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

Multiple news media covered our webinar titled “Health System Response to COVID-19: Learning Across Bangladesh and Vietnam” held on 30 June 2020.

Below are the names of the news media. Interested readers, just click on the name to read the news:

English News:

Bengali News:

This was initially published in the Daily Star – a leading Newspaper in Bangladesh.

Main Article

The spread of Covid-19 has critically exposed the long-standing weaknesses of Bangladesh’s health system. This is not surprising, as the health sector had always remained neglected in the government’s priorities. In the fiscal year 2019/20, the Ministry of Health and Family Welfare (MOHFW) was allocated 4.9 percent of the national budget, which is one of the lowest in South Asia. Out-of-pocket health expenditure—which is directly paid by a patient during service use and not reimbursed by any insurance coverage—is still very high in Bangladesh (74 percent of current health expenditure in 2017) compared to the global average (18 percent) and many neighbouring countries (62 percent in India, 58 percent in Nepal, and 50 percent in Sri Lanka). Some might argue that, despite spending only 0.9 percent of Gross Domestic Product (GDP) on health, our health indicators are better than many developing countries. However, this is the time to realise that all low hanging fruits in the health sector have been consumed through improved child immunisation, maternal health care and basic curative care. The government now needs to take measures to restructure the health system to cater to the health needs of our large population.

The health sector definitely needs additional budget expenditure, but unfortunately, only increasing budgetary allocation can never solve its problems. More emphasis has to be given on how the MOHFW can use the budget efficiently, especially since the government itself has announced the Health Ministry will not see a significant rise in allocation in the upcoming budget due to its lack of capacity to utilise funds. The current health budget is allocated based on the number of beds and staff in salaried posts. The Ministry needs to critically think of how to change this incremental, norm based allocation system to a “needs-based” allocation model. The first step is to assess the population health needs of districts based on size of the population, their demographic status, disease pattern, and service utilisation—and allocate resources according to “need”.

Bangladesh has an extensive network of government hospitals at community, upazila and district levels. Every year, a large proportion of the budget is spent on infrastructure development and procurement of equipment. However, according to the Bangladesh Health Facility Survey 2017, only 28 percent of health facilities have all six basic equipment—a stethoscope, thermometer, blood pressure apparatus, adult scale, child or infant scale, and light source—while 80 percent of Upazila (sub-district) Health Complexes do not have functioning x-ray machines. It is therefore not surprising that these public hospitals are not equipped with oxygen and ventilators, which have been crucial for Covid management. This needs the immediate attention of policymakers. There should have been systems in place to assess the need of equipment at hospitals at different levels, functionality of the equipment, and requirements for repair and maintenance. There needs to be district level planning for this, with budgetary allocation and capacity development of district and sub-district hospitals.

Severe shortages in the workforce is another core issue in our health system that requires immediate attention. For every 1,581 people, there is only one physician—in a country with a population of over 164 million. The number of medical technologists working under the Directorate General of Health Services (DGHS) per 10,000 populations is 0.32, and the number of community and domiciliary health workers is 2.13 per 10,000, according to the 2018 Bangladesh Health Bulletin. The MOHFW lacks all types of health professionals including medical technologists, nurses and other support staff, such as cleaners, who have all been providing crucial services during the pandemic. The shortage of the health workforce with non-functioning equipment has always been a challenge for providing quality care at government facilities. During this pandemic, where people of all ages are affected, hospitals under the MOHFW faced difficulties in providing required services with reasonable quality.

Some other functions have also received less attention. There is little emergency care in public facilities, and services are provided for limited hours at the upazila and district levels. Where will a pregnant woman in a rural area go if she has complications in the middle of the night, or if someone has a heart attack? There is no population health status monitoring, which is the bedrock of any effective public health programme. Although certain issues have been repeatedly mentioned in multiple health sector plans or programme reviews—such as institutional focus on developing mental health services and an increased focus on urban population health—they have been followed by limited investment. Urban health is another critical sector that requires attention in the new budget. Since provisions for primary healthcare for urban populations is under the ambit of the Ministry of Local Government, Rural Development and Cooperatives (LGD), the lack of coordination between the Health and LGD ministries is a challenge that needs overcoming.

It Is hight time for the Health Ministry to focus on public health under the guidance of experts. The MOHFW can negotiate with the Ministry of Public Administration and Ministry of Finance to approve the required number of “posts” at different levels within the health system and recruit public health professionals and other support staff urgently. Leadership on developing a comprehensive approach to issues of public and population health with appropriate accountability is urgent. We can then place related public health functions in groups—such as water and sanitation and waste management, and the concerned in-charges can coordinate their policies according to a comprehensive plan to address public health issues.

The private-for-profit sector plays a crucial role in healthcare, especially in urban areas. However, the role of the private sector was disappointing during the beginning of the outbreak in Bangladesh—a huge number of private hospitals refused to admit patients out of fear of coronavirus, denying care to both Covid and non-Covid patients. It is important now to clarify the role of the private sector, and hold private for-profit hospitals to account. A coordinated approach is required to ensure that the private sector plays an effective and complementary role during such emergencies. The MOHFW should develop their capacity to monitor private sector hospitals, and should consider this as a priority, and coordinate with respective ministries for proper implementation of accreditation and licensing of private-for-profit providers.

The Bangladesh government has announced incentive packages of Tk 100 crore for government physicians, nurses and health workers treating Covid-19 patients, and Tk 750 crore for health and life insurance for those affected while on duty. In the new fiscal year, there needs to be transparent mechanisms for the disbursement of these funds to beneficiaries. In addition, comprehensive Covid-19 management through long-term, sustainable investments should be reflected in the new budget.

Due to various favourable factors, such as a large number of the young population, relatively less urbanisation and varying disease patterns, the Bangladesh health sector has had certain remarkable achievements in the last two decades. However, growing urbanisation and an increasing number of the elderly population, combined with the dual burden of communicable and non-communicable disease, will create huge pressures on the health system in future. Considering these factors, the government should definitely prioritise the health sector in the development agenda, gradually increasing the budget for the health sector up to five percent of GDP in the next three years, and developing the capacity of the MOHFW to plan and implement the budget efficiently.

Dr Rumana Huque is Professor at the Department of Economics, University of Dhaka and the Executive Director of ARK Foundation.

In Bangladesh, every year, more than 350,000 people are affected by Tuberculosis (TB), and more than 70,000 people die due to the same. 20% of the deaths are attributed to tobacco. These toll of death can easily be avoided by collecting information and counselling on tobacco use among TB patients by the TB care providers. The information was revealed in a study conducted by ARK Foundation.

A dissemination seminar titled as ‘Tobacco cessation within TB Programme’ on the TB & Tobacco project was organized at a hotel in the capital city on 6th October 2019. Md. Saidur Rahman, Additional Secretary (World Health) of the Health Services Division of the Ministry of Health and Family Welfare was the chief guest of the event. Prof. Dr Shamiul Islam, Line Director, National Tuberculosis Control Program and Prof. Dr Shah Monir Hossain were the special guests of the seminar. The findings of the study were presented by the Executive Director of ARK Foundation, Dr Rumana Huque.

In this study funded by the European Union, it was further revealed, that 18% of the TB patients are smokers. At least one in every three male patients smoke. The risk of death among TB patients who are smokers increases two-fold. A brief counselling session provided by the healthcare provider can play a vital role in helping patients quit smoking. This kind of support for tobacco cessation can annually help 14,000 TB patients to quit tobacco.

Prof. Rumana Huque mentioned, taking the initiative to integrate the information collected on tobacco use, reporting and counselling, is of extreme importance.

Within this study, ARK foundation has trained healthcare providers of 4 districts, to hone their skills in counselling patients for tobacco cessation. Later, 28% of the TB patients and 40% of males were identified as smokers. The trained healthcare workers were successful in providing counselling and supporting these patients to quit smoking. This proves that, for patients to quit tobacco, providing support through a brief counselling session, is effective and feasible on a large scale.

Through the provision of straightforward simple training to the healthcare providers, it is possible to support patients quit tobacco, and this will cost the government only 65 BDT per month.

In his speech, Chief Guest Md. Saidur Rahman mentioned, “Quitting tobacco use must be made mandatory for those who attended the DOTS centre for treatment. It is possible to help patients quit tobacco during their treatment period of six months. Today, from here, we should make a decision that we will begin a support programme to help TB patients stop smoking and quit tobacco.”  He mentioned, “All TB patients should be free from tobacco use. This programme must be made compulsory in all hospitals providing treatment for TB”.

The Line Director of the National TB Control Programme, Dr Shamiul Islam stated, “The government has committed to making the country TB free by 2035 and tobacco-free by 2040. For this commitment to be fulfilled, integrating tobacco control within TB treatment, and incorporating information on tobacco use, and helping patients to quit tobacco, is extremely important. For this reason, it is necessary to enhance the skills of healthcare providers and maintain their professional safety.”

Prof. Dr Shah Monir stated, “For the treatment of TB patients who use tobacco, collecting information on their use of tobacco and quitting the same, coupled with counselling which is easy for them to understand, is very important.

The integration of this arrangement is not only possible for TB patients but in other sectors of health is as well.

As a consequence, this will not only help in the development of evidence-based policies and management to control the disease, but it’ll also help to improve the condition of the patients and reduce the death rates due to TB.

The seminar was also attended by Honourable Former Joint Secretary Md. Ruhul Kuddus,  Dr Golam Mohiuddin Faruque from the Cancer Society, Dr Sohel Reza Chowdhury from the National Heart Foundation, Syedul Mahbubul Alam, Technical Advisor of The Union, and renowned clinician Dr M. S. Choudhury Lelin.

Few newspapers in the country reported abou this event which can be found as follows:

Dr. Rumana Huque, Professor, Department of Economics, University of Dhaka and Executive Director, ARK Foundation, moderated a panel discussion on “Sustainable Health Financing ” yesterday, in International Conference for Economists organized jointly by Bureau of Economic Research and Department of Economics, University of Dhaka.

Among the panelists were Professor Sushil Ranjan Howlader, Founder Director of Institute of Health Economics (IHE), University of Dhaka, Dr. Shakil Ahmed, Senior Economist (Health), The World Bank, and Md. Ashadul Islam, Secretary, Health Services Division, Ministry of Health and Family Welfare. Professor Syed Abdul Hamid, IHE, DU presented the key note paper.

The event was also covered in a leading newspaper of the country:

Newspaper Coverage

Two of the researchers from ARK Foundation, Fariza Fieroze and Zunayed Al Azdi, joined the Global Conference on Implementation Science and Scale-up, 2019 to present their research work in front of the researchers and implementers from all over the world. The conference was held at Radisson Blu, Dhaka from June 29 to July 1, 2019, organised by BRAC James P Grant of School Health, BRAC University and UNICEF.

Fariza Fieroze, Research Associate, presented a paper titled ‘ Urban day-care for improved health and social outcomes: research to understand demand and implementation of day-care in Dhaka’. This research sought to understand the demand for day-care and the challenges of implementing a day-care model to improve health and ECD among under-5 children from Dhaka’s urban poor. Researchers used a sequential mixed methods design, including participatory action research (PAR) to understand how to implement day-care in the urban context.

The team found a great need for day-care among vulnerable families. Our survey found 71% [95% CI: 56, 83] of respondents living in ‘slum’ (UNHabitat definition) households needed daycare compared to 44% [95% CI: 24, 67] non-slum (AOR 3.5 [95% CI: 1.6, 7.6]). Qualitative findings confirmed women’s need for long day-care, current lack of provision and concerns for children’s safety. PAR highlighted implementation issues:
i) building trust in the community, ii) providing food, iii) role of Madrassa schools, iv) the need for a curriculum to strengthen ECD and v) sustainability.

Zunayed Al Azdi, Research Associate and Uptake Manager, presented a poster titled ‘Muslims for Better Health: Developing a smoke-free home intervention for delivery in mosques’ in the conference. The poster was to show the methodologies, strategies and ideas that helped develop an intervention to be delivered by the religious leaders to change smoking behaviour of people inside their homes. This intervention is the first of its kind in the country that targets second-hand smoking (SHS).

The intervention components were targeted to improve knowledge, develop a positive attitude, encourage motivation, enhance confidence and increase peoples’ intention to act on quitting smoking at homes. The findings of the study have the potential to influence policy and practice on tobacco control, particularly SHS exposure, in Bangladesh.

To see the poster along with the full abstract, please click on the link below:

Poster and Abstract

For more information, you can communicate with the presenters via the following e-mail address:

fariza@arkfoundationbd.org

azdi@arkfoundationbd.org