By Tahmid Hasan

In Bangladesh, NCDs are estimated to account for 67% of all deaths. In low and middle-income countries, urbanization has been identified as one of the crucial underlying reasons for the increasing trends of NCDs. Bangladesh has also been experiencing rapid urbanization for the past two decades. The urban population of Bangladesh has increased exponentially, from 21.3 million in 1990 to 53.1 million in 2014, and it is expected to reach 112.4 million by 2050. Almost one-third of the urban population lives in densely populated slums with poor housing conditions. The socioeconomic and living conditions in these urban slums are very substandard, and in most cases, the residents do not have access to the basic amenities required for urban life. It puts them at the risk of contracting different types of communicable and non-communicable diseases. The need to focus on NCDs in the urban health care system increases when the growth of the urban population has been so rapid.

The majority of deaths from NCDs in Bangladesh can be attributed to cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases. Cardiovascular diseases account for the highest mortality rate among NCD patients in Bangladesh. Besides, most NCDs have associated risk factors that have significant health implications. Risk factors such as inadequate intake of fruits and vegetables, tobacco use, unhealthy diet, physical inactivity, obesity, sodium intake, and high blood pressure have been identified among urban adults in Bangladesh. According to Bangladesh NCD Risk Factor Survey 2018, most of the population has one or two risk factors, and a substantial proportion of the population has three or more risk factors.

The presence of NCDs among urban slum dwellers worsens their already poor-quality living standards. Due to high costs and significant out-of-pocket health expenditure, urban poor communities have limited access to good quality health care in Bangladesh. As such, the prevalence of NCDs puts many families in financial hardships and exacerbates their economic situation. Although Bangladesh has witnessed success in terms of providing equitable healthcare services for the rural population, healthcare for the urban poor remains highly inaccessible and inequitable. There has also been a lack of care towards Non-Communicable Diseases (NCD), specifically in the urban setting.

The rural poor now have better access to health services compared to the poor in urban settings. People in the rural areas can visit the community clinics in villages to get treatment for basic diseases and maternal health. Rural health complexes also now have dedicated NCD corners available, following the WHO recommendation to integrate NCD in to primary healthcare. These NCD corners provide prevention, screening, and treatment for common NCDs at the Upazila/sub-district level in its three-tiered Primary Health Care (PHC). There are still major gaps in the availability and accessibility of NCD services in the primary and secondary levels of the health system due to the scarcity of the government’s health budget.

However, health facilities like community clinics are largely absent for the urban poor. For availing of health care, they have the option to either go for expensive private facilities or neglected public hospitals. The existing provision of urban primary health care falls under the purview of the Ministry of Local Government, Rural Development and Co-operatives (MoLGRD), which aggravates the situation. Health is one of the many priorities of the MoLGRD, and NCD care remains mostly absent in the primary health care centres under their authority.

There are many national guidelines and protocols formulated by the government to improve the situation of NCDs, and NCDs appear in key government policy documents. However, in reality, there is a lack when it comes to the implementation of such protocols, especially at the primary care level of the urban health centres. Moreover, there is no mechanism of record-keeping and following up of NCD patients, and no formal referral pathway, causing a lack of standardized care for patients suffering from NCD across urban areas. In addition, there is a lack of digitalization of urban health data.

The Government certainly prioritizes NCDs and hence, it has adopted the multi-sector action plan for prevention and control of non-communicable diseases. It points out the key strategies and sets priorities for the primary stakeholders. It has been developed following the key strategic plans like the 8th Five-Year Plan, 4th Health, nutrition, and population strategic investment plan (HNPSIP), and other crucial legislation and guidelines. If the strategies pointed out in these documents can be implemented then Bangladesh will move a long way towards improving the NCDs care in urban settings. We must remember that the COVID-19 has had a serious impact on the lives of the urban poor. Most of them have seen a decline in their income levels. Besides economic issues, COVID-19 put the fragile health conditions of the urban poor at further risk. As COVID unfolded, it exposed our longstanding weaknesses in the health sector. However, while it exposed the lacking of health centers in providing basic health care, it has also left some room to utilize this experience and improve the existing situation. With a constantly growing urban population, we must focus on the improvement of the care of NCDs and follow the existing guidelines to mitigate the associated risk factors. The government needs to focus on further research to generate evidence-based decisions to strengthen the urban health systems and ensure healthy environments to facilitate behavioural change.

Tahmid Hasan is a Research and Communications Officer at the ARK Foundation. He can be reached at tahmid@arkfoundationbd.org

Cigarette price increases are more effective in reducing cigarette demand among poorer people.  A recently conducted research study finds that the demand for cigarette responds less than proportionately to changes in cigarette price. Moreover, the study finds that an increase in cigarette price by 10 percent results in a 9 percent decrease of cigarette demand among poorer people compared to 3.9 percent among wealthier people. The findings came up in a recently conducted research study by ARK Foundation, Bangladesh and Tobacconomics based at the University of Illinois, Chicago.

A workshop was organized by ARK Foundation in collaboration with the Tobacconomics on  January 12, 2022 to share findings from two recently conducted research studies as a part of their commitment to accelerate progress on tobacco taxes in Low- and Middle-Income Countries. Bangladesh has one of the largest populations of tobacco users in the world. According to the Global Adult Tobacco Survey (GATS) 2017, overall cigarette smoking prevalence is 14 percent among adults and 28.7 percent among men.

SM Abdullah, Associate Professor of Economics at the University of Dhaka and researcher at the ARK Foundation, presented a paper which focused on the estimation of cigarette demand responsiveness against price using GATS 2009 and 2017 data. While sharing the research findings he said that a ten percent increase in the price of cigarettes would reduce overall cigarette smoking among people by 7.1 percent.

He also said that increasing the price of cigarettes reduces smoking participation and encourages smokers to smoke less. He suggested the government to introduce specific tax on cigarette and increase the price substantially to reduce cigarette smoking prevalence in Bangladesh. He also suggested adjusting the prices of cigarettes annually for inflation and income growth to reduce the affordability of cigarettes.

Another paper was presented in the event by Md. Nazmul Hossain, Assistant Professor of Economics at the University of Dhaka and researcher at the ARK Foundation. He said that Bangladesh has a very complicated multi-tiered cigarette tax structure which has made tobacco tax a less effective instrument to control cigarette smoking. “The significantly lower price, together with a lower excise tax for low-tier cigarettes, created a window of opportunity for the manufacturers to expand low tier cigarette market which resulted in lower tax revenues for the government”, he made the remark while sharing his research findings.

The research shows that the introduction of a new low-tier cigarette in FY 2019-20 has caused a significant revenue loss of 273.5 crore taka for the government. The research also finds that had the government imposed a policy combining an increase in the base price of low-tier cigarettes from 37 to 45 taka along with uniform ad valorem excise tax rate of 65% for all tiers, the government tax revenue would have been 1958.4 crore taka higher than the actual tax revenue in FY 2019-20. Mr. Nazmul strongly suggested increasing the base price along with an increase in the excise tax rate for low-tier cigarettes.

Professor Dr Rumana Huque, Executive Director, ARK Foundation led the research team in conducting these two studies. She said that, Bangladesh primarily needs to design and implement a specific tax structure to reduce the use of tobacco. She suggested increasing the price of cigarette so that it becomes unaffordable for the general people and also recommended stopping the purchase and sale of single stick cigarettes to reduce its consumption. “To dream of a tobacco free country by 2041 as per Prime Minister’s vision, we need to design and implement an effective tobacco tax policy as soon as possible” said Professor Rumana.

Dr Nasiruddin Ahmed, Former NBR Chairman, who was present in the workshop, said that the government’s share in the tobacco companies allows the tobacco industry to continously interfere in the policy making process. He called for collective action from all concerned stakeholders and recommended building up a national movement to reduce tobacco usage.

Dr. Sohel Reza Choudhury, Professor & Chairman, Department of Epidemiology & Research at the National Heart Foundation Hospital and Research Institute said that effective taxation is the most effective instrument in controlling tobacco. He applauded the conducted research studies and said that the findings would be extremely helpful in designing policies to reduce cigarette smoking among people.

Mr. Mostafizur Rahman, Lead Policy Advisor, Campaign for Tobacco Free Kids (CTFK-Bangladesh) focused on the importance of increasing cigarette prices and excise duties to reduce smoking prevalence in Bangladesh. He suggested creating widespread awareness about the harmful effects of cigarette smoking. He said that the findings generated from the studies would be helpful in forwarding advocacy campaigns against tobacco use.

Advocate Syed Mahbubul Alam Tahin, Secretary, Center for Law and Policy Affairs, said that the tobacco companies spread misinformation whenever there is a talk about increasing tobacco taxes. He also said that the companies use external as well as internal influence to interfere in the government decision making system. As a result, the government fails to devise effective strategies to control tobacco. He suggested bringing changes in the existing tax policies and recommended strong implementation of the tax laws to reduce cigarette smoking and tobacco usage.

The event was also joined by development workers, tobacco control advocates, academicians, students, policy makers, and media outlets.

Media Coverage:

https://www.tbsnews.net/bangladesh/health/10-increase-price-cigarettes-reduce-cigarette-smoking-71-356545

https://www.bd-pratidin.com/life/2022/01/13/730461?fbclid=IwAR3o8kVz7KghEj75iA9qaoMKi2dVJf7HeYx-mAckFwU4aSGar4WzUJ7XI5I