Health system preparedness for responding to the growing burden of non-communicable disease – a case study of Bangladesh (WP25)

AusAID KNOWLEDGE HUBS FOR HEALTH

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


Mahmudul Hassan


Health system preparedness for responding to the growing burden of non-communicable disease—a case study of Bangladesh

First draft – February 2013

© 2013 Nossal Institute for Global Health

Corresponding author:

Dewan AlamCentre for Control of Chronic Diseases, International Centre for Diarrhoeal Disease Research, [email protected]

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.

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Health Policy and Health Finance Knowledge Hub WORKING PAPER 25

Health system preparedness for responding to the growing burden of non-communicable disease — a case study of Bangladesh

SUMMARYBangladesh 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 cost-effective 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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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 conditions—cardiovascular 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 Bangladesh’s 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 co-morbidities 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

INTRODUCTIONThere 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

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

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 under-served 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, El-saharty 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 country-by-country comparisons of health development assistance (WHO 2009). Regardless of the exact level,

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.

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 framework—building 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 services—using the indicators in the cells of the framework, to provide a systematic analysis of the national response.

COUNTRY CONTEXTBangladesh 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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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

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

TABLE 1. BANGLADESH ECONOMIC, SOCIAL AND HEALTH INDICATORS (2010)

Subject Key Indicators Value

Population Total millions in 2010 (1) 164

percent of population living in rural areas (2) 75+

percent of population over 65 years 4

Economic Indicators GNI per capita—US$ (1) $640

PPP GNI per capita—US$ (1) $1620

Annual growth rate ( percent) (3) 6.3

Health Indicators Infant mortality per 1000 live births (4) 38

Maternal mortality per 100,000 live births (5) 194

Crude death rate per 1000 population (6) 6

Life expectancy (years) (7)

Males 66

Females 68

Health Services Persons per hospital bed (2) 1860

No. of doctors per 10,000 population (8) 7.7

Health Financing Total expenditure on health ( percent of GDP) 3.5

Health expenditure, public (percent of government expenditure)

7.4

Out-of-pocket expenditure as a percentage of total health expenditure (2009) (9)

65.9

percent

Per capita total expenditure on health—US$ 23

Per cent coming from development aid/partners (10) 8

(1) World Bank 2012d.(2) Bangladesh Bureau of Statistics 2011.(3) Trading Economics 2012a.(4) World Bank 2012a.

(5) World Bank 2011c.(6) World Bank 2012b.(7) World Bank 2012c.(8) Bangladesh Health Watch 2007.

(9) Trading Economics 2012b.(10) DGHS n.d.

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

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 men—51 percent;

• inadequate fruit and/or vegetable intake—95.7 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.

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-of-pocket costs. The mixed health system, its variable quality of care and poor distribution of services are challenges for improving national health outcomes.

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,

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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 out-of-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 country’s 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

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

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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:

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. Self-reported 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.

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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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 non-government organisations (Beatty 2012).

FINDINGSIn 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 middle-income 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

• 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 NCDs—cardiovascular diseases, diabetes and cancer—as 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).

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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.


• 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.

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 non-government, autonomous and PPP organisations Bangabandhu Sheikh Mujib Medical University, National Heart Foundation Hospital & Research Institute, Bangladesh Diabetic Somity/Diabetic Association of Bangladesh and Bangladesh Anti-Tobacco 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 NCD-related 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

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• 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 system’s 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 Community-Based 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

Service Delivery Models

Service delivery is summarised in Annex 6.


• 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 Community-Based Surveillance of NCDs, Bangladesh Anti-Tobacco 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 non-government 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).

11



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.

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


• 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.

DISCUSSIONThis 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

12



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.

(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.

CONCLUSIONSBangladesh 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.

13



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 People’s 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. WHO’s budgetary allocations and burden of disease: a comparative analysis. Lancet 372 (9649): 1563-1569.

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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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Bangladesh Society of Medicine (BSM). 2011. Bangladesh NCD risk factor survey 2010. Available from http://www.who.int/chp/steps/2010_Bangladesh_FactSheet.pdf (Accessed on 19 August 2011).

Beaglehole, R., R. Bonita, G. Alleyne, R. Horton, L. Li, P. Lincoln et al. 2011. UN high-level meeting on non-communicable diseases: Addressing four questions. Lancet 378 (9789), 449- 455.

Beatty, A. 2012. Country-level decision making for control of chronic diseases: Workshop summary. Washington, DC: National Academies Press.

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Directorate General of Health Services (DGHS). n.d. Financing health care of Bangladesh. http://nasmis.dghs.gov.bd/dghs_new/dmdocuments/All/Financing percent20Health percent20Care percent20of percent20Bangladesh.pdf (accessed 1 February 2013).

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of Non-Communicable Diseases in Low- and Middle-Income Countries. http://www.who.int/nmh/publications/best_buys_summary.pdf (Accessed 18 April 2012).

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15



ANN

EX 1

. S

TRAT

EGIC

FR

AMEW

OR

K F

OR

RES

PON

DIN

G T

O N

CD

S

Ele

men

t P

hase

1P

hase

2P

hase

3P

hase

4

1.

Bui

ldin

g c

om

mit

men

t an

d a

dd

ress

ing

hea

lth

syst

ems

cons

trai

nts

Bro

aden

ed a

war

enes

s of

pro

blem

acr

oss

gove

rnm

ent a

nd

com

mun

ity

Str

ong

com

mitm

ent b

y ke

y pl

ayer

sD

rug

purc

hasi

ng p

olic

ies

to m

eet N

CD

ne

eds

revi

sed

and

refin

edN

atio

nal h

ealth

pla

ns a

nd b

udge

ts

have

bee

n al

igne

d w

ith s

trat

egy

Iden

tified

par

tner

s—pu

blic

, pr

ivat

e, a

cade

mic

, NG

Os,

C

SO

, ext

erna

l—to

form

al

lianc

es

Sys

tem

for

keep

ing

indi

vidu

al

heal

th re

cord

s ha

s be

en d

ecid

edH

uman

reso

urce

s pl

an fo

r he

alth

re

vise

d to

cov

er p

reve

ntio

n, d

iagn

osis

an

d de

liver

y of

goo

d qu

ality

NC

D

mod

els

Com

mun

ity is

sat

isfie

d w

ith s

ervi

ces

Dev

elop

adv

ocac

y st

rate

gy

and

busi

ness

cas

eE

lem

ents

of a

nat

iona

l NC

D p

lan

agre

edS

ourc

es fo

r ne

w fi

nanc

es id

entifi

ed

thro

ugh

taxe

s; e

ffici

enci

es a

s pa

rt o

f na

tiona

l hea

lth b

udge

ts

Bas

elin

e da

ta fo

r po

pula

tion

usin

g S

TEP

s or

m

ini-S

TEP

s ap

proa

ch

N

atio

nal N

CD

pla

n fo

r ne

xt fi

ve y

ears

an

d co

st fo

r de

liver

y of

cor

e se

rvic

es

refin

ed

2.

Pub

lic p

olic

y in

p

op

ulat

ion

heal

th

pro

mo

tio

n

Det

erm

ine

over

all s

trat

egic

ap

proa

ch in

side

and

ou

tsid

e go

vern

men

t

Pre

vent

ion

stra

tegy

dev

elop

ed,

part

ners

iden

tified

Bus

ines

s an

d in

dust

ry e

ngag

ed a

s pa

rtne

rs in

the

com

mun

ity

Com

mun

ity, b

usin

ess

and

indu

stry

are

pl

ayin

g th

eir

role

in n

atio

nal s

trat

egy

Eva

luat

ion

and

acco

unta

bilit

y fra

mew

ork

agre

ed a

t hig

h le

vel

Impl

emen

tatio

n of

pop

ulat

ion

stra

tegi

es b

egun

Str

ateg

y de

velo

ped

for

legi

slat

ion,

taxa

tion

and

regu

latio

n

Str

ateg

y fo

r mob

ilisin

g co

mm

unity

ag

reed

3.

Ser

vice

del

iver

y m

od

els

Hig

h-ris

k po

pula

tions

id

entifi

ed b

y ch

arac

teris

tics

of g

ende

r, ag

e, lo

catio

n,

ethn

icity

Ser

vice

del

iver

y m

odel

dev

elop

ed

for

smal

l-sca

le in

terv

entio

n fo

r ea

rly d

iagn

osis

and

trea

tmen

t

Less

ons

from

Pha

se 1

and

sca

le-u

p bu

ilt o

n to

exp

and

cove

rage

Trea

tmen

t of N

CD

s fu

lly in

tegr

ated

in

to m

ains

trea

m p

rimar

y he

alth

car

e se

rvic

es n

atio

nally

and

are

sus

tain

able

NG

O a

nd c

omm

unity

pa

rtne

rs fo

r se

rvic

e de

liver

y id

entifi

ed

Trai

ning

nee

ds fo

r pi

lot

deliv

ery

iden

tified

APP

END

ICES

16



Ele

men

t P

hase

1P

hase

2P

hase

3P

hase

4

4.

Ens

urin

g e

qui

ty in

ac

cess

and

pay

men

ts

for

serv

ices

Equ

ity in

acc

ess

to a

nd

cost

s of

pre

vent

ion

and

trea

tmen

t ser

vice

s ex

amin

ed fo

r hi

gh-r

isk

popu

latio

ns

App

ropr

iate

low

cos

t ser

vice

s de

velo

ped

and

pilo

ted

for

high

-ris

k gr

oups

with

ineq

uita

ble

acce

ss o

r co

st b

urde

n

Mea

sure

men

t of e

quity

of a

cces

s an

d pa

ymen

ts p

art o

f sca

le-u

p O

ngoi

ng m

onito

ring

of e

quity

of

acce

ss a

nd p

aym

ents

App

ropr

iate

fina

ncia

l sup

port

pro

vide

d to

thos

e w

ith fi

nanc

ial b

arrie

rs

Ind

icat

ors

Key

par

tner

s ar

e on

bo

ard—

insi

de a

nd o

utsi

de

gove

rnm

ent

Pol

itica

l will/

lead

ersh

ip a

nd

advo

cacy

are

sol

idE

xpan

ded

evid

ence

bas

e in

pla

ce to

su

ppor

t pol

icy/

deci

sion

mak

ing

Pat

ient

sat

isfa

ctio

n le

vels

are

m

easu

red

Key

mes

sage

s an

d ad

voca

cy c

ase

are

clea

rC

omm

unity

invo

lvem

ent i

s gr

owin

gLo

nger

term

str

ateg

y in

volv

ing

key

part

ners

is a

gree

dFo

rwar

d pl

an is

fully

fund

ed a

nd

staf

fed

B

asel

ine

data

are

col

lect

ed a

nd

used

effe

ctiv

ely

Pre

vent

ion

and

trea

tmen

t are

cov

ered

fo

r 75

per

cen

t of h

igh-

risk

popu

latio

nP

reva

lenc

e is

trac

ked

and

decl

inin

g ac

ross

all

maj

or p

opul

atio

n gr

oups

P

opul

atio

n pr

even

tion

stra

tegy

re

ady

for

impl

emen

tatio

nS

ervi

ce d

eliv

ery

is e

valu

ated

for

affo

rdab

ility,

acc

essi

bilit

y an

d qu

ality

Le

gisl

ativ

e/ re

gula

tory

pro

gram

on

trac

k

P

ilot s

ervi

ce d

eliv

ery

mod

els

read

y fo

r im

plem

enta

tion,

in

clud

ing

relia

ble

indi

vidu

al,

hum

an re

sour

ces,

dia

gnos

tic

proc

esse

s

17



ANN

EX 2

. STA

KEH

OLD

ER A

NAL

YSIS

Pro

gra

m/I

nsti

tuti

on

Sec

tor

Targ

etO

bje

ctiv

e/A

ctiv

itie

s

Hea

lth P

opul

atio

n an

d N

utrit

ion

Sec

tor

Dev

elop

men

t Pro

gram

(HP

NS

DP

)G

over

nmen

t N

CD

sA

five

-yea

r (2

011-

2016

) pol

icy

and

prog

ram

mat

ic fr

amew

ork.

NC

D is

one

of t

he fi

ve p

riorit

y ar

eas.

Aim

is to

redu

ce m

orbi

dity

and

pre

mat

ure

mor

talit

y du

e th

roug

h ac

tions

at a

ll le

vels

from

pr

imar

y pr

even

tion

to in

tegr

ated

trea

tmen

t and

reha

bilit

atio

n.

Str

ateg

ic P

lan

of S

urve

illanc

e an

d P

reve

ntio

n of

Non

-Com

mun

icab

le

Dis

ease

s (2

011-

15)

Gov

ernm

ent

NC

Ds

The

plan

pro

vide

s gu

idan

ce fo

r su

rvei

llanc

e of

NC

D r

isk

fact

ors

to c

ontr

ol a

nd p

reve

nt e

mer

ging

N

CD

s. It

inte

grat

es N

CD

and

com

mun

icab

le d

isea

se s

urve

illanc

e.

Nat

iona

l Can

cer

Con

trol

Str

ateg

y an

d P

lan

of A

ctio

n (2

009-

15)

Gov

ernm

ent

Can

cer

Aim

s to

dev

elop

and

impl

emen

t a c

oord

inat

ed p

rogr

am to

con

trol

can

cer.

Nat

iona

l Tob

acco

Con

trol

cel

lG

over

nmen

t To

bacc

o co

ntro

lA

ctiv

ities

incl

ude

orga

nisi

ng s

emin

ars,

mee

tings

and

wor

ksho

ps re

late

d to

toba

cco;

pub

lishi

ng

book

s, tr

aini

ng m

anua

ls, l

eafle

ts, p

oste

rs a

nd IE

C m

ater

ials

to r

aise

aw

aren

ess

amon

g ge

nera

l po

pula

tion

and

heal

th p

rofe

ssio

nals

.

Ban

glad

esh

NC

D N

etw

ork

Gov

ernm

ent

NC

Ds

Cor

e ob

ject

ives

are

col

lect

ing

epid

emio

logi

cal d

ata,

pro

mot

ing

surv

eilla

nce,

dis

sem

inat

ion

of

colle

cted

info

rmat

ion,

faci

litat

ion

of u

se o

f the

dat

a in

pre

vent

ion

and

cont

rol o

f NC

Ds.

The

ne

twor

k un

dert

akes

thre

e ke

y ac

tiviti

es: p

erio

dica

l mee

tings

of t

he m

embe

rs to

exc

hang

e kn

owle

dge,

info

rmat

ion

and

expe

rienc

e; c

omm

unic

atio

n th

roug

h w

eb s

ite a

nd n

ewsl

ette

r to

es

tabl

ish

furt

her

linka

ge in

side

the

coun

try

as w

ell a

s w

ith re

gion

al a

nd g

loba

l org

anis

atio

ns; a

nd

gene

ratio

n of

info

rmat

ion

thro

ugh

hosp

ital a

nd c

omm

unity

-bas

ed s

urve

illanc

e (M

OH

FW 2

011a

).

Allia

nce

for

Com

mun

ity-B

ased

S

urve

illanc

e of

NC

Ds

Gov

ernm

ent

NC

Ds

It ai

ms

at g

ener

atio

n of

info

rmat

ion

thro

ugh

perio

dic

com

mun

ity s

urve

ys o

n N

CD

s an

d th

eir

risk

fact

ors,

par

ticul

arly

toba

cco

use,

and

initi

atio

n of

pop

ulat

ion-

base

d re

gist

ries

(MO

HFW

201

1a).

Ban

glad

esh

Ant

i-Tob

acco

Allia

nce

Gov

ernm

ent

NC

Ds

Est

ablis

hed

in 1

999

in re

spon

se to

agg

ress

ive

mar

ketin

g ca

mpa

ign

of a

tran

snat

iona

l tob

acco

co

mpa

ny. M

ajor

act

iviti

es in

clud

e tr

aini

ng o

f pub

lic a

nd N

GO

sta

ff on

toba

cco

cont

rol l

aw

and

its im

plem

enta

tion,

arr

angi

ng n

atio

nal l

evel

sem

inar

s su

ch a

s ‘W

orld

Tob

acco

Day

’ and

pa

rtic

ipat

ing

in in

tern

atio

nal;

wor

ksho

ps a

nd s

emin

ars

on to

bacc

o co

ntro

l and

sub

mis

sion

of

toba

cco

cont

rol l

egis

latio

n to

gov

ernm

ent (

MO

HFW

200

5; M

OH

FW 2

009;

MO

HFW

201

1a).

Nat

iona

l Ins

titut

e of

Car

diov

ascu

lar

Dis

ease

(NIC

VD

)G

over

nmen

t C

VD

Est

ablis

hed

in 1

978,

NIC

VD

Hos

pita

l in

Dha

ka p

rovi

des

post

grad

uate

and

dip

lom

a co

urse

s on

ca

rdio

vasc

ular

dis

ease

s fo

r he

alth

pro

fess

iona

ls. I

t is

the

larg

est p

ublic

tert

iary

car

e ho

spita

l an

d re

ferr

al c

entr

e fo

r C

VD

. NIC

VD

edu

cate

s th

roug

h se

min

ars

and

leafl

ets

on p

reve

ntio

n an

d co

ntro

l of N

CD

.

Nat

iona

l Ins

titut

e of

Can

cer

Res

earc

h &

Hos

pita

l (N

ICR

H)

NG

O/

Nat

iona

l O

rgan

isat

ion

Can

cer,

CO

PD

Est

ablis

hed

in 1

982,

this

is th

e co

untr

y’s

only

tert

iary

cen

tre

enga

ged

in m

ultid

isci

plin

ary

canc

er m

anag

emen

t. It

offe

rs c

ance

r tr

eatm

ent,

educ

atio

n an

d re

sear

ch. I

t mai

ntai

ns a

can

cer

regi

stry

—a

hosp

ital-b

ased

sur

vey—

and

prov

ides

sec

onda

ry a

nd te

rtia

ry c

are.

Aw

aren

ess-

rais

ing

activ

ities

incl

ude

orga

nisi

ng W

orld

Can

cer

Day

and

lim

ited

prev

entio

n ac

tiviti

es.

Nat

iona

l Hea

rt F

ound

atio

n H

ospi

tal &

R

esea

rch

Inst

itute

(NH

FH&

RI)

NG

O/

Nat

iona

l O

rgan

isat

ion

CV

D a

nd

hype

rten

sion

NH

FH&

RI i

s th

e m

ain

proj

ect o

f the

Nat

iona

l Hea

rt F

ound

atio

n of

Ban

glad

esh.

It p

rimar

ily

prov

ides

sec

onda

ry a

nd te

rtia

ry c

are

to C

VD

pat

ient

s. It

run

s a

smok

ing

cess

atio

n cl

inic

that

pr

omot

es h

ealth

.

18



Pro

gra

m/I

nsti

tuti

on

Sec

tor

Targ

etO

bje

ctiv

e/A

ctiv

itie

s

Nat

iona

l Ins

titut

e of

Dis

ease

s of

the

Che

st a

nd H

ospi

tal (

NID

CH

)N

GO

TB a

nd c

hest

di

seas

es N

IDC

H is

the

only

inst

itute

of B

angl

ades

h th

at e

xten

ds m

oder

n sp

ecia

lised

med

ical

and

sur

gica

l tr

eatm

ent t

o co

mpl

icat

ed c

hest

and

TB

pat

ient

s an

d al

so o

ffers

trai

ning

of m

edic

al m

anpo

wer

in

tube

rcul

osis

and

che

st d

isea

ses.

ICD

DR

, B B

angl

ades

hN

GO

/ R

esea

rch

Inst

itute

NC

Ds

Cen

tre

for

Con

trol

ling

Chr

onic

Dis

ease

s ha

s be

en e

stab

lishe

d, w

hich

car

ries

out p

opul

atio

n as

w

ell a

s ho

spita

l-bas

ed re

sear

ch o

n N

CD

.

BR

AC

NG

OLi

mite

dE

st. i

n 19

72, B

RA

C is

a d

evel

opm

ent o

rgan

isat

ion

dedi

cate

d to

alle

viat

ing

pove

rty

by

empo

wer

ing

the

poor

to b

ring

abou

t cha

nge

in th

eir

own

lives

. Cur

rent

ly it

has

lim

ited

activ

ities

in

NC

Ds.

Em

inen

ceN

GO

NC

Ds

Con

duct

s ho

me

visi

ts a

nd p

rovi

des

heal

th e

duca

tion

to r

aise

aw

aren

ess.

The

pro

gram

is li

mite

d to

Dha

ka c

ity a

nd c

arrie

s ou

t ser

vice

del

iver

y th

roug

h co

mm

unity

cou

nsel

lors

.

Adh

unik

N

GO

Toba

cco

Est

ablis

hed

in 1

970,

it w

orks

on

rais

ing

awar

enes

s of

har

mfu

l effe

ct o

f sm

okin

g th

roug

h se

min

ars,

sym

posi

a, m

eetin

gs a

nd p

roce

ssio

ns, T

V a

nd r

adio

pro

gram

s.

Cen

tre

for

Can

cer

Pre

vent

ion

and

Res

earc

h (C

CP

R).

NG

O C

ance

rC

CP

R is

invo

lved

in a

war

enes

s ra

isin

g, s

cree

ning

and

ear

ly d

etec

tion

and

rese

arch

on

canc

er.

It ha

s a

focu

s on

bre

ast c

ance

r an

d m

aint

ains

a c

ance

r re

gist

ry. O

ther

are

a of

inte

rest

s ar

e to

bacc

o co

ntro

l and

sur

veilla

nce

and

prev

entio

n of

maj

or N

CD

s.

Aga

Kha

n Tr

ust

NG

OC

ance

rTh

e tr

ust r

uns

wom

en’s

can

cer

and

NC

D s

cree

ning

pro

gram

in tw

o la

rge

urba

n sl

ums

in

Dha

ka. I

t pro

vide

s he

alth

edu

catio

n on

sel

f-ex

amin

atio

n fo

r or

al a

nd b

reas

t can

cer.

It ca

rrie

s ou

t co

mm

unity

aw

aren

ess

activ

ities

.

Inte

rnat

iona

l Prim

ary

Car

e R

espi

rato

ry

Gro

up-B

angl

ades

h (IP

CR

G-B

D) &

B

ette

r B

reat

hing

Ban

glad

esh

(BB

B)

NG

OR

espi

rato

ry d

isea

ses

Pro

vide

s ed

ucat

ion

and

trai

ning

to h

ealth

car

e pr

ofes

sion

als

on e

vide

nce-

base

d ca

re fo

r pat

ient

s su

fferin

g fro

m re

spira

tory

dis

ease

s, p

artic

ular

ly a

sthm

a an

d C

OP

D.

Nat

iona

l Hea

rt F

ound

atio

n H

ospi

tal &

R

esea

rch

Inst

itute

Pub

lic-p

rivat

e pa

rtne

rshi

ps

CV

DIt

is o

ne o

f the

maj

or te

rtia

ry c

are

hosp

itals

for

com

preh

ensi

ve c

are

for

card

iova

scul

ar d

isea

ses.

It

is a

mem

ber

of W

orld

Hea

rt F

eder

atio

n, W

orld

Hyp

erte

nsio

n Le

ague

and

Inte

rnat

iona

l S

ocie

ty o

f Hyp

erte

nsio

n. M

ainl

y in

volv

ed in

aw

aren

ess

rais

ing

thro

ugh

publ

icat

ion

of a

qu

arte

rly n

ewsl

ette

r R

ydro

ug B

arta

, boo

klet

s, p

oste

rs a

nd e

duca

tiona

l mat

eria

ls a

nd m

ass

med

ia. O

rgan

ises

a H

eart

Cam

p an

d ob

serv

es s

peci

al d

ays

rela

ted

to N

CD

s su

ch a

s W

orld

H

yper

tens

ion

day,

Wor

ld S

alt A

war

enes

s W

eek

and

Wor

ld H

eart

Day

. It h

as 3

3 af

filia

tes

in

Ban

glad

esh.

Ban

glad

esh

Hyp

erte

nsio

n S

ocie

ty,

Hyp

erte

nsio

n C

omm

ittee

(a c

omm

ittee

of

Nat

iona

l Hea

rt F

ound

atio

n)

Hea

lth

prof

essi

onal

as

soci

atio

ns

Hyp

erte

nsio

nTh

e B

angl

ades

h H

yper

tens

ion

Com

mitt

ee o

f the

Nat

iona

l Hea

rt F

ound

atio

n of

Ban

glad

esh

crea

tes

awar

enes

s by

obs

ervi

ng W

orld

Hyp

erte

nsio

n D

ay, p

ublic

sem

inar

s, r

allie

s, T

V/r

adio

etc

.

Ban

glad

esh

Can

cer

soci

ety

Hea

lth

prof

essi

onal

as

soci

atio

ns

Can

cer

Can

cer

cont

rol p

rogr

am in

clud

es fo

llow

-up

and

reha

bilit

atio

n of

the

trea

ted

case

s, tr

eatm

ent o

f re

curr

ent c

ases

and

relie

f of p

ain

for

patie

nts

with

incu

rabl

e ca

ncer

s (p

allia

tive

care

). E

valu

atio

n of

the

prog

ram

is n

eces

sary

from

tim

e to

tim

e as

per

dat

a pr

ovid

ed b

y th

e C

ance

r R

egis

try.

19



Pro

gra

m/I

nsti

tuti

on

Sec

tor

Targ

etO

bje

ctiv

e/A

ctiv

itie

s

Ast

hma

Ass

ocia

tion

Ban

glad

esh

Hea

lth

prof

essi

onal

as

soci

atio

ns

Ast

hma/

CO

PD

Act

iviti

es in

clud

e tr

eatm

ent o

f ast

hma

patie

nts

at th

e N

atio

nal A

sthm

a C

entr

e in

Dha

ka,

regi

stra

tion

and

man

agem

ent f

ollo

win

g as

thm

a gu

idel

ines

, fre

e ne

bulis

atio

n in

acu

te a

sthm

a pa

tient

s, a

war

enes

s ra

isin

g an

d ed

ucat

ion

for

/by

patie

nts

and

gene

ral p

ublic

thro

ugh

vide

o,

film

s, g

roup

dis

cuss

ions

, ral

lies,

pos

ters

, obs

erva

nce

of W

orld

Ast

hma

Day

etc

, orie

ntat

ion

trai

ning

for

doct

ors

and

nurs

es, r

esea

rch

activ

ities

on

asth

ma

and

CO

PD

, edi

ting

and

upda

ting

natio

nal a

sthm

a gu

idel

ines

, and

free

med

ical

cam

p fo

r as

thm

a pa

tient

s.

Ban

gaba

ndhu

She

ikh

Muj

ib M

edic

al

Uni

vers

ity (B

SM

MU

)A

cade

mic

Trea

tmen

t of N

CD

sTh

e on

ly m

edic

al u

nive

rsity

and

tert

iary

car

e ho

spita

l for

NC

Ds

in B

angl

ades

h. N

o fo

rmal

aw

aren

ess

rais

ing

activ

ity is

con

duct

ed o

n N

CD

.

WH

O B

angl

ades

hD

evel

opm

ent

part

ners

/IN

GO

sN

CD

sW

HO

pro

vide

s te

chni

cal s

uppo

rt fo

r co

ntro

lling

NC

Ds

and

risk

fact

ors.

It h

elpe

d in

the

deve

lopm

ent o

f sev

eral

str

ateg

ic p

lans

suc

h as

Nat

iona

l Str

ateg

ic P

lan

for

Pre

vent

ion

and

Sur

veilla

nce

(200

7-10

and

201

1-15

), N

atio

nal C

ance

r C

ontr

ol P

lan,

Nat

iona

l Tob

acco

Con

trol

P

lan.

US

AID

Dev

elop

men

t pa

rtne

rs /

ING

Os

NC

Ds

Sup

port

s th

e H

PN

SD

P th

roug

h S

WA

P m

echa

nism

.

Wor

ld B

ank

Dev

elop

men

t pa

rtne

rs /

ING

Os

NC

Ds

The

Wor

ld B

ank

appr

oved

US

$359

milli

on c

redi

t in

2011

for

the

Hea

lth S

ecto

r D

evel

opm

ent

Pro

gram

. It h

as p

ublis

hed

seve

ral r

esea

rch

pape

rs a

nd b

ooks

ack

now

ledg

ing

the

risin

g N

CD

bu

rden

in th

e co

untr

y. A

num

ber

of N

CD

-rel

ated

pro

ject

s ar

e fu

nded

by

the

bank

.

Eur

opea

n U

nion

Dev

elop

men

t pa

rtne

rs /

ING

Os

NC

Ds

The

EC

sup

port

s th

e H

PN

SD

P (€

108,

000,

000)

thro

ugh

cont

ribut

ions

to a

Wor

ld B

ank-

adm

inis

tere

d po

ol-f

und.

Ban

glad

esh

Dia

betic

Som

ity/D

iabe

tic

Ass

ocia

tion

of B

angl

ades

h (B

AD

AS

)P

ublic

-priv

ate

part

ners

hips

D

iabe

tes

and

CV

DB

AD

AS

pro

vide

s cl

inic

al c

are

and

educ

atio

n on

dia

bete

s. It

pro

vide

s se

cond

ary

and

tert

iary

pr

even

tion

and

care

and

is in

volv

ed in

aw

aren

ess-

rais

ing

prog

ram

s th

roug

h m

edia

, sem

inar

s,

dist

ribut

ion

of m

ater

ials

, film

s.

Nat

iona

l Cen

tre

for

cont

rol o

f R

heum

atic

Fev

er H

eart

dis

ease

s (N

CC

RFH

D)

Pub

lic-p

rivat

e pa

rtne

rshi

ps

CV

DIt

offe

rs c

linic

al s

ervi

ces

for

rheu

mat

ic fe

ver

and

has

a pr

even

tion

prog

ram

. It i

s in

volv

ed in

aw

aren

ess

rais

ing

thro

ugh

mas

s m

edia

, lea

flets

, pos

ters

, film

pro

duct

ion.

It a

rran

ges

sem

inar

s fo

r co

mm

unity

lead

ers,

teac

hers

and

NG

O s

taff

on r

heum

atic

feve

r.

Del

ta H

ospi

tal

Priv

ate

initi

ativ

esN

CD

s/ca

ncer

Pro

vide

s cl

inic

al c

are

for

canc

er a

nd h

ealth

mes

sage

s fo

r se

cond

ary

prev

entio

n of

can

cers

.

Uni

ted

Foru

m a

gain

st T

obac

co (U

FAT)

Priv

ate

initi

ativ

esTo

bacc

o co

ntro

lTa

rget

s he

alth

car

e pr

ofes

sion

als,

doc

tors

and

nur

ses

to b

e in

volv

ed in

cam

paig

n ag

ains

t to

bacc

o an

d ra

isin

g aw

aren

ess

abou

t hea

lth im

pact

of t

obac

co u

se. P

lays

an

advo

cacy

role

in

rein

forc

ing

anti-

toba

cco

polic

ies

and

effe

ctiv

enes

s of

ant

i-tob

acco

pro

gram

s.

20



ANN

EX 3

. BU

ILD

ING

CO

MM

ITM

ENT

AND

AD

DR

ESSI

NG

HEA

LTH

SYS

TEM

S C

ON

STR

AIN

TS

Pha

se 1

Pha

se 2

Pha

se 3

Pha

se 4

Bro

aden

ed a

war

enes

s o

f p

rob

lem

acr

oss

g

ove

rnm

ent

and

co

mm

unit

yS

tro

ng c

om

mit

men

t to

NC

D p

rob

lem

by

key

pla

yers

Dru

g p

urch

asin

g

po

licie

s to

co

ver

NC

D

need

s an

d r

efine

d

Nat

iona

l hea

lth

pla

ns

and

bud

get

s ha

ve b

een

alig

ned

wit

h st

rate

gy

Bas

elin

e su

rvey

s/in

form

atio

n on

aw

aren

ess

rais

ing

wer

e un

avai

labl

e.

Sev

eral

initi

ativ

es h

ave

been

take

n by

gov

ernm

ent a

nd

non-

gove

rnm

ent o

rgan

isat

ions

.

The

gove

rnm

ent h

as ta

ken

initi

ativ

es s

uch

as (1

) sig

ning

th

e Fr

amew

ork

Con

vent

ion

on T

obac

co C

ontr

ol in

20

04 a

nd r

atify

ing

the

Toba

cco

Con

trol

Act

in 2

005;

(2)

Incl

usio

n of

NC

D in

the

HN

PS

SP

200

7; (3

) com

plet

ion

of n

atio

nal N

CD

ris

k fa

ctor

sur

vey;

(4) i

nteg

ratin

g N

CD

an

d C

D s

urve

illanc

e in

the

Str

ateg

ic P

lan

of S

urve

illanc

e an

d P

reve

ntio

n of

NC

D b

y th

e D

GH

S a

nd a

ppro

ved

by M

OH

FM; (

5) e

ndor

sing

nat

iona

l str

ateg

ies

such

as

Nat

iona

l NC

D P

reve

ntio

n an

d S

urve

illanc

e, N

atio

nal

Toba

cco

Con

trol

Str

ateg

y an

d N

atio

nal C

ance

r S

trat

egy;

(6

) cre

atin

g a

new

line

dire

ctor

in D

GH

S o

n N

CD

s.

Cur

rent

ly s

tron

g co

mm

itmen

t fro

m th

e go

vern

men

t. Th

is is

de

mon

stra

ted

by th

e st

rate

gic

plan

s de

velo

ped.

How

ever

, unc

lear

how

reso

urce

s w

ill be

mob

ilised

for

NC

D

cont

rol a

nd tr

eatm

ent.

Cur

rent

bud

get i

s in

suffi

cien

t to

addr

ess

the

curr

ent a

nd

proj

ecte

d ne

ed. C

omm

itmen

t fro

m m

ultil

ater

al d

onor

s is

lim

ited.

Ther

e is

incr

easi

ng in

tere

st in

inte

rnat

iona

l dev

elop

men

t pa

rtne

rs s

uch

as W

HO

, Wor

ld B

ank,

EU

, int

erna

tiona

l NG

Os.

W

HO

is c

omm

itted

to p

rovi

de te

chni

cal s

uppo

rt fo

r co

ntro

lling

NC

Ds

and

risk

fact

ors.

ICD

DR

,B is

com

mitt

ed to

rese

arch

wor

k. T

he C

entr

e fo

r C

ontr

ollin

g C

hron

ic D

isea

ses

has

been

est

ablis

hed

and

is

cond

uctin

g a

num

ber

of p

opul

atio

n as

wel

l as

hosp

ital-b

ased

st

udie

s.

Wor

ld B

ank

has

publ

ishe

d se

vera

l res

earc

h pa

pers

and

boo

ks

rais

ing

awar

enes

s of

NC

Ds

in th

e co

untr

y.

Dru

gs re

quire

d fo

r N

CD

s ar

e lim

ited

on th

e na

tiona

l es

sent

ial d

rugs

pol

icy,

w

hich

the

publ

ic h

ealth

sy

stem

follo

ws.

The

re is

a

need

to re

fine

the

drug

pr

ocur

emen

t pol

icy.

No.

The

cur

rent

pla

n is

an

upd

ated

ver

sion

of t

he

earli

er p

lan.

Gov

ernm

ent

need

s to

be

advo

cate

d fo

r tim

ely

adde

ndum

to th

e pl

an a

nd e

vent

ually

incl

ude

NG

Os,

as

wel

l as

effic

ient

bu

dget

allo

catio

n.

Iden

tifi

ed p

artn

ers—

pub

lic, p

riva

te, a

cad

emic

N

GO

s, C

SO

s—to

fo

rm a

llian

ces

Sys

tem

fo

r ke

epin

g in

div

idua

l hea

lth

reco

rds

Hum

an r

eso

urce

s p

lan

for

heal

th t

o c

ove

r p

reve

ntio

n, d

iag

nosi

s an

d d

eliv

ery

of

go

od

q

ualit

y N

CD

mo

del

s re

vise

d

Co

mm

unit

y is

sat

isfi

ed

wit

h se

rvic

es

Thre

e al

lianc

es w

ere

foun

d re

late

d to

NC

Ds:

Ban

glad

esh

NC

D N

etw

ork,

Allia

nce

for

Com

mun

ity-B

ased

S

urve

illanc

e of

NC

Ds,

Ban

glad

esh

Ant

i-Tob

acco

A

llianc

e.

Cur

rent

ly s

ome

e-re

cord

s ex

ist w

ith p

aper

wor

k. S

yste

m fo

r in

divi

dual

hea

lth re

cord

s is

not

in p

lace

.

The

MO

HFW

is c

ondu

ctin

g a

proj

ect t

o as

sess

the

Hea

lth

Info

rmat

ion

Sys

tem

(HIS

) nee

d of

Ban

glad

esh

and

deve

lop

a pl

an fo

r fu

ture

HIS

.

Rec

ords

of i

mm

unis

atio

n of

chi

ldre

n, s

peci

fic d

isea

ses

like

acut

e fla

ccid

par

alys

is a

nd T

B a

re m

aint

aine

d at

the

PH

C le

vel.

Dia

gnos

tic h

ealth

reco

rds

are

kept

in N

GO

s, p

rivat

e cl

inic

s fo

r pa

tient

s.

Gen

eral

pop

ulat

ion

indi

vidu

al h

ealth

reco

rds

are

not k

ept.

Pla

n fo

r N

CD

s is

no

t ava

ilabl

e. P

rior

asse

ssm

ent o

f NC

D

heal

th d

eman

d an

d pi

lotin

g of

a m

odel

are

ne

eded

to u

nder

stan

d op

tions

for

deve

lopi

ng

effe

ctiv

e hu

man

reso

urce

pl

an.

Pre

mat

ure

and

not y

et in

pl

ace.

21



Pha

se 1

Pha

se 2

Pha

se 3

Pha

se 4

Dev

elo

p a

dvo

cacy

str

ateg

y an

d b

usin

ess

case

Ag

ree

elem

ents

of

a na

tio

nal N

CD

pla

nS

our

ces

for

new

fi

nanc

es t

hro

ugh

taxe

s,

effi

cien

cies

as

par

t o

f na

tio

nal h

ealt

h b

udg

et

iden

tifi

ed

Mos

t of t

he a

dvoc

acy

wor

ks o

f NG

Os,

inte

rnat

iona

l or

gani

satio

ns, p

rivat

e or

gani

satio

ns a

re li

mite

d to

se

min

ars

and

wor

ksho

ps.

No

clea

r ad

voca

cy s

trat

egy

for

NC

Ds.

Ofte

n ad

voca

cy is

ta

rget

ed to

gov

ernm

ent.

Onl

y on

e st

udy

fund

ed b

y U

SA

ID, a

imed

at m

easu

ring

the

econ

omic

ben

efits

of i

nves

ting

in h

ealth

of w

orke

rs.

How

ever

, no

rese

arch

on

busi

ness

cas

e is

focu

sed

on

NC

Ds

Ban

glad

esh

is y

et to

dev

elop

a N

atio

nal N

CD

pla

n. H

owev

er,

the

Str

ateg

ic P

lan

for

Sur

veilla

nce

and

Pre

vent

ion

is ti

mel

y up

date

d an

d co

uld

serv

e as

a m

ajor

por

tion

of a

nat

iona

l pla

n.

Not

ava

ilabl

e

Bas

elin

e d

ata

for

po

pul

atio

n us

ing

ST

EP

S o

r m

ini-

ST

EP

s ap

pro

ach

of

WH

ON

atio

nal N

CD

pla

n fo

r ne

xt fi

ve y

ears

and

co

st f

or

del

iver

y o

f co

re

serv

ices

refi

ned

Gov

ernm

ent i

nitia

tives

incl

ude

com

plet

ion

of th

e N

CD

ris

k fa

ctor

sur

vey

(201

0) a

nd c

ance

r re

gist

ry d

one

by

NIC

RH

in 2

005

( STE

PS

not

use

d).

Nat

iona

l Ast

hma

Pre

vale

nce

stud

y in

199

9 (S

TEP

S n

ot

used

).

Med

ical

info

rmat

ion

syst

em o

f DG

HS

has

hos

pita

l-bas

ed

mor

bidi

ty d

ata

in h

ealth

car

e fa

cilit

ies

of a

ll th

ree

leve

ls.

A m

ulti-

site

cro

ss-s

ectio

nal s

tudy

is b

eing

car

ried

out i

n ni

ne r

ural

HD

SS

site

s us

ing

STE

PS

app

roac

h.

Wom

en’s

can

cer

and

NC

D s

cree

ning

pro

gram

usi

ng

STE

PS

app

roac

h is

in p

roce

ss. R

esul

ts a

re n

ot y

et

avai

labl

e.

Str

ateg

ic P

lan

for

Sur

veilla

nce

and

Pre

vent

ion

of N

CD

in

Ban

glad

esh

(201

1-15

) ha

s be

en e

ndor

sed.

H

owev

er, fi

nanc

ial

stra

tegy

and

bud

get a

re

mis

sing

. Fin

anci

al s

trat

egy

and

budg

et p

lan

are

unde

r th

e op

erat

iona

l pla

n of

DG

HS

.

22



ANN

EX 4

. AW

AREN

ESS-

RAI

SIN

G IN

ITIA

TIVE

S AT

A G

LAN

CE

Pro

gra

m /

Inst

itut

ion

Typ

eD

isea

ses/

risk

fac

tors

in

fo

cus

for

awar

enes

sA

ctiv

ity

star

ted

o

r co

mp

lete

dTo

ols

fo

r ra

isin

g a

war

enes

sTa

rget

gro

up a

nd c

ove

rag

e

Adh

unik

Volu

ntar

y an

ti-to

bacc

o sm

okin

g or

gani

satio

n

Toba

cco

1970

Sem

inar

s, s

ympo

sia,

mee

tings

an

d pr

oces

sion

s, a

nd r

adio

and

TV

pr

ogra

ms

All

over

the

coun

try

Nat

iona

l Ins

titut

e of

C

ardi

ovas

cula

r D

isea

se (N

ICV

D):

Pub

lic,

acad

emic

, te

rtia

ry fa

cilit

y

CV

D a

nd h

yper

tens

ion

and

thei

r ris

k fa

ctor

sS

emin

ars,

wor

ksho

ps, o

bser

vatio

n of

sp

ecia

l day

sH

ealth

pro

fess

iona

ls

Nat

iona

l Hea

rt F

ound

atio

n H

ospi

tal &

Res

earc

h In

stitu

te

(NH

FH&

RI)

Pub

lic-p

rivat

e,

tert

iary

CV

D, h

yper

tens

ion

and

thei

r ris

k fa

ctor

s, e

spec

ially

to

bacc

o (th

roug

h U

FAT)

Hea

lth m

essa

ges

durin

g he

alth

ca

mps

, new

slet

ter,

leafl

ets,

sem

inar

s,

obse

rvat

ion

of s

peci

al d

ays,

ral

lies,

pe

riodi

cals

, adv

ocac

y to

gov

ernm

ent

in s

emin

ars

Hea

lth p

rofe

ssio

nals

, pat

ient

s an

d fa

mily

mem

bers

att

endi

ng h

ealth

ca

mps

, gov

ernm

ent c

once

rns

BA

DA

S (B

angl

ades

h D

iabe

tic

Som

ity/

Dia

betic

Ass

ocia

tion

of

Ban

glad

esh)

Pub

lic-p

rivat

e,

prim

ary,

se

cond

ary

and

tert

iary

Dia

bete

sD

iabe

tes

mes

sage

s bo

th p

reve

ntiv

e an

d cu

rativ

e, m

edia

and

mas

s m

edia

ca

mpa

igns

, obs

erva

tion

of s

peci

al

days

, arr

angi

ng r

allie

s, d

iscu

ssio

ns,

sem

inar

s, d

iabe

tes

heal

th m

agaz

ine,

cl

asse

s, s

ocia

l eve

nts

like

child

ren’

s ar

t com

petit

ion

Pat

ient

s an

d fa

mily

mem

bers

at

tend

ing

at h

ospi

tal (

Ban

glad

esh

Inst

itutio

n of

Res

earc

h on

D

iabe

tes,

End

ocrin

e an

d M

etab

olic

D

isor

ders

and

AA

s ou

tlets

), he

alth

pro

fess

iona

ls a

nd g

ener

al

popu

latio

n

Impr

ovin

g D

iabe

tes

Nut

ritio

n E

duca

tion

Pro

gram

Impr

ovin

g nu

triti

on

educ

atio

n

Dia

betic

nut

ritio

n20

07-2

010

Trai

ning

on

diab

etic

nut

ritio

n,

educ

atio

n se

ssio

n, w

eb-b

ased

hea

lth

mes

sage

s

Hea

lth p

rofe

ssio

nals

and

gen

eral

po

pula

tion

Chi

ld S

pons

orsh

ip P

rogr

am in

B

angl

ades

hC

hild

hea

lth

care

pro

gram

s Ty

pe 1

dia

bete

sD

iabe

tes

awar

enes

s ca

mps

NIC

RH

(Nat

iona

l Ins

titut

e of

C

ance

r R

esea

rch

& H

ospi

tal).

Gov

ernm

ent,

tert

iary

, ac

adem

ic

Can

cer

and

its r

isk

fact

ors

Obs

erva

tion

of s

peci

al d

ays,

at

tend

ing

and

arra

ngin

g se

min

ars

Cen

tre

for

Can

cer

Pre

vent

ion

and

Res

earc

h (C

CP

R)

NG

Os

with

te

chni

cal

supp

ort f

rom

W

HO

NIC

RH

Can

cer

scre

enin

g,

awar

enes

s ra

isin

g fo

cuse

s on

bre

ast c

ance

r

Aw

aren

ess

build

ing

sess

ions

Gen

eral

pop

ulat

ion

and

patie

nts

and

fam

ily m

embe

rs o

f scr

eeni

ng

sess

ion

Wom

en C

ance

r an

d N

CD

S

cree

ning

Pro

gram

NG

OC

ance

r an

d ot

her

NC

Ds

2011

Can

cer-

rela

ted

mes

sage

s to

hom

e,

brea

st a

nd m

outh

exa

min

atio

n ed

ucat

ion,

hea

lth in

form

atio

n ab

out

diet

, life

styl

e an

d to

bacc

o

Wom

en re

late

d to

can

cer

and

fam

ily m

embe

rs in

two

slum

s of

D

haka

23



Pro

gra

m /

Inst

itut

ion

Typ

eD

isea

ses/

risk

fac

tors

in

fo

cus

for

awar

enes

sA

ctiv

ity

star

ted

o

r co

mp

lete

dTo

ols

fo

r ra

isin

g a

war

enes

sTa

rget

gro

up a

nd c

ove

rag

e

Ban

glad

esh

Ant

i-Tob

acco

A

llianc

e A

llianc

eTo

bacc

o19

99A

rran

ging

ant

i-tob

acco

ral

lies,

se

min

ars,

dis

sem

inat

ion

of le

aflet

s,

man

dato

ry d

ange

r m

essa

ges

on

ciga

rett

e pa

cket

s, m

edia

adv

ertis

ing

Gen

eral

pop

ulat

ion

and

gove

rnm

ent

EM

INE

NC

E, 2

pro

gram

s:

Com

mun

icab

le D

isea

ses

Pro

gram

(NC

DP

) & U

rban

Hea

lth

and

Dem

ogra

phic

Sur

veilla

nce

Pro

gram

(UH

DS

P)

NG

ON

CD

s

Info

rmat

ion

abou

t cau

ses,

co

nseq

uenc

es, a

nd p

reve

ntio

n an

d tr

eatm

ent o

ptio

ns o

f maj

or N

CD

s in

ho

me

visi

ts

Gen

eral

pop

ulat

ion

in p

rogr

am

area

(one

are

a of

Dha

ka c

ity)

24



ANN

EX 5

. PU

BLIC

PO

LIC

Y IN

PO

PULA

TIO

N H

EALT

H P

ROM

OTI

ON

Pha

se 1

Pha

se 2

Pha

se 3

Pha

se 4

Det

erm

ine

ove

rall

stra

teg

ic a

pp

roac

h in

sid

e an

d o

utsi

de

go

vern

men

tP

reve

ntio

n st

rate

gy

dev

elo

ped

, par

tner

s id

enti

fied

Bus

ines

s an

d in

dus

try

eng

aged

as

com

mun

ity

par

tner

s

Co

mm

unit

y, b

usin

ess

and

in

dus

try

are

pla

ying

the

ir

role

in n

atio

nal s

trat

egy

Gov

ernm

ent s

trat

egy

is m

ainl

y in

the

area

of n

utrit

ion,

infe

ctio

us

dise

ases

, mat

erna

l and

chi

ld h

ealth

.

Gov

ernm

ent h

as e

ndor

sed

the

Str

ateg

ic P

lan

for

Sur

veilla

nce

and

Pre

vent

ion

of N

CD

s in

Ban

glad

esh,

of w

hich

hea

lth p

rom

otio

n is

a

com

pone

nt.

Key

str

ateg

ies

incl

ude

supp

ort a

nd fa

cilit

atio

n fo

r de

velo

pmen

t of

publ

ic p

olic

y th

roug

h pr

omot

ion

of h

ealth

y lif

esty

le, c

olla

bora

tion

amon

g st

akeh

olde

rs, p

artn

ers;

invo

lvem

ent o

f hea

lth p

rofe

ssio

nals

in

hea

lth p

rom

otio

n; c

apac

ity b

uild

ing;

impr

ovin

g co

mm

unity

kn

owle

dge.

How

ever

in p

ract

ice

not m

uch

is h

appe

ning

at t

he

grou

nd le

vel.

Som

e ex

tern

al p

artn

ers

wer

e as

sign

ed h

ealth

pro

mot

ion

in th

e S

trat

egic

Pla

n fo

r S

urve

illanc

e an

d P

reve

ntio

n of

Non

-Com

mun

icab

le

Dis

ease

s in

Ban

glad

esh

2007

-10.

How

ever

, no

eval

uatio

n ha

s be

en

done

on

thei

r ac

tiviti

es. F

urth

er p

artn

ers’

nam

es h

ave

been

exc

lude

d in

the

upda

ted

2011

-15

vers

ion.

Wom

en’s

can

cer

and

scre

enin

g pr

ogra

m is

bei

ng u

nder

take

n by

a

natio

nal N

GO

.

NH

FH&

RI h

as a

sm

okin

g ce

ssat

ion

clin

ic p

rom

otin

g se

cond

ary

prev

entio

n.

Pre

vent

ion

stra

tegy

has

bee

n id

entifi

ed a

nd

deve

lope

d as

par

t of t

he s

urve

illanc

e an

d pr

even

tion

of N

CD

s. P

artn

ers

have

bee

n id

entifi

ed fo

r im

plem

enta

tion.

Som

e ke

y pa

rtne

rs a

re C

BO

s (B

angl

ades

h S

ocie

ty o

f Rad

iatio

n O

ncol

ogy,

BM

A,

OG

SB

, Ped

iatr

ic O

ncol

ogy

Soc

iety

, BN

A,

Ban

glad

esh

Can

cer

Soc

iety

), pu

blic

- pr

ivat

e pa

rtne

rshi

ps a

nd d

evel

opm

ent p

artn

ers

(Wor

ld B

ank,

DFI

D, I

DB

, JIC

A, C

IDA

, SID

A,

WH

O, U

NFP

A a

nd U

NIC

EF)

.

How

ever

ther

e is

lack

of m

onito

ring

/ ev

alua

tion

repo

rts

whi

ch s

how

s th

e ef

fect

iven

ess

of th

e st

rate

gy a

nd th

e ro

le o

f th

e pa

rtne

rs.

Cur

rent

ly lo

w e

ngag

emen

t fro

m b

usin

ess

and

indu

stry

.

Bro

ad a

dvoc

acy

and

rese

arch

is n

eede

d to

se

nsiti

se b

usin

ess

and

indu

strie

s.

Not

cle

ar y

et.

Res

earc

h is

nee

ded

to

unde

rsta

nd h

ow c

omm

unity

, in

dust

ry a

nd b

usin

ess

can

be

invo

lved

in p

opul

atio

n-ba

sed

heal

th p

rom

otio

n.

Ag

ree

eval

uati

on

and

acc

oun

tab

ility

fr

amew

ork

Imp

lem

enta

tio

n o

f p

op

ulat

ion

stra

teg

ies

com

men

ced

An

eval

uatio

n fra

mew

ork

has

been

de

velo

ped

in th

e S

trat

egic

Pla

n fo

r S

urve

illanc

e an

d P

reve

ntio

n of

NC

D. B

ut

acco

unta

bilit

y is

sue

has

not b

een

addr

esse

d in

the

fram

ewor

k.

Not

in p

lace

. It w

ould

re

quire

lot o

f fun

ds if

bot

h pr

even

tion

and

cura

tive

serv

ices

are

take

n in

to

cons

ider

atio

n.

Dev

elo

p s

trat

egy

for

leg

isla

tio

n, t

axat

ion

and

reg

ulat

ion

Str

ateg

y an

d le

gisl

atio

n fo

r to

bacc

o co

ntro

l is

in p

lace

. Ove

r th

e pe

riod

man

y le

gisl

ativ

e ac

tions

hav

e be

en im

plem

ente

d. T

axes

hav

e be

en r

aise

d fo

r to

bacc

o-re

late

d pr

oduc

ts.

25



ANN

EX 6

. SE

RVIC

E D

ELIV

ERY

MO

DEL

Pha

se 1

Pha

se 2

Pha

se 3

Pha

se 4

Iden

tify

hig

h-ri

sk p

op

ulat

ions

by

key

char

acte

rist

ics

of

gen

der

, ag

e, lo

cati

on

and

eth

nici

tyD

evel

op

ser

vice

del

iver

y m

od

el f

or

smal

l-sc

ale

inte

rven

tio

n fo

r ea

rly

dia

gno

sis

and

tre

atm

ent

Less

ons

fro

m P

hase

1 a

nd

scal

ing

up

to

exp

and

co

vera

ge

Trea

tmen

t o

f N

CD

s fu

lly in

teg

rate

d

into

mai

nstr

eam

pri

mar

y he

alth

ca

re s

ervi

ces

nati

ona

lly a

nd a

re

sust

aina

ble

Ris

k fa

ctor

sur

vey

has

iden

tified

hig

h-ris

k po

pula

tion

by

key

char

acte

ristic

sN

CD

ser

vice

mod

el ‘N

CD

cor

ners

’ are

cu

rren

tly b

eing

pilo

ted

in 3

UH

Cs.

S

ervi

ce d

eliv

ery

mod

el o

f BA

DA

S is

co

mpr

ehen

sive

(com

pris

es c

ompo

nent

s of

prim

ary,

sec

onda

ry a

nd te

rtia

ry c

are)

an

d ba

sed

on c

ross

-fina

ncin

g st

rate

gy

that

mob

ilises

reso

urce

s fro

m r

iche

r to

po

or.

Gov

ernm

ent p

lans

to e

xpan

d th

e N

CD

cor

ners

to 7

0 pr

imar

y an

d se

cond

ary

care

faci

litie

s ov

er ti

me.

N

ot m

uch

is p

ublis

hed

abou

t the

ro

le a

nd fu

nctio

ns o

f the

NC

D

corn

ers.

Not

yet

. Bef

ore

reac

hing

this

pha

se,

the

coun

try

is e

xpec

ted

to e

xam

ine

serv

ice

deliv

ery

mod

els

and

unde

rtak

e co

st-b

enefi

t ana

lysi

s.

Iden

tify

NG

O a

nd c

om

mun

ity

par

tner

s fo

r se

rvic

e d

eliv

ery

Com

mun

ity p

artn

ers

for

serv

ice

deliv

ery

have

not

bee

n id

entifi

ed a

ppro

pria

tely.

NG

Os

invo

lve

com

mun

ity p

artn

ers

on s

peci

fic d

isea

ses

and

have

lim

ited

activ

ities

on

NC

Ds

exce

pt a

war

enes

s ra

isin

g.

At P

HC

leve

l, m

ost o

f the

NG

Os,

priv

ate

and

PP

P

orga

nisa

tions

wor

k on

bui

ldin

g aw

aren

ess,

pro

vidi

ng

trai

ning

to h

ealth

car

e pr

ovid

ers

and

impl

emen

ting

pilo

t pr

ogra

ms.

At t

he s

econ

dary

and

tert

iary

leve

l, ke

y ro

le is

pla

yed

by N

HFH

&R

I, B

angl

ades

h In

stitu

tion

of R

esea

rch

on

Dia

bete

s, E

ndoc

rine

and

Met

abol

ic D

isor

ders

and

NIC

VD

Iden

tify

tra

inin

g n

eed

s fo

r p

ilot

del

iver

y

As

part

of U

pzilla

, NC

D tr

aini

ng is

bei

ng g

iven

to h

ealth

ca

re p

rovi

ders

.


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