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HEALTH POLICY & HEALTH FINANCE KNOWLEDGE HUB

NUMBER 25, FEBRUARY 2013

Health system preparedness for responding to the growing burden of non-communicable disease a case study of Bangladesh
Dewan Alam Centre for Control of Chronic Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh Helen Robinson Nossal Institute for Global Health, University of Melbourne Aparna Kanungo Nossal Institute for Global Health, University of Melbourne Mohammad Didar Hossain Centre for Control of Chronic Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh Mahmudul Hassan Centre for Control of Chronic Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh

AusAID KNOWLEDGE HUBS FOR HEALTH

Health system preparedness for responding to the growing burden of non-communicable diseasea case study of Bangladesh First draft February 2013 2013 Nossal Institute for Global Health Corresponding author: Dewan Alam Centre for Control of Chronic Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh dsalam@icddrb.org This Working Paper represents the views of its author/s and does not represent any official position of the University of Melbourne, AusAID or the Australian Government.

The Working Paper series is not a peer-reviewed journal; papers in this series are works-in-progress. The aim is to stimulate discussion and comment among policy makers and researchers. The Nossal Institute invites and encourages feedback. We would like to hear both where corrections are needed to published papers and where additional work would be useful. We also would like to hear suggestions for new papers or the investigation of any topics that health planners or policy makers would find helpful. To provide comment or obtain further information about the Working Paper series please contact; mailto:niinfo@unimelb.edu.au with Working Papers as the subject. For updated Working Papers, the title page includes the date of the latest revision.

ABOUT THIS SERIES


This Working Paper is produced by the Nossal Institute for Global Health at the University of Melbourne, Australia. The Australian Agency for International Development (AusAID) has established four Knowledge Hubs for Health, each addressing different dimensions of the health system: Health Policy and Health Finance; Health Information Systems; Human Resources for Health; and Womens and Childrens Health. Based at the Nossal Institute for Global Health, the Health Policy and Health Finance Knowledge Hub aims to support regional, national and international partners to develop effective evidence-informed policy making, particularly in the field of health finance and health systems.

DISCLAIMER
While all effort and care were taken in preparing the content of this case study of Bangladesh, the Nossal Institute for Global Health and the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) disclaim all warranties or representations, demands, charges, express or implied, as to the accuracy of the information it contains. Neither of these organisations nor any of their employees makes any warranty, express or implied, or assumes any legal liability or responsibility for the accuracy, completeness or usefulness of any information or represents that its use would not infringe privately owned rights. The views and opinions of authors expressed herein do not necessarily state or reflect any agency thereof.

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SUMMARY
Bangladesh has been going through a rapid epidemiologic transition in which non-communicable diseases (NCDs) now account for two-thirds of all deaths. To assess health system preparedness and the country capacity to address this burden, we used a newly developed tool (Robinson and Hort 2011), a four-by-four matrix that assesses health system preparedness in building commitment, reorienting policies, developing new service delivery models and ensuring equity against four descriptive levels of readiness. The study reviewed research reports and policy documents and supplemented them with key informant interviews. Data were analysed according to the four-by-four matrix. The review indicated that although a national NCD plan has been developed, a dedicated unit has been established within the Ministry of Health and Family

Welfare and new service delivery options were being piloted, these activities remain fragmented, both within the health sector and across other areas of government and civil society. It found that while levels of awareness and commitment were relatively high within the ministry, other key players, including development partners and non-government providers, were largely absent from current activities. This absence may result in weakened ability of both government and non-government service providers to generate the type of multi-sectoral action required to tackle NCDs and to deliver more costeffective services that protect the poor. The key challenge for policy makers is how to build national sustainable, multi-sectoral action commensurate with the situation of NCDs. This includes designing programmatic responses that integrate various government and non-government activities, and that also reform health systems.

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INTRODUCTION
There is growing recognition of the rapidly emerging threat of non-communicable diseases (NCDs) in low- and middle-income countries (LMICs). With 80 per cent of NCD-related deaths occurring in LMICs, increasing our understanding of the country response is important. As well as setting out the nature and complexity of the problem of NCDs in LMICs, the Political Declaration of the United Nations High Level Meeting on NCDs in September 2011 in New York also detailed a complex package of actions required for any effective national response. These include improving surveillance, integration of treatment and prevention services through the health system and ensuring that actions within the health sector are linked with multi-sectoral activities in other areas of government, civil society and the non-government sector. Robinson and Hort (2011) developed a framework to assist policy makers and researchers in more systematically assessing country actions in response to NCDs. This was developed both to assist in defining multi-sectoral action and to assist policy makers in the ministries of health to see the importance of integrating their activities with other areas of public policy. The framework (Annex1) takes in the full range of actions encapsulated in the September 2011 Political Declaration, in particular the call for multi-sectoral action. Robinson and Hort assert that this approach represents a major reform effort for health systems in LMICs, and raise the question of the readiness and ability of many, including major development partners, to take on the task. The framework was proposed as a means for collecting the evidence to assist national policy makers in the complex task of developing a new mindset. Mapping country activities against the matrix can collect the necessary evidence for both country and international debate. Discussion of this evidence at both levels was considered important because this is where decisions need to be taken about the nature and extent of program support to combat NCDs. Bangladesh has a rapidly growing NCD burden, and the government has recognised this changing situation. Bangladesh provides a major opportunity

both to test the matrix and to gather the evidence necessary to understand the processes underlying the response to NCDs in low-resource settings. A recent overview of current NCD programs in Bangladesh (Bleich, Koehlmoos et al 2011) highlights the need to build a broader basis for action. While that review identifies some priorities for country action, it restricts its call to the traditional health system areas of improved surveillance and program monitoring, and does not go into the broader multi-sectoral action called for in the Declaration or address the reforms suggested by Robinson and Hort.

METHODOLOGY
Defining NCDs
In this paper the definition of NCDs is aligned with that used in WHO (2011b), namely the four major health conditionscardiovascular diseases, diabetes, cancers and chronic obstructive pulmonary disease (COPD)that are linked through the four risk factors: tobacco use, unhealthy diet (high in fats and sugars and low in fruits and vegetables), harmful use of alcohol and low levels of physical activity. Wherever possible, the data provided is linked to these four diseases only. Where it is not possible to report on these in isolation from other health conditions, the situation is documented. In addition to these four NCDs, other health conditions are often included under the NCD umbrella. In Bangladeshs Health Population and Nutrition Development Plan (HPNSSP 2011-16) (MOHFW 2011a), for example, NCDs are defined in two broad categories, conventional and non-conventional. The former relate to the four health conditions described above but also include arsenicosis, mental health disorders, hearing disabilities and oral disease. Road injuries and violence against women are grouped under non-conventional NCDs. (MOHFW 2011a). In defining NCDs for the purpose of quantifying the relative burden of disease and disability, NCD comorbidities cannot be ignored. Any individual can have more than one diagnosable condition. We also know that there are complex interrelationships between various NCDs and TB, malaria and

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HIV (Boutayeb 2006) and emerging evidence of relationships between NCDs and other health conditions including mental illness and injuries (Prince, Patel et al 2007). How these co-morbidities manifest in Bangladesh today is being recognised only slowly and demonstrates the complexity of the situation in low-income countries.

218 million by 2030. The country is undergoing considerable social and economic changes. Key population, economic and health indicators are summarised in Table 1.

Study Design
The study used the four-by-four matrix framework for policy makers proposed by Robinson and Hort (2011) to assess Bangladesh health system preparedness to combat NCDs. It reviewed research reports and policy documents, published literature and documents from the World Bank, Bangladesh Directorate General of Health Services (DGHS), WHO, Ministry of Health and Family Welfare and local health care institutions available for 2005 to 2011. Some publications from earlier periods were included for understanding of the historical context. A small number of key informant interviews were also undertaken to check interpretation of the material reviewed. In line with the definition of NCDs discussed above, activities and programs were analysed wherever possible to ensure their focus on the four NCDs. Those programs and activities related to mental health disorders, road injuries and arsenicosis were excluded from the analysis. Information was gathered on the current NCD situation and programmatic response. This response was analysed across four elements or rows of the frameworkbuilding commitment and addressing health systems constraints; developing new public policies in health promotion and disease prevention; developing new service delivery models; and ensuring equity in access and payment for NCD servicesusing the indicators in the cells of the framework, to provide a systematic analysis of the national response.

There is a high rate of urbanisation. The capital, Dhaka, grew to 10.2 million in 2000 and is expected to increase to 16.8 million by 2015 (World Bank 2007; UN 2008). The growing population in urban areas is often underserved in security, housing and access to essential services, including health services. Despite these changes, Bangladesh is still primarily a rural country, with more than 75 per cent of the population currently estimated to be living in rural areas (Bangladesh Bureau of Statistics 2011). Nearly half the population live on less than US$1.25 per day (Bangladesh Bureau of Statistics 2011). The population is relatively young, only 4 per cent being over 65 years. However, this is expected to change, with the proportion over 65 years expected to grow to 6.6 per cent by 2025 (World Bank 2011b). Although there has been significant improvement in broad health indicators in recent years, the government faces major issues concerning its capacity to plan and implement a broad range of health and population services (Vaughan, Karim et al 2000). Many in the population experience a wide range of health problems linked to socio-economic disparities (Afsar 2003; Ullah 2004; Roy, Abduallah et al 2005; Riley Ko et al 2007). Bangladesh has low per capita health expenditure as well as a low percentage of GDP spent on health. In 2009-10, the per capita national income and GDP were US$750 and US$684 respectively (Financial System Management Unit 2011). It is estimated that public sector health care financing accounts for 35 percent of total health care expenditure, which is insufficient to meet the demands of the population (Engelgau, Elsaharty et al 2011). While the table indicates that the overall proportion of development assistance going to the health system is approximately 8 percent, Bleich, Koehlmoos et al (2011) estimated that nearly 16 percent of all health expenditures in Bangladesh are funded by international aid agencies, and this is supported by WHO countryby-country comparisons of health development assistance (WHO 2009). Regardless of the exact level,

COUNTRY CONTEXT
Bangladesh is extremely poor and densely populated. In 2010, the population was 164 million (World Bank 2012d), and it is expected to increase to around

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TABLE 1. Subject

BANGLADESH ECONOMIC, SOCIAL AND HEALTH INDICATORS (2010) Key Indicators


Total millions in 2010 (1) percent of population living in rural areas (2) percent of population over 65 years

Value
164 75+ 4 $640 $1620 6.3 38 194 6

Population

Economic Indicators

GNI per capitaUS$ (1)


PPP GNI per capitaUS$ (1) Annual growth rate ( percent) (3)

Health Indicators

Infant mortality per 1000 live births (4) Maternal mortality per 100,000 live births (5) Crude death rate per 1000 population (6) Life expectancy (years) (7) Males Females

66 68 1860 7.7 3.5 7.4 65.9 percent 23 8

Health Services

Persons per hospital bed (2) No. of doctors per 10,000 population (8)

Health Financing

Total expenditure on health ( percent of GDP) Health expenditure, public (percent of government expenditure) Out-of-pocket expenditure as a percentage of total health expenditure (2009) (9) Per capita total expenditure on healthUS$ Per cent coming from development aid/partners (10)

(1) (2) (3) (4)

World Bank 2012d. Bangladesh Bureau of Statistics 2011. Trading Economics 2012a. World Bank 2012a.

(5) (6) (7) (8)

World Bank 2011c. World Bank 2012b. World Bank 2012c. Bangladesh Health Watch 2007.

(9)

Trading Economics 2012b.

(10) DGHS n.d.

it does indicate the importance of the contribution of development partners in setting national health care priorities. In urban settings, health care is provided primarily by public primary, secondary and tertiary institutions, although private health care services have been emerging rapidly. Given the relatively high costs of private health care services, they are available only to people with disposable income. The other major urban providers of health care are public-private partnership institutions, which mostly provide specialised services at a lower cost than private institutions. Rural services are mostly provided through public institutions, but people still incur high out-of-pocket

expenditure. Private health care is becoming increasingly available, but the higher cost generally means that it is not accessible for most rural poor. The quality of care varies widely in both urban and rural settings. Despite the relatively bleak picture of the health system painted by these figures, there has been considerable success in improving maternal and child health in recent years (BBS 2011). The maternal mortality ratio went down to 194 per 100,000 live births in 2010 (World Bank 2011c), a 40 percent reduction compared to 2001, when the figure was 322 per 100,000. Although Bangladesh is still short of achieving the MDG 5 goal of 140 per 100,000 live births by 2015, this still represents

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a remarkable achievement. Infant mortality has also declined substantially (World Bank 2012a). These figures suggest that it is still possible to make significant health gains in Bangladesh despite the economic and social situation, low national health expenditure, high donor dependency and high out-ofpocket costs. The mixed health system, its variable quality of care and poor distribution of services are challenges for improving national health outcomes.

account for 61 percent of the disease burden in terms of disability adjusted life years loss (World Bank 2011a).

Non-Communicable Disease in Bangladesh


Nature and Significance of the Problem
Bangladesh is going through an epidemiologic transition in which the burden of disease is shifting from predominantly infectious diseases and conditions related to under-nutrition to those linked to NCDs, despite an overall reduction in mortality (Karar, Alam and Streatfield 2009; Bleich, Koehlmoos et al 2011). This transition has been quite rapid, and has taken many by surprise. The situation is not restricted to urban populations but is well documented in rural populations (Karar, Alam and Streatfield 2009). In Matlab, a rural area, from 1982 to 2005 the share of chronic disease in all causes of death increased from 41 percent to 79 percent (Khan Trujillo et al 2012). While earlier figures may not be completely reliable, one estimate from 1986 put the proportion of deaths due to NCDs at 8 percent , while communicable diseases accounted for 52 percent (Bleich, Koehlmoos et al 2011; WHO 2011b). By 2006, the proportion of deaths attributable to NCDs had increased to 68 percent, compared to 11 percent due to communicable disease. Thus there has been an estimated nearly eight-fold increase in NCD mortality over those two decades (Bleich Koehlmoos et al 2011; Engelgau, El-saharty et al 2011). It is important to see these figures for Bangladesh in relation to the situation for all countries, in which NCDs account for 54 percent of mortality and 47 percent of the burden of disease (WHO 2011b). Nearly 600,000 people die annually due to NCDs in Bangladesh, over 60 percent of them before 70 years of age (WHO 2011b). NCDs, including injuries,

Cardiovascular diseases now rank among the top 10 causes of death in Bangladesh (Ghaffar, Reddy et al 2004; Bleich, Koehlmoos et al 2011; Engelgau, El-saharty et al 2011; WHO 2012). Recent estimates suggest that cardiovascular disease alone accounted for 13.4 percent, mental health 11.2 percent, cancer 3.9 percent, respiratory diseases 4.0 percent, diabetes 1.2 percent and injuries 10.7 percent of total disability adjusted life years lost (Engelgau, El-saharty et al 2011). The ageing of the population projected over the next several decades will also impact on the incidence of NCDs. Estimates of an increase of people over the age of 65 years from 6.5 million (5.1 percent of the total population) in 2000 to 40.5 million (19 percent) by 2050 (Streatfield and Karar 2008) suggest that the problem will be exacerbated and increase the likelihood that individuals will experience multiple chronic conditions.
The Bangladesh Risk Factor Survey in 2010 indicated that 98.7 percent of respondents (99.6 percent of males and 97.9 percent of females) had at least one risk factor for NCDs. The survey also found: the prevalence of tobacco consumption was among the highest in the world, particularly among men51 percent; inadequate fruit and/or vegetable intake95.7 percent; the proportion overweight was 17.6 percent and proportion having increased waist circumference 21.7 percent; the proportion with raised blood pressure was17.9 percent; and diabetes mellitus (self-reported) prevalence was 3.9 percent (WHO 2011a). Together, this information suggests a rapidly changing health situation, one which presents new challenges for health policy makers.

Health System Structure and Delivery of NCD Services


In Bangladesh, health services are delivered by a variety of facilities under the control of the Ministry of Health and Family Welfare (Beatty 2012). Primary health care (PHC) operates at three tiers or levels.

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At the level closest to communities and families, Upazilla Health Complexes (UHC), Union Health and Family Welfare Centres and Community Health Care Services offer health services. These are linked with the districts as part of the public sector health service (MOHFW 2011a), in which there are 418 hospitals (50 bedded) spread across the country. According to the World Bank (2011a), health workers in the primary health care system are not trained in NCD treatment. Secondary care is mainly provided by district hospitals. Tertiary care is provided through medical college and specialised hospitals, including some specialised government and non-government hospitals, of which there are 121 in total, largely concentrated in bigger urban centres. The country has one medical university, which also provides secondary and tertiary care in addition to academic programs and research (DGHS 2010). Bangladesh has a long history of specialty hospitals and foundations in both public and private (including for-profit and not-for-profit) sectors; these provide individual clinical treatment for NCDs, but with little focus on prevention. Patients admitted to hospitals for treatment, or tertiary care, of COPD, cardiovascular events such as stroke or acute myocardial infarction and so on may suffer insufficient availability of services due to heavy patient load. The lack of adequately trained doctors, nurses and diagnosticians to address NCDs is another constraint in public secondary and tertiary facilities. The biochemical investigations required for accurate diagnosis are available on a fee-for-service basis. However certain sections of the population have difficulty in accessing these services both financially and geographically, even when offered at a minimum charge in public facilities. . Data on health workforce distribution are difficult to capture reliably, but recent estimates indicate that in 2008 the ratio reached one physician per 2860 people (BBS 2009). This is far from the ratio for optimal health care. The prevention, treatment and management of many NCDs need human resources with specialised training. Trained personnel for secondary and tertiary care services are inadequate in number considering the demand, particularly when screening and early detection services are limited. For example, there are roughly only 110 oncologists

in the country for about 160 million people, and most of them are concentrated in major cities. This uneven distribution of care providers is a barrier to geographically equitable access to NCD health care. Basic drugs for treatment are normally given to both out-patients and in-patients, but provision is subject to availability, which is limited and spasmodic at best. Any interventions and operative procedures are supposed to be free or minimally charged, but generally, when these are available, the costs are borne by the patient, and very often significant outof-pocket expenditure is incurred. In 2008, household out-of-pocket expenditures at drug outlets accounted for 46 percent of total health sector expenditures (Engelgau, El-saharty et al 2011). Bangladesh has a national essential drugs policy and a list of essential drugs for use in the public health system. Generic drugs comprise the bulk of the items on the list, but drugs for the treatment of NCDs were not included in 2011 (World Bank 2011a). There is also an informal system of primary care that includes licensed and unlicensed practitioners and pharmacists. Treatment for conditions like diabetes, hypertension and heart disease are routinely delivered outside the formal health sector. There is a need for more complete surveillance and information to support evidence-based decision making within the health sector. The WHO (2011b) highlighted this problem, particularly for health ministries in LMICs. This lack of good surveillance data on demand for and supply of services in the public and private sectors is a major barrier in tackling NCDs, as will be seen later in this study. There are a number of challenges to the countrys capacity to meet the needs of patients with, or at high risk of, NCDs. The country is yet to integrate NCD prevention and treatment into primary health care. The primary care system focuses primarily on maternal and child health, family planning, infectious diseases including TB and malaria, as well as communicable diseases like AIDS. However, at the time of this review, care for NCDs is being initiated by DGHS by establishing NCD corners in selected Upazilla Health Complexes in parallel with

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the existing services offered there. The decision to develop these corners was a result of the first national NCD survey (Bangladesh Society of Medicine 2011), which played an important role in raising awareness of the need to tackle NCDs. This initiative is a major change in service delivery for NCDs and has the initial aim to provide services for cardiovascular diseases, diabetes and chronic respiratory diseases (asthma and COPD) and screening for certain cancers. Each NCD corner will have dedicated staff and equipment such as machines for measuring blood pressure, glucometers, electrocardiographs and nebulisers, as well as enhanced laboratory facilities. Already, orientation workshops on NCDs have been arranged for the care providers working in the selected UHCs. Meetings were also conducted and publications circulated to raise awareness among the public. These activities will continue during the trials. Selfreported NCD patients will be asked to attend the NCD corner, and high-risk or suspected cases will also be asked to visit for screening and health checks. A registry of NCD cases will be maintained in the UHCs. So far, the NCD corner concept has been piloted in three UHCs in the south-western district in Khulna Division in 2012. It is planned to make NCD corner services available in 137 UHCs over the next year or so. Bangladesh is developing its first health care financing strategy under the leadership of the Health Economics Unit of the MOHFW. Currently, financing for NCD treatment is heavily dependent on out-of-pocket payments, which restricts access for many citizens. Management of NCDs, through both prevention and treatment, will demand some form of continuous funding. This is a challenge for Bangladesh. Achieving universal health coverage needs to take into account the rapid disease transition and the ageing of the population.

of Cardiovascular Disease Hospital, the National Institute of Cancer Research and Hospital (NICRH), and the National Institute of Diseases of the Chest and Hospital (NIDCH). Non-government organisations (NCDF-Eminence, Cancer Society etc.): The AK Khan Trust, Adhunik and Eminence are a few NGOs, Adhunik being a well-known voluntary anti-tobacco organisation. Academic organisations: Research organisations focusing on NCDs include Bangabandhu Sheikh Mujib Medical University, the Centre for Control of Chronic Diseases, International Centre for Diarrhoeal Disease Research, Bangladesh and BRAC University. Health professional associations: Professional associations such as the Diabetic Association of Bangladesh, Bangladesh Hypertension Society, Bangladesh Cancer Society and Asthma Association also play a role. Development partners: Development partners including the World Bank, WHO, European Union, USAID and UN agencies play an important role in policy development. Public-private partnerships: Notable public-private partnership institutions are the National Heart Foundation Hospital and Research Institute, which provides care for cardiovascular diseases, and the Bangladesh Institution of Research on Diabetes, Endocrine and Metabolic Disorders, which is the premier institution for these NCDs. These PPPs provide services at a subsidised cost. Private organisations: The private sector provides substantial health care to NCD patients, but the costs of services are generally high in comparison to services provided by NGOs and the government. Private hospitals such as Delta Hospital and Ahsania Mission Hospital have specialised care facility for cancers (Beatty 2012).

Government Policy
Historically government policy in response to NCDs has not received adequate attention from policy makers, development partners, researchers and academicians (MOHFW 2011a). NCDs were not considered a public health priority until 2007, when they were included in the Health Nutrition and Population Sector Programme (MOHFW 2009). However, the government did take a few critical policy decisions, including:

Key Actors
Stakeholder analysis (Annex 2) shows multiple players with a range of expertise. These can be broadly divided into the following categories: Government ministries and departments: Government organisations playing a prominent role in specific NCDs include the National Institute

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signing the Framework Convention on Tobacco Control in 2004 and ratifying it in 2005; several legislative initiatives including amendment of the Mental Health Act, a recommendation to increase tobacco tax by the National Board of Revenue and amendment of the Tobacco Control Law; endorsing several national strategies related to NCDs: national NCD prevention and surveillance, National Tobacco Control Strategy (MOHFW 2005; WHO 2007), National Cancer Control Strategy Injury Prevention Strategy, Deafness Prevention Strategy, National Eye Care Plan; developing the first Strategic Plan of Surveillance and Prevention of Non-Communicable Diseases 2007-10 (MOHFW 2011b); undertaking the national risk factor survey in 2010 (WHO 2011a; BSM 2011); establishing a separate operational plan for NCDs under one line director in the Directorate General of Health Services (World Bank 2011a). The Health, Population and Nutrition Sector Development Program 2011-2016 (MOHFW 2011a) identifies three NCDscardiovascular diseases, diabetes and canceras major public health problems (World Bank 2011a). It includes an operational plan for the prevention, management and control of NCDs (Beatty 2012). The primary aim of the operational plan is to reduce morbidity and premature mortality due to NCDs through actions at all levels from primary prevention to treatment and rehabilitation. The Strategic Plan for Surveillance and Prevention of Non-Communicable Diseases, 2011-15 (MOHFW 2011b), was developed by MOHFW in consultation with institutions including the ministries of Education, Local Government and Information, Bangabandhu Sheikh Mujib Medical University, some NGOs, UNICEF, UNFPA, World Bank, JICA, Asian Development Bank and DFID, and with technical assistance from the World Health Organization. The aim of the Strategic Plan is to reduce NCD-related deaths by 2 percent per annum in alignment with the global target set by the World Health Assembly by focusing on three major areas: surveillance of NCDs and their risk factors; health promotion and prevention; health care services (MOHFW 2011b).

The Bangladesh Network for Non-Communicable Diseases Surveillance and Prevention, a collaborative forum for government organisations and private clinical institutions, has been established at DGHS with technical support from the WHO (MOHFW 2011b). This effort is supplemented by the NCD Forum, which works to reduce chronic diseases by coordinating the efforts and resources of public and private health care providers and other partners such as nongovernment organisations (Beatty 2012).

FINDINGS
In this section, we present the results of data collection. The material is presented using the four elements or rows of the framework.

Building Commitment and Addressing Health System Constraints


Health system constraints are summarised in Annex 3. Bangladesh is one of the 17 low- and middleincome countries reporting to WHO and having an integrated NCD policy, strategy and operational, plan (WHO 2011e; Beatty 2012). The importance of NCDs is slowly gaining recognition by both the government and NGOs. This is demonstrated by giving priority to NCDs in the Health Population & Nutrition Sector Strategic Development Program 2011-2016 (MOHFW 2011a) and developing the Strategic Plan for Surveillance and Prevention of NCDs (MOHFW 2011b).

Our key findings are:


Awareness of NCDs in the public sector is rising. This is evident through the signing, ratifying and enforcing of the Tobacco Control Act, related to international efforts through the Framework Convention on Tobacco Control (World Bank 2011a), inclusion in the Health Nutrition and Population Sector Programme 2007, completion of a national NCD risk factors survey, creation of a separate operational plan for NCDs in the DGHS and the endorsing of several national strategies for prevention and control of NCDs. Both government and non-government organisations have undertaken awareness-raising

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initiatives (Annex 4). Notable contributors among the government organisations are the National Institute of Cardiovascular Disease, National Tobacco Control Cell and National Institute of Cancer Research and Hospital, and among the nongovernment, autonomous and PPP organisations Bangabandhu Sheikh Mujib Medical University, National Heart Foundation Hospital & Research Institute, Bangladesh Diabetic Somity/Diabetic Association of Bangladesh and Bangladesh AntiTobacco Alliance. Advocacy activities by different organisations were found to be limited to seminars and workshops, without a specific strategy. Bangladesh is yet to develop a national NCD plan that includes a human resources plan to cover prevention, diagnosis and treatment. The Strategic Plan for Surveillance and Prevention (2011-2015) provides a framework and guidance for interventions to control and prevent NCDs. However, there is no ongoing monitoring and evaluation of the plan (MOHFW 2011b). Currently there is no routine surveillance of NCDrelated morbidity and mortality (Bleich, Koehlmoos et al 2011). There is a need for more complete surveillance and information related to the economic burden of these diseases. Coordination is lacking between public and private services (Beatty 2012). The Matlab Health Research Centre, in rural Bangladesh, monitors population and health indicators for approximately 225,000 residents and routinely collects some NCD-related risk factors, morbidity and mortality data (World Bank 2011a). There is a lack of systematically collected and available data. This makes tracking of trends, evidence-based policy and research more difficult. Baseline surveys aimed at assessing national NCD awareness were unavailable. One study, the Bangladesh NCD Risk Factor Survey 2010 (BSM 2011), used the WHO STEPS questionnaire with some adaptation. Bangladesh has a national essential drugs policy and a list of essential drugs to be used in the public health services system. Most of the essential drugs are generics. However, drugs for treating NCDs are not included in the list (World Bank 2011a). The current budget allocation of an estimated 2 percent of the overall health expenditure of HPNSDP for 2011-16 (MOHFW 2011a) for NCDs does not

seem adequate. However, it is unclear how more resources will be mobilised towards NCDs. Systems for adequately tracking the resources dedicated to NCDs over time need to be put in place so that this can be reported in a transparent manner. The role of development partners is crucial to tackle the long-term need for technical assistance and funding. Given their contribution to health development assistance nationally, their profile in NCDs is very low.

Public Policy in Population Health Promotion


Health promotion policy is summarised in Annex 5. Health promotion is a key component in the Strategic Plan for Surveillance and Prevention of NCDs. Strategies includes support and facilitation for development of public policy through promotion of healthy lifestyles, collaboration among stakeholders and partners, involvement of health professionals in health promotion, capacity building and improving community knowledge.

Our key findings are:


Not much is happening on the ground. Some external partners were assigned to these activities in the Strategic Plan in 2007-10, but no evaluation was done. Further, partners names have been excluded in the updated 2011-15 version of the plan, indicating a possible lack of accountability and responsibility. Prevention and health promotion activities are a big challenge because of diverse strategies, which need to be organised with limited human and technical capacity (MOHFW 2011b; World Economic Forum and WHO 2011). An evaluation framework was developed in the Strategic Plan for Surveillance and Prevention of NCDs, but no ongoing monitoring and evaluation of the strategy has been conducted to assess its effectiveness. There is negligible engagement from business and industry as partners in the community. Research is needed to understand how community, industry and business can be involved more positively in population-based health promotion activities.

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Service Delivery Models


Service delivery is summarised in Annex 6.

Our key findings are:


The risk factor survey identified the high-risk population by characteristics of gender, age, location and ethnicity. The Strategic Plan recognises the role of different actors but fails to identify strategies to engage NGOs, academic institutions, research organisations and autonomous PPP (Beatty 2012). Stakeholder analysis (Annex 1) shows multiple players with a range of expertise. However, most of these agencies have their own disease-specific agendas, different rationales and constituencies, and are not united. So far only three alliances Bangladesh NCD Network, Alliance for CommunityBased Surveillance of NCDs, Bangladesh AntiTobacco Alliance (Karar, Alam and Streatfield 2009; Bleich, Koehlmoos et al 2011; Osei and Nwasike 2011; Beatty 2012)have been formed that include members from both government and nongovernment agencies. The role of professional associations and development partners is unclear (Beatty 2012). There is minimal involvement of private sector agencies, NGOs, PPPs and development partners in NCDs. Further, there is a lack of a clear business case and advocacy strategy, and community awareness of the issue is low (WHO 2011c; WHO 2011d). There is a lack of coordination of NCD activities and services in primary health care (Karar, Alam and Streatfield 2009; Beaglehole, Bonita et al 2011; Osei and Nwasike 2011). The country is yet to integrate NCD primary prevention and treatment. The World Bank (2011a) identified the lack of implementation initiatives for NCDs as a big health system issue. This lack is partly due to the absence of dedicated funding, a lack of clear lines of responsibility and competing priorities. NCD prevention and treatment are not included in the primary care essential services package. Most people, including the poor, use private practitioners for first-line clinical care. It is unclear how these services will be coordinated (Bleich, Koehlmoos et al 2011; WHO 2011c).

Currently, NCD treatment comes mostly from the tertiary level and mostly in the city. Thus it is difficult to access care in remote areas. This creates disparity and inequitable distribution of health services. NGOs mainly involve community partners on awareness raising activities of specific NCDs. At the PHC level, most of the NGOs, PPP work on building awareness, providing training to health care providers, and implementing pilot programs. Community partners are yet to be identified for service delivery. Success will not be achieved until community involvement is ensured (WHO 2008a). An NCD service model, NCD corners, has been developed and is currently being piloted in three UHCs. The government has plans to expand the corners to 137 primary and secondary care facilities. How these will be evaluated is not evident. Several pilot programs have been planned or initiated. Training needs should be assessed beforehand and incorporated with the plan for the pilot delivery. For example, the Centre for the Control of Chronic Diseases in Bangladesh, which aims to develop community-based prevention and management programs, will evaluate the link between NCDs and poverty and identify the health systems response to NCDs (Gaziano, Galea and Reddy 2007; Bleich, Koehlmoos et al 2011; Beatty 2012). The Bangladesh Network for Non-Communicable Disease Surveillance and Prevention data network has been created, involving government and private clinical institutions. The Alliance for CommunityBased Surveillance is also promoting periodic population-based surveys of NCDs and their risk factors (World Bank 2011a). More research needs to be done on social and economic factors related to NCDs. Research on health insurance is needed. Public and private insurance models should be examined and should include NCDs.

Ensuring Equity in Access and Payment for Services


Several studies have examined equity issues in general in Bangladesh. The studies show that inequity exists in different socio-economic groups and is related to gender. However, no article was found that examined

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equity in access to and costs of NCD prevention and treatment.

Our key findings are:


Bangladesh research results related to identification of groups at high risk of NCDs exclusively were unavailable. Appropriate low-cost services for high risk groups with inequitable access have not been discussed or adopted. No measurement of equity of access and payment was found. There is no ongoing monitoring of equity of access and payments, nor is there any evidence that is has been discussed.

and involving civil society and the private sector among others. Multi-sectoral action is the key to success in controlling NCDs in countries like Finland and Australia; this analysis indicates that several potential actors are being underutilised in current efforts in Bangladesh, and that some are notably absent. While the MOH is key to success, it will not be able to produce the necessary results if it continues on the current largely health-centric path. (3) Key development partners, particularly the traditional donors, are remarkably absent from the process. This would indicate that the bias toward communicable disease observed in donor behaviour elsewhere also occurs in Bangladesh (Stuckler, King et al 2008). (4) Given the laudable progress towards MDGs 4 and 5 in Bangladesh, it seems that it is possible to produce remarkable change at the national level through effective alliances and careful planning and monitoring. This indicates that Bangladesh has the capacity to bring about real change in its health sector. Lessons learned from the achievements in maternal and child health need to be carefully examined to determine what can be effectively applied to the control of NCDs. (5) Issues of equity in relation to NCD control seem remarkably absent in documents and reports of discussions. More research needs to be done to address equity in service provision, payments, health outcomes and access to and utilisation of preventive and curative services. Equity in access to NCD health services and possible interventions needs testing from primary to tertiary care level. Research on health insurance is needed. Public and private insurance models should be examined and should involve NCDs. It is expected that any final insurance package will address prevention, early diagnosis and treatment issues and integrate them eventually. (6) The costs of providing NCD care need to be estimated, and the expected distribution of costs across government, patients and development partners should be planned taking into consideration funding capacity; finally, projections should be made for how this distribution should change over time.

DISCUSSION
This study reveals that it is important to look behind official reports, web sites and speeches to determine and evaluate progress. For the authors, seven main points to guide policy makers and development partners in low-income countries like Bangladesh arise from the application of the framework to NCDs. (1) Current activities are not commensurate with the scope and the complexity of the problem; despite efforts since 2007, most activities appear weakly connected and somewhat spasmodic. Given the likely rate of growth of the incidence of NCDs in the next 20 years or so, the pace of action of recent years will not be sufficient to address even the increase in cases requiring primary care services. The lack of emphasis so far on prevention of NCDs is problematic because the costs associated with treatment will put at risk the gains being made in health outcomes. Emphasis on the four NCDs and their related risk factors is a story of prevention; without a greater focus on prevention and behavioural change, particularly among the younger generation, the ability to control the social and economic costs of NCDs will be severely weakened. (2) Activities and actors are too narrowly focused in Bangladesh; the good examples of control of NCDs are based on long-term, multi-sectoral action across a range of government departments

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(7) Lastly, the application of the framework provides useful information. It could be applied regularly, perhaps every two or three years, to assess progress and shed light on areas where results are being achieved and generate discussion on where more effort is required.

NCD awareness-raising activities of different intensity and coverage are being undertaken. These activities are occurring across public, public-private and private institutions, but they are limited to clinical settings, are mostly in urban locations and are yet to reach the general public in any systematic or sustainable way. Investment in preventive and curative care for NCDs is very scanty, and those that are funded tend to be bundled with other problems such as arsenicosis. As funding for health in general in Bangladesh is relatively low, the setting of priorities among the various calls on the health budget is very important. Key development partners, including the major donors, are not yet sufficiently focused on NCDs to provide support specifically for combating chronic diseases. However, the key finding in this study is that despite the call for a multi-sectoral approach to NCD prevention and control, as set out in the 2011 Political Declaration on NCDs and in various WHO reports and documents, it is very difficult to make this happen, particularly when the health ministry is the central focus. Without putting the NCD challenge higher up the national political and financial agenda, it is hard to imagine a response that is commensurate with the problem. Policy makers have a key role in this process.

CONCLUSIONS
Bangladesh faces many challenges in health. Limited resources, the high prevalence of NCDs, side by side with high prevalence of communicable diseases, inequitable access to services, weak public health systems, a largely unregulated private health sector, ageing population and lack of NCD-related financing from government and international donors, all combine to present significant challenges for tackling NCDs (Bleich, Koehlmoos et al 2011, World Bank 2011b). This study has broadened the scope of the critique of the response to NCDs in the country. The application of the framework has highlighted important gaps and limitations in that response. At the same time it has also shed light on areas where refocusing and redirection of attention and resources are needed. NCDs have been taking an increasingly greater toll both socially and economically in Bangladesh, and the epidemiologic transition is well documented. The emerging threat of NCD epidemic is well recognised by the government, and gradually increasing commitments are evident.

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REFERENCES
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Khan, A.M.J., A. Trujillo, Ahmed, A.T. Siddiquee, A. Nurul, A. Mirelman et al. 2012. Distribution of chronic disease mortality and deterioration in household socioeconomic status in rural Bangladesh: An analysis over a 24 year period. Unpublished Manuscript. Ministry of Health and Family Welfare (MOHFW). 2005. National policy and plan of action for tobacco control 2006-2008. Dhaka: MOHFW. Ministry of Health and Family Welfare (MOHFW). 2009. Bangladesh health, nutrition and population sector programme (HNPSP): Annual Program Review. Volume 1, Main consolidated report key findings, conclusions and recommendations.Dhaka. Ministry of Health and Family Welfare (MOHFW). 2011a. Health, population and nutrition sector development program (HPNSDP) 2011-2016; PIP; Program Implementation Plan. Volume I. Dhaka: Government of the Peoples Republic of Bangladesh. Ministry of Health and Family Services (MOHFW). 2011b. Strategic plan for surveillance and prevention of non-communicable diseases in Bangladesh 2011-2015. Dhaka: Directorate General of Health Services. Osei, P.D., J.N. Nwasike, Commonwealth Secretariat. 2011. Commonwealth health ministers update 2011. Commonwealth Secretariat.London. Prince, M., V. Patel, S. Saxena, M. Maj, J. Maselko, M.R. Phillips et al. 2007. No health without mental health. Lancet 370 (9590): 859-877. Riley, L., A. Ko, A. Unger and M. Reis. 2007. Slum health: Diseases of neglected populations. BMC International Health and Human Rights 7 (2): 1-6. Robinson, H.M. and K. Hort. 2011. Non-communicable diseases and health systems reform in low- and middle-income countries. Working Paper 13. Melbourne: Nossal Institute for Global Health. Roy, G.S. and A.Q.M. Abduallah. 2005. Assesing needs and scopes of upgrading urban squatters in Bangladesh. BRAC University Journal 2 (1): 33-41. Streatfield, P.K. and Z.A. Karar. 2008. Population challenges for Bangladesh in the coming decades. Journal of health, population, and nutrition 26 (3): 261-272. Stuckler, D., L. King, H. Robinson and M. McKee. 2008. WHOs budgetary allocations and burden of disease: a comparative analysis. Lancet 372 (9649): 1563-1569. Trading Economics. 2012a. Bangladesh GDP Annual Growth Rate. http://www.tradingeconomics.com/bangladesh/gdpgrowth-annual (accessed 18 April 2012). Trading Economics. 2012b. Out-of-pocket health expenditure ( percent of total expenditure on health) in Bangladesh. http:// www.tradingeconomics.com/bangladesh/out-of-pockethealth-expenditure-percent-of-total-expenditure-on-health-wbdata.html (accessed 6 September 2012). Ullah, A.K.M.A. 2004. Bright city lights and slums of Dhaka city: Determinants of rural-urban migration in Bangladesh. Migration Letters 1 (1): 26-41.

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United Nations. 2008. World Urbanization Prospects. The 2007 Revision: Executive Summary. New York: United Nations Department of Economic and Social Affairs/Population Division. Vaughan, J.P., E. Karim and K. Buse. 2000. Health care systems in transition III. Bangladesh, part I. An overview of the health care system in Bangladesh. Journal of Public Health 22 (1): 5-9. World Bank. 2007. Improving living conditions for the urban poor. Bangladesh Development Series, paper no. 17. Dhaka. World Bank. 2011a. NCDs policy brief: Bangladesh, South Asia human development, health nutrition and population. http:// siteresources.worldbank.org/SOUTHASIAEXT/Resources /223546-1296680097256/7707437-1296680114157/NCD_ BD_Policy_Feb_2011.pdf (Accessed on 5th october 2011) World Bank. 2011b. BangladeshHealth Sector Development Program. Dhaka. World Bank. 2011c. Reproductive health at a glance, Bangladesh. Dhaka. World Bank. 2012a. Mortality rate, infant (per 1,000 live births), Bangladesh. http://data.worldbank.org/indicator/SP.DYN. IMRT.IN (accessed 18April 2012) World Bank. 2012b. Death rate, crude (per 1,000 people), Bangladesh 2012. : World Bank. http://data.worldbank.org/ indicator/SP.DYN.CDRT.IN (accessed 19 April 2012) World Bank. 2012c. Life expectancy at birth, total (years), Bangladesh. : World Bank. http://data.worldbank.org/ indicator/SP.DYN.LE00.IN (accessed 2 May 2012) World Bank. 2012d. World development report 2012: Gender equality and development. Washington, DC. World Economic Forum and World Health Organization. 2011. From Burden to Best Buys: Reducing the Economic Impact

of Non-Communicable Diseases in Low- and Middle-Income Countries. http://www.who.int/nmh/publications/best_buys_ summary.pdf (Accessed 18 April 2012). World Health Organization. 2007. Tobacco control, poverty reduction and the millennium development goals (MDGs). Report of an Inter-country Meeting Dhaka, Bangladesh. : WHO, New Delhi. World Health Organization. 2008a. Health situation in the SouthEast Asia region 2001-2007. : WHO, New Delhi. World Health Organization. 2008b. 2008-2013 Action plan for the global strategy for the prevention and control of noncommunicable diseases. Geneva: WHO, Geneva. World Health Organization. 2009. WHO estimates for country national health. : WHO, New Delhi. World Health Organization. 2011a. Non-communicable disease risk factor survey, Bangladesh 2010. : WHO, New Delhi. World Health Organization. 2011b. Global status report on noncommunicable diseases 2010. Geneva: WHO, Geneva. World Health Organization. 2011c. Noncommunicable diseases in the South-East Asia region: Situation and response 2011. : WHO, Geneva. World Health Organization (WHO). 2011d. Noncommunicable diseases country profiles 2011.WHO Geneva.. World Health Organization. 2011e. Bangladesh Health Profile. : WHO. http://www.who.int/countries/bgd/en/ (Accessed on 9 August 2011). World Health Organization. 2012. Country health system profile Bangladesh: Health services. 2012. http://www.searo.who. int/en/Section313/Section1515_6918.htm. (Accessed on 10 August 2011).

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APPENDICES
Phase 2
Strong commitment by key players Drug purchasing policies to meet NCD needs revised and refined

ANNEX 1. Phase 3 Phase 4


National health plans and budgets have been aligned with strategy

STRATEGIC FRAMEWORK FOR RESPONDING TO NCDS

Element

Phase 1

1. Building commitment and addressing health systems constraints System for keeping individual health records has been decided Human resources plan for health revised to cover prevention, diagnosis and delivery of good quality NCD models Sources for new finances identified through taxes; efficiencies as part of national health budgets National NCD plan for next five years and cost for delivery of core services refined Prevention strategy developed, partners identified Evaluation and accountability framework agreed at high level Strategy developed for legislation, taxation and regulation Strategy for mobilising community agreed Service delivery model developed for small-scale intervention for early diagnosis and treatment Lessons from Phase 1 and scale-up built on to expand coverage Business and industry engaged as partners in the community Implementation of population strategies begun

Broadened awareness of problem across government and community

Identified partnerspublic, private, academic, NGOs, CSO, externalto form alliances Elements of a national NCD plan agreed

Community is satisfied with services

Develop advocacy strategy and business case

Baseline data for population using STEPs or mini-STEPs approach

2. Public policy in population health promotion

Determine overall strategic approach inside and outside government

Community, business and industry are playing their role in national strategy

3. Service delivery models

High-risk populations identified by characteristics of gender, age, location, ethnicity

Treatment of NCDs fully integrated into mainstream primary health care services nationally and are sustainable

Health system preparedness for responding to the growing burden of

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NGO and community partners for service delivery identified

Training needs for pilot delivery identified

15

Element
Appropriate low cost services developed and piloted for highrisk groups with inequitable access or cost burden Appropriate financial support provided to those with financial barriers Expanded evidence base in place to support policy/decision making Longer term strategy involving key partners is agreed Prevention and treatment are covered for 75 per cent of high-risk population Service delivery is evaluated for affordability, accessibility and quality Forward plan is fully funded and staffed Prevalence is tracked and declining across all major population groups Patient satisfaction levels are measured Political will/leadership and advocacy are solid Community involvement is growing Baseline data are collected and used effectively Population prevention strategy ready for implementation Legislative/ regulatory program on track Pilot service delivery models ready for implementation, including reliable individual, human resources, diagnostic processes Measurement of equity of access and payments part of scale-up Ongoing monitoring of equity of access and payments

Phase 1

Phase 2

Phase 3

Phase 4

16

4. Ensuring equity in access and payments for services

Equity in access to and costs of prevention and treatment services examined for high-risk populations

Indicators

Key partners are on boardinside and outside government

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non-communicable disease a case study of Bangladesh

Health system preparedness for responding to the growing burden of

Key messages and advocacy case are clear

ANNEX 2. STAKEHOLDER ANALYSIS Target


NCDs A five-year (2011-2016) policy and programmatic framework. NCD is one of the five priority areas. Aim is to reduce morbidity and premature mortality due through actions at all levels from primary prevention to integrated treatment and rehabilitation. The plan provides guidance for surveillance of NCD risk factors to control and prevent emerging NCDs. It integrates NCD and communicable disease surveillance. Aims to develop and implement a coordinated program to control cancer. Activities include organising seminars, meetings and workshops related to tobacco; publishing books, training manuals, leaflets, posters and IEC materials to raise awareness among general population and health professionals. Core objectives are collecting epidemiological data, promoting surveillance, dissemination of collected information, facilitation of use of the data in prevention and control of NCDs. The network undertakes three key activities: periodical meetings of the members to exchange knowledge, information and experience; communication through web site and newsletter to establish further linkage inside the country as well as with regional and global organisations; and generation of information through hospital and community-based surveillance (MOHFW 2011a). It aims at generation of information through periodic community surveys on NCDs and their risk factors, particularly tobacco use, and initiation of population-based registries (MOHFW 2011a). Established in 1999 in response to aggressive marketing campaign of a transnational tobacco company. Major activities include training of public and NGO staff on tobacco control law and its implementation, arranging national level seminars such as World Tobacco Day and participating in international; workshops and seminars on tobacco control and submission of tobacco control legislation to government (MOHFW 2005; MOHFW 2009; MOHFW 2011a). Established in 1978, NICVD Hospital in Dhaka provides postgraduate and diploma courses on cardiovascular diseases for health professionals. It is the largest public tertiary care hospital and referral centre for CVD. NICVD educates through seminars and leaflets on prevention and control of NCD. Established in 1982, this is the countrys only tertiary centre engaged in multidisciplinary cancer management. It offers cancer treatment, education and research. It maintains a cancer registrya hospital-based surveyand provides secondary and tertiary care. Awareness-raising activities include organising World Cancer Day and limited prevention activities. NHFH&RI is the main project of the National Heart Foundation of Bangladesh. It primarily provides secondary and tertiary care to CVD patients. It runs a smoking cessation clinic that promotes health.

Program/Institution

Sector

Objective/Activities

Health Population and Nutrition Sector Development Program (HPNSDP) NCDs

Government

Strategic Plan of Surveillance and Prevention of Non-Communicable Diseases (2011-15) Cancer Tobacco control

Government

National Cancer Control Strategy and Plan of Action (2009-15)

Government

National Tobacco Control cell

Government

Bangladesh NCD Network

Government

NCDs

Alliance for Community-Based Surveillance of NCDs NCDs

Government

NCDs

Bangladesh Anti-Tobacco Alliance

Government

National Institute of Cardiovascular Disease (NICVD)

Government

CVD

Health system preparedness for responding to the growing burden of


Cancer, COPD CVD and hypertension

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National Institute of Cancer Research & Hospital (NICRH)

NGO/ National Organisation

National Heart Foundation Hospital & Research Institute (NHFH&RI)

NGO/ National Organisation

17

Program/Institution
TB and chest diseases NCDs Limited Est. in 1972, BRAC is a development organisation dedicated to alleviating poverty by empowering the poor to bring about change in their own lives. Currently it has limited activities in NCDs. Conducts home visits and provides health education to raise awareness. The program is limited to Dhaka city and carries out service delivery through community counsellors. Established in 1970, it works on raising awareness of harmful effect of smoking through seminars, symposia, meetings and processions, TV and radio programs. CCPR is involved in awareness raising, screening and early detection and research on cancer. It has a focus on breast cancer and maintains a cancer registry. Other area of interests are tobacco control and surveillance and prevention of major NCDs. The trust runs womens cancer and NCD screening program in two large urban slums in Dhaka. It provides health education on self-examination for oral and breast cancer. It carries out community awareness activities. Provides education and training to health care professionals on evidence-based care for patients suffering from respiratory diseases, particularly asthma and COPD. It is one of the major tertiary care hospitals for comprehensive care for cardiovascular diseases. It is a member of World Heart Federation, World Hypertension League and International Society of Hypertension. Mainly involved in awareness raising through publication of a quarterly newsletter Rydroug Barta, booklets, posters and educational materials and mass media. Organises a Heart Camp and observes special days related to NCDs such as World Hypertension day, World Salt Awareness Week and World Heart Day. It has 33 affiliates in Bangladesh. The Bangladesh Hypertension Committee of the National Heart Foundation of Bangladesh creates awareness by observing World Hypertension Day, public seminars, rallies, TV/radio etc. Cancer control program includes follow-up and rehabilitation of the treated cases, treatment of recurrent cases and relief of pain for patients with incurable cancers (palliative care). Evaluation of the program is necessary from time to time as per data provided by the Cancer Registry. Centre for Controlling Chronic Diseases has been established, which carries out population as well as hospital-based research on NCD. NIDCH is the only institute of Bangladesh that extends modern specialised medical and surgical treatment to complicated chest and TB patients and also offers training of medical manpower in tuberculosis and chest diseases.

Sector

Target

Objective/Activities

18
NCDs Tobacco Cancer Cancer Respiratory diseases CVD Hypertension Cancer

National Institute of Diseases of the Chest and Hospital (NIDCH )

NGO

ICDDR, B Bangladesh

NGO/ Research Institute

BRAC

NGO

Eminence

NGO

Adhunik

NGO

Centre for Cancer Prevention and Research (CCPR).

NGO

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Aga Khan Trust

NGO

Health system preparedness for responding to the growing burden of

International Primary Care Respiratory Group-Bangladesh (IPCRG-BD) & Better Breathing Bangladesh (BBB)

NGO

National Heart Foundation Hospital & Research Institute

Public-private partnerships

Bangladesh Hypertension Society, Hypertension Committee (a committee of National Heart Foundation)

Health professional associations

Bangladesh Cancer society

Health professional associations

Program/Institution
Asthma/ COPD Activities include treatment of asthma patients at the National Asthma Centre in Dhaka, registration and management following asthma guidelines, free nebulisation in acute asthma patients, awareness raising and education for /by patients and general public through video, films, group discussions, rallies, posters, observance of World Asthma Day etc, orientation training for doctors and nurses, research activities on asthma and COPD, editing and updating national asthma guidelines, and free medical camp for asthma patients. The only medical university and tertiary care hospital for NCDs in Bangladesh. No formal awareness raising activity is conducted on NCD. WHO provides technical support for controlling NCDs and risk factors. It helped in the development of several strategic plans such as National Strategic Plan for Prevention and Surveillance (2007-10 and 2011-15), National Cancer Control Plan, National Tobacco Control Plan. Supports the HPNSDP through SWAP mechanism. The World Bank approved US$359 million credit in 2011 for the Health Sector Development Program. It has published several research papers and books acknowledging the rising NCD burden in the country. A number of NCD-related projects are funded by the bank. The EC supports the HPNSDP (108,000,000) through contributions to a World Bankadministered pool-fund. BADAS provides clinical care and education on diabetes. It provides secondary and tertiary prevention and care and is involved in awareness-raising programs through media, seminars, distribution of materials, films. It offers clinical services for rheumatic fever and has a prevention program. It is involved in awareness raising through mass media, leaflets, posters, film production. It arranges seminars for community leaders, teachers and NGO staff on rheumatic fever. Provides clinical care for cancer and health messages for secondary prevention of cancers. Targets health care professionals, doctors and nurses to be involved in campaign against tobacco and raising awareness about health impact of tobacco use. Plays an advocacy role in reinforcing anti-tobacco policies and effectiveness of anti-tobacco programs.

Sector

Target

Objective/Activities

Asthma Association Bangladesh

Health professional associations

Bangabandhu Sheikh Mujib Medical University (BSMMU) NCDs

Academic

Treatment of NCDs

WHO Bangladesh

Development partners /INGOs

USAID NCDs

Development partners /INGOs

NCDs

World Bank

Development partners /INGOs NCDs Diabetes and CVD

European Union

Development partners /INGOs

Bangladesh Diabetic Somity/Diabetic Association of Bangladesh (BADAS) CVD

Public-private partnerships

National Centre for control of Rheumatic Fever Heart diseases (NCCRFHD) NCDs/cancer Tobacco control

Public-private partnerships

Delta Hospital

Private initiatives

Health system preparedness for responding to the growing burden of

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United Forum against Tobacco (UFAT)

Private initiatives

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ANNEX 3. BUILDING COMMITMENT AND ADDRESSING HEALTH SYSTEMS CONSTRAINTS Phase 2


Strong commitment to NCD problem by key players Drug purchasing policies to cover NCD needs and refined National health plans and budgets have been aligned with strategy

Health Policy and Health Finance Knowledge Hub WORKING PAPER 25

20
Phase 3 Phase 4
Currently strong commitment from the government. This is demonstrated by the strategic plans developed. However, unclear how resources will be mobilised for NCD control and treatment. Current budget is insufficient to address the current and projected need. Commitment from multilateral donors is limited. There is increasing interest in international development partners such as WHO, World Bank, EU, international NGOs. WHO is committed to provide technical support for controlling NCDs and risk factors. ICDDR,B is committed to research work. The Centre for Controlling Chronic Diseases has been established and is conducting a number of population as well as hospital-based studies. World Bank has published several research papers and books raising awareness of NCDs in the country. System for keeping individual health records Human resources plan for health to cover prevention, diagnosis and delivery of good quality NCD models revised Community is satisfied with services Drugs required for NCDs are limited on the national essential drugs policy, which the public health system follows. There is a need to refine the drug procurement policy. No. The current plan is an updated version of the earlier plan. Government needs to be advocated for timely addendum to the plan and eventually include NGOs, as well as efficient budget allocation. Currently some e-records exist with paperwork. System for individual health records is not in place. The MOHFW is conducting a project to assess the Health Information System (HIS) need of Bangladesh and develop a plan for future HIS. Records of immunisation of children, specific diseases like acute flaccid paralysis and TB are maintained at the PHC level. Diagnostic health records are kept in NGOs, private clinics for patients. General population individual health records are not kept. Plan for NCDs is not available. Prior assessment of NCD health demand and piloting of a model are needed to understand options for developing effective human resource plan. Premature and not yet in place.

Phase 1

Broadened awareness of problem across government and community

Baseline surveys/information on awareness raising were unavailable.

non-communicable disease a case study of Bangladesh

Several initiatives have been taken by government and non-government organisations.

Health system preparedness for responding to the growing burden of

The government has taken initiatives such as (1) signing the Framework Convention on Tobacco Control in 2004 and ratifying the Tobacco Control Act in 2005; (2) Inclusion of NCD in the HNPSSP 2007; (3) completion of national NCD risk factor survey; (4) integrating NCD and CD surveillance in the Strategic Plan of Surveillance and Prevention of NCD by the DGHS and approved by MOHFM; (5) endorsing national strategies such as National NCD Prevention and Surveillance, National Tobacco Control Strategy and National Cancer Strategy; (6) creating a new line director in DGHS on NCDs.

Identified partnerspublic, private, academic NGOs, CSOsto form alliances

Three alliances were found related to NCDs: Bangladesh NCD Network, Alliance for Community-Based Surveillance of NCDs, Bangladesh Anti-Tobacco Alliance.

Phase 1
Agree elements of a national NCD plan Sources for new finances through taxes, efficiencies as part of national health budget identified Not available

Phase 2

Phase 3

Phase 4

Develop advocacy strategy and business case

Most of the advocacy works of NGOs, international organisations, private organisations are limited to seminars and workshops.

Bangladesh is yet to develop a National NCD plan. However, the Strategic Plan for Surveillance and Prevention is timely updated and could serve as a major portion of a national plan.

No clear advocacy strategy for NCDs. Often advocacy is targeted to government.

Only one study funded by USAID, aimed at measuring the economic benefits of investing in health of workers. However, no research on business case is focused on NCDs National NCD plan for next five years and cost for delivery of core services refined

Baseline data for population using STEPS or miniSTEPs approach of WHO

Government initiatives include completion of the NCD risk factor survey (2010) and cancer registry done by NICRH in 2005 ( STEPS not used).

National Asthma Prevalence study in 1999 (STEPS not used).

Medical information system of DGHS has hospital-based morbidity data in health care facilities of all three levels.

A multi-site cross-sectional study is being carried out in nine rural HDSS sites using STEPS approach.

Strategic Plan for Surveillance and Prevention of NCD in Bangladesh (2011-15) has been endorsed. However, financial strategy and budget are missing. Financial strategy and budget plan are under the operational plan of DGHS.

Health system preparedness for responding to the growing burden of

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non-communicable disease a case study of Bangladesh

Womens cancer and NCD screening program using STEPS approach is in process. Results are not yet available.

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ANNEX 4. AWARENESS-RAISING INITIATIVES AT A GLANCE Diseases/risk factors in focus for awareness Tools for raising awareness
Seminars, symposia, meetings and processions, and radio and TV programs Seminars, workshops, observation of special days Health messages during health camps, newsletter, leaflets, seminars, observation of special days, rallies, periodicals, advocacy to government in seminars Diabetes messages both preventive and curative, media and mass media campaigns, observation of special days, arranging rallies, discussions, seminars, diabetes health magazine, classes, social events like childrens art competition 2007-2010 Training on diabetic nutrition, education session, web-based health messages Diabetes awareness camps Observation of special days, attending and arranging seminars Awareness building sessions General population and patients and family members of screening session 2011 Cancer-related messages to home, breast and mouth examination education, health information about diet, lifestyle and tobacco Women related to cancer and family members in two slums of Dhaka Health professionals All over the country

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Activity started or completed Target group and coverage
1970 Tobacco CVD and hypertension and their risk factors CVD, hypertension and their risk factors, especially tobacco (through UFAT) Health professionals, patients and family members attending health camps, government concerns Diabetes Patients and family members attending at hospital (Bangladesh Institution of Research on Diabetes, Endocrine and Metabolic Disorders and AAs outlets), health professionals and general population Health professionals and general population Diabetic nutrition Type 1 diabetes Cancer and its risk factors Cancer screening, awareness raising focuses on breast cancer Cancer and other NCDs

Program / Institution

Type

Adhunik

Voluntary anti-tobacco smoking organisation

National Institute of Cardiovascular Disease (NICVD):

Public, academic, tertiary facility

National Heart Foundation Hospital & Research Institute (NHFH&RI)

Public-private, tertiary

non-communicable disease a case study of Bangladesh

Health system preparedness for responding to the growing burden of

BADAS (Bangladesh Diabetic Somity/ Diabetic Association of Bangladesh)

Public-private, primary, secondary and tertiary

Improving Diabetes Nutrition Education Program

Improving nutrition education

Child Sponsorship Program in Bangladesh

Child health care programs

NICRH (National Institute of Cancer Research & Hospital).

Government, tertiary, academic

Centre for Cancer Prevention and Research (CCPR)

NGOs with technical support from WHO NICRH

Women Cancer and NCD Screening Program

NGO

Program / Institution
Tobacco 1999 Arranging anti-tobacco rallies, seminars, dissemination of leaflets, mandatory danger messages on cigarette packets, media advertising Information about causes, consequences, and prevention and treatment options of major NCDs in home visits General population in program area (one area of Dhaka city) General population and government

Type

Diseases/risk factors in focus for awareness Tools for raising awareness Target group and coverage

Activity started or completed

Bangladesh Anti-Tobacco Alliance

Alliance

EMINENCE, 2 programs: Communicable Diseases Program (NCDP) & Urban Health and Demographic Surveillance Program (UHDSP)

NGO

NCDs

Health system preparedness for responding to the growing burden of

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ANNEX 5. PUBLIC POLICY IN POPULATION HEALTH PROMOTION Phase 2


Prevention strategy developed, partners identified Prevention strategy has been identified and developed as part of the surveillance and prevention of NCDs. Partners have been identified for implementation. Some key partners are CBOs (Bangladesh Society of Radiation Oncology, BMA, OGSB, Pediatric Oncology Society, BNA, Bangladesh Cancer Society), public- private partnerships and development partners (World Bank, DFID, IDB, JICA, CIDA, SIDA, WHO, UNFPA and UNICEF). However there is lack of monitoring / evaluation reports which shows the effectiveness of the strategy and the role of the partners. Broad advocacy and research is needed to sensitise business and industries. Currently low engagement from business and industry. Not clear yet. Research is needed to understand how community, industry and business can be involved in population-based health promotion. Business and industry engaged as community partners Community, business and industry are playing their role in national strategy

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Phase 3 Phase 4
Agree evaluation and accountability framework An evaluation framework has been developed in the Strategic Plan for Surveillance and Prevention of NCD. But accountability issue has not been addressed in the framework. Develop strategy for legislation, taxation and regulation Strategy and legislation for tobacco control is in place. Over the period many legislative actions have been implemented. Taxes have been raised for tobacco-related products. Implementation of population strategies commenced Not in place. It would require lot of funds if both prevention and curative services are taken into consideration.

Phase 1

Determine overall strategic approach inside and outside government

Government strategy is mainly in the area of nutrition, infectious diseases, maternal and child health.

Government has endorsed the Strategic Plan for Surveillance and Prevention of NCDs in Bangladesh, of which health promotion is a component.

non-communicable disease a case study of Bangladesh

Key strategies include support and facilitation for development of public policy through promotion of healthy lifestyle, collaboration among stakeholders, partners; involvement of health professionals in health promotion; capacity building; improving community knowledge. However in practice not much is happening at the ground level.

Health system preparedness for responding to the growing burden of

Some external partners were assigned health promotion in the Strategic Plan for Surveillance and Prevention of Non-Communicable Diseases in Bangladesh 2007-10. However, no evaluation has been done on their activities. Further partners names have been excluded in the updated 2011-15 version.

Womens cancer and screening program is being undertaken by a national NGO.

NHFH&RI has a smoking cessation clinic promoting secondary prevention.

ANNEX 6. SERVICE DELIVERY MODEL Phase 2


Develop service delivery model for small-scale intervention for early diagnosis and treatment NCD service model NCD corners are currently being piloted in 3 UHCs. Service delivery model of BADAS is comprehensive (comprises components of primary, secondary and tertiary care) and based on cross-financing strategy that mobilises resources from richer to poor. Government plans to expand the NCD corners to 70 primary and secondary care facilities over time. Not much is published about the role and functions of the NCD corners. Lessons from Phase 1 and scaling up to expand coverage Treatment of NCDs fully integrated into mainstream primary health care services nationally and are sustainable Not yet. Before reaching this phase, the country is expected to examine service delivery models and undertake cost-benefit analysis.

Phase 1

Phase 3

Phase 4

Identify high-risk populations by key characteristics of gender, age, location and ethnicity

Risk factor survey has identified high-risk population by key characteristics

Identify NGO and community partners for service delivery

Community partners for service delivery have not been identified appropriately.

NGOs involve community partners on specific diseases and have limited activities on NCDs except awareness raising.

At PHC level, most of the NGOs, private and PPP organisations work on building awareness, providing training to health care providers and implementing pilot programs.

At the secondary and tertiary level, key role is played by NHFH&RI, Bangladesh Institution of Research on Diabetes, Endocrine and Metabolic Disorders and NICVD

Identify training needs for pilot delivery

Health system preparedness for responding to the growing burden of

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As part of Upzilla, NCD training is being given to health care providers.

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