The Ottawa Charter for Health Promotion and its stand on health could be considered a new era of public health revolution, conceptualising health as a “resource for everyday life, not the object of living.”
The charter underpinned a philosophy: “Health for all,” which facilitated a shift in focus from factors that cause the disease to those who support human health and well-being and subsequently became the driving force of the New Public Health movement.
It proposed a revolutionary shift in perspective from input to outcomes, and governments at different levels were to be held accountable for ensuring health care of their populations, not just for the health services they provided.
Although mythically accepted, the famous proverb “prevention is better than cure” is hardly practised in most of the situations. In fact, preventive health care aims to control disease through restricting exposure to causal factors.
Famous epidemiologist Geoffrey Rose coined the term “prevention paradox” to describe a paradoxical situation whereby the burden of disease in populations of low or moderate health risk is actually higher than that of high risk populations.
This discovery asks to move away from the traditional preventative approach, which usually used to target just those people considered “high risk” to reduce the burden of disease within a population by targeting the main source of diseases with low or moderate risk.
Rose proposed two distinct but complementary approaches to prevention, ie individual cases of disease as well as those amongst a population, termed as high-risk and population-level strategy.
The high-risk approach aims to take preventive interventions to individuals at greatest risk and the population approach attempts to lower the level of risk within a population group by reducing the exposure levels.
Why is a population strategy necessary for Bangladesh?
Bangladesh has been very successful in preventing diseases which were once believed to be highly epidemic in nature, eg polio, tuberculosis, and diarrhoea through effective implementation of high-risk strategies by identifying the vulnerable group of the population and reaching out.
These types of diseases are known as communicable or infectious diseases.
On the other hand, globally, an epidemiological transition from communicable/infectious diseases is profoundly noticeable, as in Bangladesh.
Comparing the disease burden data of WHO for 2000 and 2012 measured by disability-adjusted life year (DALY), it can be seen that Bangladesh is experiencing the epidemiological transition to more non-communicable diseases.
A non-communicable disease (NCD) is by definition non-infectious and non-transmissible among people.
Although NCDs have been variously defined, from a health science perspective, they are limited to four major disease categories and are linked by common risk factors: Cardiovascular diseases, diabetes mellitus, cancers, and chronic obstructive pulmonary disease (COPD).
In addition, stress and psychological depression are the very common types of NCDs among the urban population. Currently, NCDs are the leading cause of death in low and middle-income countries. Research shows that over 80% of cardiovascular and diabetes deaths, and almost 90% of deaths from chronic obstructive pulmonary disease, occur in low and middle-income countries. Compared with high-income countries, NCDs also kill at a younger age in low and middle-income countries.
Statistics show that the 10-19 age group is currently the most vulnerable group. This young group can serve Bangladesh by contributing to the economy, provided they remain healthy and active
Statistics show that the 10-19 age group is currently the most vulnerable group. This young group potentially can serve Bangladesh by contributing to the economy, provided they remain healthy and active.
Therefore, a population-level strategy is urgently required to reduce the risk factors of non-communicable diseases.
Most of the NCDs are influenced by behavioural, socio-economic, and environmental risk factors. Behavioural risk factors include tobacco use, physical inactivity, and unhealthy diet.
Socio-economic risk factors include poverty, lack of resources and access to health services, education; and environmental risk factors include ambient air quality, etc.
To ensure productive and sustainable usage of this manpower, Bangladesh will need to create a healthy living environment for them, which is possible by adopting the population-level strategy.
High personal cost in health care
A newspaper published a report last year on the basis of Bangladesh National health Accounts (1997-2012) report. It showed that house-holds of Bangladesh have to pay about 63.3% as health care cost whereas the government’s expenditure is only 23.09%.
According to a WHO estimate, Bangladesh government spends only 2% in the public health sector of the total cost involved in the health sector. Ironically, the highest household out-of-pocket expenditure (43%) goes to purchasing of medicine and equipment, which is even higher compared to other lower and middle-income countries (27.6%).
This is a frustrating situation from both a government and population perspective. High dependency of “high-risk” or clinical solution of health care pushes the median income households towards socio-economic risk factors.
On the other hand, the government is not in a situation to formulate a citizen-friendly health policy. To overcome this, a concerted effort is required to change the medicine dependency mindset of Bangladeshi population.
This concluding part of this long form will be published tomorrow.