance from the health facilities.

Distance from the health facilities was one of the significant barriers to accessing healthcare facilities for all the MVGs in both communities; particularly the pregnant and lactating mother, PDW, and elderly participants. Our data suggest that the lack of support personnel and limited transport facilities hindered them from visiting the health facilities amid the pandemic.

In the Rohingya Camps, multiple health facilities remained open during the lockdown. However, the majority of the PWD and elderly participants shared their struggle in terms of availing the health services due to the distance of the health facilities and the lack of accompanying persons. Not all the health facilities were easily accessible for the community people as for the hilly terrain and most of the time they had to walk 15-minutes to an hour to reach the health facility. Their caregivers did not want to take them to the hospitals as they thought the hospitals could be the areas from where they could be infected. Moreover, PWD, elderly, or females both single and pregnant could not go to those health facilities alone since they were not near their homes. As a result, these groups of people often chose to avoid visiting those facilities during the lockdown. As one elderly female participant narrated,

“I don’t have a son or a daughter. if I fall sick there’s no one to look after me. I am helpless. There’s even no one who would take me to the doctor.” (65-year-old female, Unemployed. Rohingya)

Similar experiences were shared by many participants from the host community as well. According to them, they could not visit the hospitals because of the absence of caregivers and the unavailability of transportation. Due to this reason, sometimes the external caregivers (mostly their neighbors) demanded extra money to accompany them to the hospitals. As one PWD participant shared,

“Visiting a doctor during the lockdown was not easy for me. Since I have difficulties walking, I always need assistance when I go out… During the lockdown, it was quite difficult to find caregivers because they did not want to go to the hospitals…they thought they would get infected with the virus from the hospitals” (30-year-old male, Unemployed, Host). Therefore, they opted to visit informal providers who lived nearby and were thus more accessible and cost-effective.

Approach of health professionals.

In the studied context, one of the primary reasons for the unwillingness to avail healthcare services from the health facilities was the health professionals’ approaches towards a patient.

In the Rohingya community, though many of the health facilities were open amid the pandemic, the utilization of health facilities was less due to the reported unsatisfactory behavior of the healthcare staff. The majority of the participants, including the pregnant and lactating mothers, PWD, and elderly, reported their dissatisfaction regarding the doctors and medical staff. According to them, the doctors did not perform appropriate check-ups since the pandemic started. Many of them pointed out that before the pandemic, doctors performed comprehensive check-ups using multiple instruments, and physical touch. However, they experienced a changed behavior during the pandemic as the medical staff specifically the doctors sat very far from them, did not touch them, and expressed hurry while listening to their problems. One elderly male participant shared, “The doctor did not even come near me or check me properly… I am just upset by their behavior. Why would they do that?” (64-year-old male, Unemployed, Rohingya). “

A similar experience was shared by one of the PWD participants as well. As he narrated,

"We had to stand 4 feet away from the doctors. How could a doctor check me up properly if he did not come close to me? I am not sure about the quality of the treatment given during the pandemic” (34-year-old male, Unemployed, Rohingya).

In addition, a number of participants expressed discontent with the quantity and variety of medicines they received from the health centre. Respondents also reported that doctors recommended paracetamol-based medications for the majority of their disease treatments without conducting a thorough assessment. Furthermore the facility did not give all of the prescribed medications. Due to this reason, patients were not recovering as early as the pre-pandemic period. Therefore, many opted to visit the informal providers since they listened to more time and care. Hence, they prescribed them appropriate medicine as believed by the participants. As one pregnant woman said, “We visited the health care facilities for treatment, but health facilities provided us with less medicine during this pandemic. They only provided paracetamol which we bought from outside. So, what is the point of going to the health facilities? Rather we could go to the pharmacy where doctors (attending person) would listen to our problems with more time and could give us the proper medicine” (23-year-old female, Homemaker, Rohingya).

In the host community, most participants shared experiences. Before the pandemic, most of the host people went to seek healthcare services from Government-owned health facilities. Since the medical staff was not compassionate towards the patients, some participants did not go to those hospitals anymore, prompting them to go to the informal health care provider (Vaidya) instead. As one PWD participant shared,

“Getting quality treatment was so challenging during the pandemic. Doctors maintained the distance strictly for everything. If the condition was too serious, they wore gloves to check the patient and prescribe medicine…I thought, what is this disease that they won’t even check up on properly? ’ I had doubts whether the prescribed medicines were right or not. If the health service quality was that bad, why would we go to the healthcare facilities? We can rather go to the nearby ‘Vaidya,’ who would treat us even better than them” (28-year-old female, Homemaker, Host)

One single female household head shared a similar experience. She said,

“The doctors examined their patients from a long-distance during the pandemic. Even if the patient were in critical condition, the doctors would perform a check-up from a distance. The patient might die because of this, right? (55-year-old female, Homemaker, Host). Additionally, ‘talking while wearing a mask’ was identified as another problem; the doctors could not hear the patients clearly, and they could not understand what doctors were saying. This also refrained them from visiting the health care facilities during the pandemic