Were Bangladesh's Growth Monitoring and Promotion (GMP) programmes resilient during a health system crisis? A qualitative study

IntroductionIn Bangladesh, growth monitoring and promotion (GMP) is delivered through both facility-based (FGMP) and non-government organisation (NGO)-supported home-plus-facility approaches (HGMP+FGMP). The COVID-19 pandemic disrupted health services, but little is known about the resilience of GMP delivery in rural community clinics (CCs) during this health system crisis. This study examined facilitators and barriers to GMP utilisation and implementation before and during COVID-19. MethodsWe conducted a longitudinal qualitative study in six rural sub-districts of Mymensingh at two timepoints before and after the lockdown of the COVID-19 crisis. We interviewed 84 participants, including government officials, CC providers, NGO managers, and caregivers of children under two, and indirectly observed GMP service provision at 23 CCs before lockdown. Data were thematically analyzed using the WHOs health systems building blocks framework to examine resiliency during a health system crisis. ResultsCaregivers awareness and engagement in GMP were low across both programmes and timepoints. Most CC providers and caregivers equated GMP with weight measurement for sick children alone. Length/height measurement and counselling were rarely provided. HGMP+FGMP improved access and uptake before the pandemic through home visits and immunization programme integration. Common barriers included workforce shortages, high workloads, weak government-NGO coordination, limited logistics and poor infrastructure, and inadequate supervision. The COVID-19 pandemic exacerbated these challenges, leading to partial suspension of FGMP and complete suspension of home-based services. Staff redeployment, supply chain disruptions, and caregiver disengagement were reported during the pandemic. Both programmes lacked health system-level guidance for crisis response. ConclusionsGMP programmes in rural Bangladesh exhibited limited resilience during a health system shock. Integrated HGMP+FGMP models can enhance access and engagement, but they need sustained institutional support, workforce capacity, caregiver communication, and resiliency and preparedness policies to maintain programme continuity during crises.Strengthening these areas can safeguard essential child nutrition services in future shocks. Key messagesO_ST_ABSWhat is already knownC_ST_ABSO_LILike in other settings globally, health services in Bangladesh face persistent implementation challenges and are disrupted during health system shocks, such as the COVID-19 pandemic. C_LI What this study addsO_LIGrowth Monitoring and Promotion (GMP) programmes in Bangladesh lacked resilience, with pre-existing health system weaknesses limiting their ability to adapt and maintain service delivery during a crisis. C_LI How this study might affect research, practice or policyO_LIStrengthening GMP programmes requires integrating emergency preparedness, improving caregiver communication, building provider capacity, and ensuring sustainable resources and system-level support. C_LIO_LIEmbedding resilience principles into GMP programme design, including community outreach, supervision, workforce support, and contingency planning, can help safeguard essential child nutrition services during future health system crises. C_LI