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 [email protected]

Antibiotic resistance (ABR) arises when bacteria develop resistance to antibiotics. In other words, antibiotics are ineffective against them. It is a common myth that people or animals develop resistance to antibiotics, whereas, in reality, it is germs that become resistant antibiotics.

Vector illustration of superbugs.No gradients used. CMYK. Objects grouped for easy editing. Created with AI CS3.

When AMR becomes dominant in the health sphere of our daily life, it will pose a grave danger to the very existence of human and animal health. It is pervasive for us-humans and our domestic and wildlife animals to get sick due to different bacterial attacks and infections.

According to the UK Government-commissioned Review on Antimicrobial Resistance, by 2050, AMR might kill 10 million people each year. In 2019, an estimated 4.95 million fatalities were linked to bacterial AMR, and AMR caused an estimated 1.27 million deaths. The World Health Organization (WHO) has also raised its concerns about AMR, claiming that it might be the most serious threat to global human health and food security in the upcoming days.

To address this alarming issue, especially in the low-resource settings where community people have unrestricted accessibility to over-the-counter (OTC) antibiotics and have little or no knowledge regarding antimicrobial resistance, expansive community engagement is required.

ARK Foundation along with the University of Leeds has launched a new project titled “Community Solutions to Antimicrobial Resistance (COSTAR)” to address the alarming issue of AMR in Bangladesh. An online launching event was organized on March 13, 2022 to inaugurate the project. COSTAR, a joint initiative by the University of Leeds, ARK Foundation Bangladesh, HERD International Nepal, Chittagong Veterinary University (Bangladesh), Malaria Consortium, University of Liverpool, and the University of Western Australia, is being implemented in Bangladesh and Nepal. The project is being implemented with the support of UK Research and Innovation GCRF collective fund.

The aim of this project is to engage community through participatory approaches to tackle AMR.   The project has several interventions planned to exercise at the community level in Bangladesh and Nepal. The main component of the project is Community Dialogue Approach (CDA) which will be implemented based on two previously funded studies. to them.

Professor Rumana Haque, PhD, Executive Director of the ARK Foundation said in her welcome speech that Antimicrobial Resistance is a growing threat to both human and animal health. The irrational use of antibiotics among humans and animals further worsens the situation. Stressing on the economic impact of AMR, she mentioned a recent study that finds that Bangladesh can face almost BDT 788 thousand crores decrease in GDP by 2050 if AMR is not curbed now. She said that the COSTAR project would prevent antimicrobial resistance in Bangladesh through community dialogue approach (CDA) interventions.

Dr. A H M Enayet Hussain, Director General of Directorate General of Medical Education (DGME) Ministry of Health and Family Welfare, chaired the session. He expressed concerns over the misuse of antibiotics in Bangladesh and urged immediate multisectoral collaboration to tackle the growing antimicrobial resistance in Bangladesh

Dr. Khaleda Islam, Surveillance Lead of AMR Control Program, Fleming Fund, said that it is very important to trace the drivers and factors behind the irrational use of antibiotics at the household level and the decision-maker of using them. Dr. Tahmina Shirin, Director, Institute of Epidemiology, Disease Control and Researchstated that the trend of AMR is constantly rising all over the country for the past five years. The current data suggest that the AMR is rising not only in the hospitals but also in the communities. Motivating community people alone will not enable us to get rid of this problem. We need  revised and regulations to address the irrational use of antibiotic.  She stressed on the importance of increasing country wide effective surveillance mechanism in hospitals to address AMR.

Dr Abul Kalam from USAID addressed the importance of community engagement to solve issues like antibiotic resistance. He acknowledged the community involvement in achieving the country’s freedom in 1971 and said that community engagement has always been a great tool to Bangladesh’s armory. He hoped that COSTAR through its community engagement approach will succeed in tackling AMR in Bangladesh.

Dr. Nitish C Debnath, Country Lead, Fleming Fund, appreciated the multidisciplinary approach of the COSTAR project and hoped that this project will enable the researchers to generate better information.

Dr. Rebecca King, Principal Investigator of the COSTAR project said in her video message that COSTAR will  address the drivers of AMR in Bangladesh and globally in order to help protect antimicrobials and prevent deaths from preventable diseases for future generations.

Dr. Tim Ensor, Professor, University of Leeds, mentioned about the lack of evidence to design interventions to reduce the harmful consequences of AMR. The COSTAR project aims to understand what types of interventions through community engagement might help to address the health and the economic consequences of resistance.

All of the guests, the chair, and the chief guest applauded the initiative in the country and expressed that this project has the potential to become an impeccable example to follow for low-resource settings in the country.

Written by: Badruddin Saify, Research Assistant, ARK Foundation

News Links:

1. https://www.tbsnews.net/economy/corporates/ark-foundation-launches-costar-address-antimicrobial-resistance-384628
2. https://bangladeshpost.net/posts/concern-over-inefficacy-of-antimicrobials-in-bangladesh-81651
3. https://sharebiz.net/%E0%A6%85%E0%A7%8D%E0%A6%AF%E0%A6%BE%E0%A6%A8%E0%A7%8D%E0%A6%9F%E0%A6%BF%E0%A6%AE%E0%A6%BE%E0%A6%87%E0%A6%95%E0%A7%8D%E0%A6%B0%E0%A7%8B%E0%A6%AC%E0%A6%BF%E0%A7%9F%E0%A6%BE%E0%A6%B2%E0%A7%87%E0%A6%B0/

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

With 37.8 million adults consuming tobacco products, Bangladesh has one of the largest populations of tobacco users in the world. Although the overall prevalence of tobacco use among adults declined from 43.3 percent to 35.3 percent from 2009 to 2017, the overall prevalence of cigarette smoking is still very high and did not change at all over the period (GATS, 2017). According to the Global Adult Tobacco Survey (GATS) 2017, overall cigarette smoking prevalence is 14 percent among adults and 28.7 percent among men.

The high prevalence of tobacco use and cigarette smoking remains a major health concern for Bangladesh. As a part of its continuous effort to generate effective knowledge and evidence for advocating better tobacco policies, ARK Foundation, Bangladesh with the support of the Tobacco Control Capacity Programme (TCCP) organized a stakeholder engagement meeting to share research findings and gather further insights from the various stakeholders on the main research themes of the TCCP: Illicit trade in Tobacco for Bangladesh and Implementation of Article 5.3 of the Framework Convention on Tobacco Control (FCTC).

The workshop was helpful in circulating the recent evidences on the aforementioned issues and discussing possible interventions to reduce the illicit trade of such products. The workshop was attended by policymakers, health experts, development workers, academicians, policy advocates, and youths. They emphasized the importance of implementing evidence-based policies to reduce the prevalence of illicit trade and called for greater cooperation among all stakeholders to tackle industry interference in Bangladesh. The participants called for strengthened cooperation among all stakeholders and recommended stronger implementation of policies to achieve tobacco-free Bangladesh by 2041.

২৬ ডিসেম্বর আর্ক ফাউন্ডেশন নিম্ন এবংমধ্যম আয়ের দেশগুলোতে তামাকজনিত ক্ষতি কমানোর লক্ষ্যে গবেষণা সক্ষমতা বৃদ্ধি বিষয়ে একটি অংশীজন মতবিনিময় সভার আয়োজন করে। যুক্তরাজ্যের গ্লোবাল চ্যালেঞ্জস রিসার্চ ফান্ডের টোব্যাকো কন্ট্রোল ক্যাপাসিটি প্রোগ্রামের তত্ত্বাবধানে এই সভার আয়োজন করা হয়।

অধ্যাপক রুমানা হক তামাক কোম্পানীর অবৈধ হস্তক্ষেপ বিষয়ে তাঁর প্রবন্ধে বলেন, গবেষণায় অংশগ্রহণ করা অধিকাংশ মানুষ মনে করেন যে তামাক কোম্পানিতে সরকারের শেয়ার থাকা তামাক নিয়ন্ত্রণে বড় বাঁধা হয়ে দাঁড়াচ্ছে।

তিনি বলেন, বাংলাদেশে তামাক নিয়ন্ত্রণ করতে হলে আর্টিকেল ৫.৩ এর অতি দ্রুত বাস্তবায়ন প্রয়োজন এবং একই সাথে বাস্তবায়নকারী সংস্থার সক্ষমতা বাড়ানো প্রয়োজন সভায় অবৈধভাবে সিগারেট উৎপাদন এবং বিক্রি বিষয়ে আরো একটি গবেষণা প্রবন্ধ উপস্থাপন করেন ঢাকা বিশ্ববিদ্যালয় অর্থনীতি বিভাগের সহযোগী অধ্যাপক এবং আর্ক ফাউন্ডেশনের গবেষক এস এম আব্দুল্লাহ।

অনুষ্ঠানে বিশেষজ্ঞ আলোচক হিসেবে উপস্থিত ছিলেন জাতীয় রাজস্ব বোর্ডের সাবেক চেয়ারম্যান ডঃ নাসির উদ্দিন আহমেদ, স্বাস্থ্য অর্থনীতি ইউনিটের পরিচালক (গবেষণা) ড. মো. নুরুল আমিন ও সেন্টার ফর ল এন্ড পলিসি আফেয়ার্সের সেক্রেটারি এডভোকেট সৈয়দ মাহবুবুল আলম তাহিন।

Rumana Huque | Published:  August 26, 2021 21:17:50

Bangladesh is currently the eighth-largest tobacco market in the world. Cigarette production is increasing at a rate of 2 per cent per annum. Bangladesh is one of the largest tobacco consumers in the world with 37.8 million adults aged 15 years and above. It means about 35.3 per cent of the country’s population is consuming tobacco products, according to the Global Adult Tobacco Survey (GATS) 2017.

However, there is a lack of proper monitoring and evaluation in terms of regulating the tobacco industry. The tax structure for tobacco products is also riddled with loopholes. In this context, it is extremely crucial to shed light on the policy lapses in the tobacco industry. The revision of the existing policies and proper enforcement of the policies can bring the tobacco market under control.

REDEFINING TOBACCO TAXATION MECHANISMS:

The taxation mechanism of all types of tobacco products highly matters as it influences the prices of the tobacco products in the market which has implications on public health and government revenue. In Bangladesh, there exists a very complex multi-tiered ad valorem tobacco -tax system. The price of cigarettes is determined according to four-tier cigarettes categorised by the government — premium, high, medium, and low. The tax base and rates vary based on the tiers.  Unfortunately, this differential tax mechanism fails to keep the tobacco market in check as it opens opportunities for product substitution, that is, a person can easily switch from a high or medium-tier cigarette to a low one since the price does not increase similarly across all tiers of the cigarette.

Currently, the retail price that the consumers have to pay to buy cigarettes in Bangladesh is much lower compared to many developing countries. Historically, the tax base of tobacco products in the country has been very low. This is especially true in the case of the low-tier cigarettes and smokeless tobacco products (SLT) such as zarda and gul. The current market structure of cigarettes reveals that around 84 per cent of the total cigarettes supplied in the country comes from the “Medium” and “Low” price slab and the rest 16 per cent is attributed to “High” and “Premium” price slabs. However, there has not been any change in the proposed price (BDT 39) and supplementary duty (SD) of the low-tier cigarette (57 per cent of MRP) in the proposed budget for the year 2021/22. The price and SD of the medium-tier cigarettes also remains the same as last year.

Though the prices of high and premium-tier cigarettes have been increased marginally, there is no change in the SD (65 per cent) compared to last year. This will have a limited impact on the consumption of expensive cigarettes. The prices and tax rates of biri, zarda, and gul have also not been changed in the proposed budget. Such a situation does not do much to dissuade consumers from the consumption of tobacco products. The taxation proposed in the budget will not reduce consumption of low and medium-tier cigarettes as no price and tax change have been essentially proposed. It also keeps the option open for high and premium-tier cigarette consumers to easily switch on to a medium or low-tier cigarette. And when consumers switch to cheaper brands in such a manner, the government also loses high levels of revenue.

Sometimes, the tobacco companies use this tier system to evade taxes. For example, a tobacco company can easily shut down a brand of a medium-tired cigarette and release a similar product under a different brand name in low tier by just changing the price marginally so they have to pay lower taxes. Many tobacco companies are evading taxes by taking advantage of the multi-tiered taxation system and lack of proper monitoring by the government.

NECESSITY OF STRINGENT GOVERNMENT POLICIES:

The government of Bangladesh has its share in a multi-national tobacco company and a number of government officials hold positions on the board of the company. This poses a clear conflict of interest. It also violates the WHO Framework Convention on Tobacco Control of which Bangladesh is a signatory. After the independence of Bangladesh, there were plans to nationalise the big industries which resulted in acquiring shares in the cigarette company. But since no such plans exist now, there is no point in having a share or government presence in tobacco companies.  If we want to impose stricter taxation on tobacco products, there is no alternative to curbing the influence of the tobacco industry on the government. They must stop consulting the tobacco industry about tobacco leaf pricing, divest its shares in the tobacco industry, and ban all forms of tobacco-related CSR programmes. The honourable prime minister of Bangladesh has set a goal that Bangladesh will be tobacco-free by 2040. The government has also started to levy a 1 per cent health development surcharge (HDE) on all tobacco products. The government is committed to reaching that goal but they need to do more.

It is of absolute importance that the government move towards a uniform specific tax structure and reduce the number of tax tiers. This simplifies the tobacco tax-system and makes it easy to administer. With a specific tax system, a regular increase in the price of tobacco will reduce consumption and generate high revenues. The consumption of tobacco cannot be controlled without significantly increasing prices of all types of cigarettes and other SLTs. The government should digitise the monitoring system by adopting unique identifiers (i.e.: barcodes) on the cigarettes and also provide adequate training to the personnel involved in the monitoring. These steps can play a crucial role in reducing tax evasion by companies. Similarly, there should be strict regulation and monitoring of  Biri and SLT products so they can’t evade taxes. Besides, the relevant authorities should also strictly monitor advertising strategies that tobacco companies undertake in the name of CSR activities.

Tobacco cultivation also poses a serious threat to the environment and causes serious diseases to the farmers. But the good thing is that the government of Bangladesh has drafted a tobacco cultivation control policy to limit tobacco farming. The policy targets to increase the production of food crops and dissuade them from tobacco farming. They plan to do so by giving them easy loans and incentives for fertiliser, seeds, and other farm inputs and equipment so that transition can be done easily to the cultivation of other types of crops.

CRAFTING SMARTER ANTI-SMOKING CAMPAIGNS:

Although the tobacco industry cannot market its products openly in any form of media due to existing tobacco laws, they have found smarter ways to promote or encourage smoking. We can often see characters in the movies and television shows smoking. It results in encouraging young people to indulge in cigarette smoking. The anti-smoking awareness programmes in the country are very traditional and mostly limited to human chains, rallies, and webinars. There are pictorial warnings about health hazards in the cigarette box. But it does not help much since it is allowed to buy single sticks and most people do not buy whole boxes. As such, they do not come across the warnings. The organisers of the awareness programmes and campaigns need to rethink their approach to combat these issues. Advocacy campaigns should be conducted to discourage filmmakers from showing smoking onscreen. To build national consensus regarding the harmful effects of smoking, social media platforms should be widely and smartly used. Youth idols can be engaged in making people aware of the deadly consequences of smoking. There should also be programmes to assist smokers to break free from their addiction. They should also make the most use of social media to amplify their message.

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

[email protected]

Originally Published in The Financial Express Bangladesh

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.

Health systems in both developed and developing countries are now struggling to respond to the challenges posed by COVID-19. Ministry of Health and Family Welfare (MOHFW), Bangladesh has already taken several immediate actions to combat COVID-19. ARK Foundation proposes to develop a ‘Comprehensive National COVID-19 Response Management Policy’ under the leadership of MOHFW of Bangladesh, outlining short, medium and long-run action plans. The policy must adopt a whole-society approach, consider both preventive and curative measures, and strengthen the World Health Organisation’s six building blocks of the health system.

To strengthen the health service delivery to address COVID-19, ARK Foundation recommends:

Short term actions

1. Prioritise safety of health professionals, procure and distribute personal protective equipment (PPE) as per need
2. Update treatment protocols, guidelines and manuals to include new knowledge and evidence

Medium and long-run action

1. Develop ‘District level planning’ to assess the need of each district, and allocate resources based on need, develop the capacity of diagnosis and treatment at district and sub-district levels, and procure and distribute test kits as per requirement across the districts.
2. Plan for increasing the capacity of government hospitals at national, district and sub-district levels to diagnose and treat patients, including serious and critical patients, requiring mechanical ventilation and intensive care.
3. Adequately address mental health of the people.
4. Coordinate with other ministries and private health care providers for a comprehensive management of COVID-19.

Health service delivery is just one part of the comprehensive plan when considered the entire health system.

More upcoming. Stay tuned.

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