93857 Knowledge Brief Health, Nutrition and Population Global Practice POLICY OPTIONS FOR TACKLING NONCOMMUNICABLE DISEASES IN BANGLADESH Sameh El-Saharty and Karar Zunaid Ahsan July 2014 The Growing Burden of NCDs KEY MESSAGES: Bangladesh has made impressive progress in the social  Bangladesh is undergoing an epidemiologic sectors during the last decade. It has increased its literacy transition with a growing burden of non- rate and life expectancy at birth; continued its fertility communicable diseases (NCDs) accounting for reduction; sustained child immunization above 90 percent a larger proportion of mortality and morbidity. (lowering infant and child mortality); and cut its maternal mortality ratio by 40 percent. In health services delivery,  The major causes of mortality from NCDs are cardiovascular diseases, cancer, respiratory antenatal care visits for pregnant women by medically diseases, injuries, and diabetes, which are all trained providers rose from 33 percent in 1999–2000 to linked to a few common risk factors such as 53 percent in 2013, and delivery by such providers from tobacco, air pollution, dietary and occupational 12 percent to 34 percent in the same period (NIPORT risks, hypertension, and high blood glucose. 2012; Sultana et al. 2014) (Box 1).  As the population is aging, the population suffering from hypertension and diabetes are Box 1: Economic and social gains—but still high projected to reach 39 million and 27 million by poverty levels 2025, respectively. Since the turn of the century, gross domestic product  Health spending is projected to rise by about (GDP) has been rising at a respectable 5.9 percent a year in real terms, or by 4.5 percent per capita, 47.7 percent by 2020, due to population contributing to a decline in poverty from 49 percent in growth and aging, exacerbated by NCDs. 2000 to 32 percent in 2010, in a period when  To address these challenges, the health Bangladesh had disproportionate poverty reduction for system needs to adjust to focus on prevention, its growth. Annual population growth has dropped from 2.3 percent in 1981 to 1.4 percent in 2011. Life improve coordination across sectors, balance expectancy at birth for men and women is rising clinical with population-based interventions, constantly and stands at 69 years in 2011, up from 58 and ensure the provision of coordinated care years in 1994. These health and social gains are across the service delivery system. remarkable because Bangladesh remains one of the poorest countries in the world—in 2010 an estimated 32 percent of the population, mainly in rural areas, still lived below the national poverty line. Source: World Bank 2015. Source: World Bank 2013. Page 1 HNPGP Knowledge Brief  New population and health challenges have arisen from Figure 2. Leading NCD Risk Factors for rapid demographic and epidemiological transitions, Bangladesh, 2010 Estimates urbanization, social transformation, and human development:  The proportion of the population aged 60 years or more is projected to increase hugely, such that the elderly will make up 19 percent of the total population by mid-century, potentially increasing the NCD burden and spending on health. An overall rise of about 47.7 percent in health spending between 2000 and 2020 is projected, due to population growth (29.7 percent) and aging (about 18 percent), exacerbated by growth in NCDs.  The burden of disease is shifting—NCDs (including injuries) now account for a larger proportion of mortality and morbidity than communicable diseases, maternal and child health illnesses, and nutrition Box 2: An alarming NCD burden and associated causes combined (Figure 1). This pattern is similar to risk factors in Bangladesh that of high-income countries decades ago. 7.3 percent of the population have CVDs; 66 percent of cancer patients are of working age; Figure 1: Leading Causes of Mortality and Tobacco use rate is one of the highest in the world Morbidity in Bangladesh, 2010 Estimates among both men and women; Salt intake is high; The rate of low birth weight (36 percent) is among the highest in the world; and Nearly 40 percent of children under five are moderately stunted.  The NCD epidemic has an indirect impact on the economy and a direct impact on the financial vulnerability, particularly for the poor (Box 3). NCDs can hold back economic development and poverty reduction efforts. They may reduce per capita income through ripple effects by lowering the labor force headcount and productivity, access to factors of production, savings, and investment in physical capital, while increasing the dependency ratio and  The population suffering from major NCDs like hypertension and diabetes is alarmingly high (one in Box 3: NCDs cost money—for individuals and the every four people) and expected to increase in the wider economy future. A study in 2011 estimated that around 25 Spending on the risk factors for NCDs and managing million people in Bangladesh are hypertensive/ these disorders can hit families’ financial status. For prehypertensive, and 17 million people are diabetic/ example, treatment for diabetes can cost 6–12 months’ prediabetic. As the population is aging, by 2025 the wages ($160 a year); and about half of rural poor numbers are projected to reach 39 million and 27 households in Bangladesh were not poor before a traffic million, respectively. accident. Economywide, one World Health Organization  The major causes of mortality from NCDs are (WHO) study found that tobacco was a major risk factor cardiovascular diseases (CVDs), cancer, respiratory and, alone, cost Bangladesh about $44 million annually. diseases, injuries, and diabetes. Aside from injuries, Another study indicated that the cost for the clinical all are linked to a few common risk factors —(see management of the estimated diabetes prevalence for Figure 2). With other social determinants such as 2011 was $262 million, equivalent to 24percent of the poverty, low education, urbanization, and changing total budget in 2010–11 of the Ministry of Health and lifestyles, the risk of NCDs rises (Box 2). These Family Welfare (MOHFW). factors have long-lasting, transgenerational impacts. Source: Talukder and Ahsan 2011. Page 2 HNPGP Knowledge Brief  personal consumption. The following bullets explore in more detail these options  The NCD burden varies by socioeconomic stratum and form the basis for policy dialogue on how to integrate and gender. For example, the richest households interventions into the national NCD program. have higher prevalence of high blood pressure and  Stewardship and Regulatory Policy Options and diabetes, while the prevalence of serious injury Strategies: Representing the health sector, the among males and females aged 15–59 worsens with MOHFW leads efforts to combat NCDs, including decreasing socioeconomic status. mobilizing non-health sectors. The MOHFW will have to As the burden shifts from maternal and child deaths to spearhead development and implementation of these NCDs, so must the focus of the country’s health system strategic priorities and their full integration in the shift to continue meeting the needs of the population, relevant operational plans. These steps will demand particularly the poor. The health system faces real new skills so that the MOHFW can work effectively with challenges: other sectors to build a multisectoral alliance and o The health system focuses on treatment, not ensure synergy among actions. Further, the MOHFW prevention. should consider: o The regulatory framework is weak. o Assessing periodically NCD mortality, morbidity, o Strategic planning and coordination are lacking burden of disease, high-risk populations, risk-factors across sectors. and their determinants in the health and non-health o The objectives and interventions identified in the sectors, and beyond that the gaps in the policy and country’s health plan—the HPNSDP Strategic regulatory framework for NCD prevention and control. Plan—are not fully reflected in operational plans. o The health service delivery system is fragmented, o Assessing current and future public health spending leading to lack of coordinated care that is critical and health system capacity (institutional and for effectively managing NCDs. management capacity and system intelligence) as well as health service delivery capacity (facilities, human resources, drugs, etc.) and current utilization Key Policy Options and Strategic of ambulatory and inpatient care. Priorities o Reviewing evidence-based public policies, Tackling NCDs comprehensively requires an integrated population-based interventions, and cost-effective approach to mobilize the different sectors of the prevention and treatment interventions (including government, as well as a partnership between the public those in similar countries). and private sectors. Figure 3 represents a Policy Options Framework for the Prevention and Control of NCDs (see o Developing a national policy and multisectoral Table 5.1 in El-Saharty et al. 2013). strategic plan for the prevention and treatment of NCDs in consultation with the major stakeholders The framework is founded on the health sector’s leading (health and non-health, public and private) and stewardship and regulatory role, represented by the improving coordination across the NCD program. MOHFW, including mobilizing the non-health sectors. This foundation upholds two broad categories: population-  Population-based Policy Options and Strategies for based and individual-based policy interventions, on which the Non-Health Sectors: The government should four pillars stand: multisectoral and health sector consider the following policy options that would involve interventions, and clinical preventive and treatment the different sectors: services. o Developing and enforcing laws and regulatory Each policy intervention mobilizes different parts of the mechanisms for the non-health sectors, like health and non-health sectors, and requires very different strengthening policies for tobacco control, food inputs in infrastructure, capacity, and skill sets, while regulation, and road traffic injuries as well as yielding very different outputs and outcomes. Harmonizing strategies to reduce child injury. both sets of policy interventions is necessary to get the o Developing the institutional and human capacity of the right strategic mix so that the population-based policy non-health sectors to address NCD risk-factor interventions complement those delivered to individuals determinants, mobilize the necessary financial within the clinical care system. resources, and develop an effective monitoring and A key initial challenge is to determine the strategic evaluation system. priorities that will capitalize on existing activities, while taking into account the available resources and the main o Population-based Policy Options and Strategies risk factors listed earlier. for the Health Sector: The MOHFW should consider the following actions as its primary options: Page 3 HNPGP Knowledge Brief  health sector in support of NCD prevention and Figure 3. A Policy Options Framework for the treatment. Prevention and Control of NCDs o Establishing a monitoring system for the NCD prevention indicators in public health facilities and conducting impact evaluation studies. Prevention and control of NCDs  Policy Options and Strategies for Individual Clinical Interventions for the Treatment of NCDs in the Health Sector: The MOHFW, working with the private health) interventions Multisectoral (non- Treatment services Clinical preventive sector, should consider the following: interventions Health sector o Strengthening health service delivery to provide high- services quality and effective NCD control and treatment services in selected public health facilities. o Developing strategic purchasing mechanisms to motivate public and private service providers to provide cost-effective and high-quality prevention and Population-based Individual-based treatment services. interventions interventions o Developing and monitoring NCD treatment indicators, Stewardship and regulatory policies and strategies and conducting impact evaluation studies. (leading role by the MOHFW) References El-Saharty, Sameh., Karar Zunaid Ahsan, Tracey L. P. Koehlmoos, and Michael M. Engelgau. 2013. Tackling Noncommunicable Diseases in o Strengthening the health promotion and risk reduction Bangladesh: Now Is the Time. Directions in Development. Washington, DC: World Bank. doi:10.1596/978-0-8213-9920-0. interventions for the general population and/or high- risk groups. NIPORT, Mitra and Associates, and MEASURE DHS ICF. 2012. Bangladesh Demographic and Health Survey 2011: Preliminary Report. o Developing the MOHFW’s institutional and human Dhaka. capacity to manage population-based health Sultana, Shahin, Subrata K. Bhadra, and Mohammed Ahsanul Alam. promotion and risk reduction, and an effective system 2014. Utilization of Essential Service Delivery (UESD) Survey 2013. Dhaka: National Institute of Population Research and Training intelligence and information technology for NCDs, as (NIPORT). well as strengthening and expanding the national surveillance system to include NCDs and their risk Talukder, S.H., and Karar Zunaid Ahsan. “Hypertension and Diabetes,” in Bangladesh Demographic and Health Survey 2011: Policy Briefs. factors Dhaka: NIPORT, Mitra and Associates. 2013: 17-21.  Policy Options and Strategies for Individual Clinical World Bank. 2015. World DataBank World Development Indicators Interventions for Prevention of NCDs in the Health (accessed January 05, 2015). http://databank.worldbank.org/data/views/reports/tableview.aspx. Sector: Along with the options above, the MOHFW will need to adopt, on a priority basis, many of the following actions to complement the population-based interventions while engaging with the private sector: This HNP Knowledge Brief highlights the key findings from o Developing and implementing basic health services in the Directions in Development series publication “Tackling public health facilities for reducing risk factors and Noncommunicable Diseases in Bangladesh: Now is the preventing NCDs. Time” written by Sameh El-Saharty, Karar Zunaid Ahsan, o Strengthening the institutional and human resources Tracey L. P. Koehlmoos, and Michael M. Engelgau (2013). capacity to provide facility-based health promotion, behavior change, and risk-reduction services. o Mobilizing additional financial resources for the health sector, and considering budget reallocation within the The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4