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Dhaka Tribune

OP-ED: Non-communicable disease: Incidence, threat, and surveillance

Bangladesh needs a value-based approach to health care that also promotes wellness

Update : 06 Dec 2020, 11:19 PM

Four major non-communicable diseases (NCD) are responsible for 67% of all premature deaths in Bangladesh: Cardiovascular disease, diabetes, cancer, and chronic respiratory disease. The World Health Organization (WHO) estimates that globally, seven out of 10 deaths are caused by these chronic illnesses.

While the epidemiological burden is shifting to non-communicable diseases, in Bangladesh our health system is still primarily focused on addressing acute illnesses, communicable diseases, as well as maternal and child health care. It is essential that our health care sector improve NCD care to avoid long-term population productivity loss and high health expenditure. 

In the absence of health insurance, health care is an out-of-pocket expense in Bangladesh. The medical expenditure of any household with at least one chronic disease is significantly higher when compared to households having no disease. NCD-afflicted households are more prone to fall into financial hardships by selling assets or informal borrowing to cover their medical costs. This is a core concern behind the UN Sustainable Development Goals’ (SDG) universal health coverage component.

NCDs are directly related to diet and lifestyle. Elevated blood pressure, high blood sugar level, high blood cholesterol level, and obesity are the risk factors that are precursors of developing heart disease, diabetes, cancer, stroke, and kidney disease. These risk factors are linked to a lack of physical activity, unhealthy dietary habits, smoking, alcohol abuse, stress, and air pollution. 

Ironically, economic prosperity indirectly causes these poor habits. Higher discretionary income, time constraints, and the availability of processed convenient food makes it easier for people to fall into poor eating and physical habits. Bangladesh’s economic transition is reflected in people’s behaviour, where more people choose comfort over effort, and consume readily available food laden with high concentrations of salt, sugar, and fat. These dietary elements when taken in excess increase the risk of developing the common NCDs along with kidney disease, which is also disturbingly high in the country.

The Covid-19 pandemic has also proven to be more fatal among people with NCDs. Studies have shown that individuals with diabetes, hypertension, and ischaemic heart disease endure a long haul to recovery and are more likely to suffer from severe forms of Covid-19. 

What are the guidelines to reduce NCD prevalence?

The Sustainable Development Goal 3.4 seeks to reduce one-third of premature mortality from NCDs by the year 2030. WHO has also set a target to reduce mortality from NCDs by 25% by the year 2025. To achieve this, certain risk factors were identified to be reduced globally: Smoking, alcohol consumption, salt intake, physical inactivity, hypertension, diabetes, and obesity. 

Additionally, essential medicines to treat NCDs and counseling drug therapy for eligible people should be made available. A financial analysis done by WHO claims that an annual investment of less than $1 per person -- or 4% of total health care spending -- in a country like Bangladesh can avoid substantial gross national productivity loss. 

Bangladesh already has policies that address tobacco use, alcohol consumption, salt intake, diabetes control, and some clinical and dietary guidelines. There is no policy yet to tackle physical inactivity, saturated and trans-fat consumption, hypertension, and medicine supplies. Also, even though an NCD monitoring department has been established in the Directorate General of Health Services to supervise primary health care facilities and community clinics, there is no specific surveillance system that reports NCD prevalence or NCD-related morbidity and mortality. 

Ideally, the NCD department should report the rise of all chronic diseases and collaborate with the nutrition department to design actionable plans. It is also the responsibility of the Management Information System to support their work by generating reports of the NCD burden from across the country through an effective health information system. However, most of these departments work in silo, and data feeding into the health information system in DGHS lacks compartmentalization. 

It is imperative to measure the major prevailing risk factors to evaluate, anticipate the trends, and take appropriate measures to contain NCD outbreaks. Hence, the importance of an NCD surveillance system. 

What is the correlation between nutrition and NCDs?

41% of Bangladesh’s population is between the ages of 25 to 54. Understanding macro- and micronutrients in food and their effect on our health is vital to avoiding an epidemic of NCDs in the near future. Physical activities must be promoted to burn the higher calories consumed since our genetic makeup remains the same and does not change with our changing habits. 

Guidance on important nutrition questions should be offered: What is whole grain and resistant starch?  Why are they better than refined carbohydrates? How can they reduce insulin surge and sudden sugar spike? How can foods containing unsaturated fats help lower bad cholesterol? What are the foods containing saturated and trans fats? How does salt intake increase blood pressure? How does a plant-based, fibre-rich diet with modest amounts of meat and dairy help maintain a healthy weight, reduce blood pressure, and diabetes?  What does a meal of wholegrain, minimally processed, and nutrient-rich food look like? 

Individual behavioural change requires a supportive environment. Transparency in the food supply system, including wholesome food production and distribution, restrictions on promoting unhealthy processed food, and front pack labelling must also be advocated so that consumers can make informed choices. 

What are the targeted actions to tackle NCDs?

Bangladesh follows the interventions set by WHO when designing policies, but we should also recognize the country-specific incidence of specific diseases to enable a well-rounded approach to tackle NCDs. 

Nutrition- and lifestyle-specific intervention policies that needs revisiting: 

1) Reduce the level of salt, sugar, and fats in packaged food and improve food labeling 

2) Ban and eliminate industrial trans-fat use 

3) Impact on children of advertisements of foods and beverages high in saturated fats, sugars, and salts 

4) Create mass media campaigns and institutional support to promote intake of fruits and vegetables 

5) Reduce intake of high calorie foods rich in saturated fats and sugars 

6) Encourage physical activities and daily movement by building safe sidewalks, parks, and tracks

The government must prioritize implementation of: 

1) Referral systems from primary health care level and up 

2) Scale up early detection and cost-effective interventions 

3) Train and develop a skilled health workforce 

4) Procure basic essential medicines to prevent and manage NCDs from the community clinic level and up

On top of a nationwide NCD surveillance system, innovative digital approaches can scale up cost-effective screening to ensure better prognosis of chronic diseases. 

Are all the policies and activities relevant for Bangladesh?

The argument is not about setting policies after policies. In fact there are extensive programs and operational policies on both NCDs and nutrition in Bangladesh. The problem is whether there is forceful implementation and monitoring of these policies.

Are the actions that are taken ever measured? Is there any accountability of failure or success and retrospective study? And what about integration with other sectors? It is clearly indicated that nutritional and NCD programs require collaboration not only with each other but with other sectors as well to minimize the risk factors. How do we analyze all of this without surveillance? 

NCD surveillance on a regular basis will generate evidence for further policy dialogues and advocacy. To achieve this, Bangladesh must prioritize the implementation of a robust health care information system that includes a multi-layered surveillance system monitoring all the health outcomes, the risk factors, and geographical distribution of disease prevalence.

Bangladesh needs a value-based health care approach that promotes health and wellness and is focused on prevention. As our resources are limited, investing in health data collection and integration systems will generate analysis that will indicate cost-effective interventions that can potentially lessen the economic burden of providing expensive curative health care. 

It is a country of the youth and to ensure a generation of high productivity, we need to take measures that protect them.

Dr Maliha Mannan Ahmed is the Founder and Executive Director of Organikare. She has an MBBS, MBA, and a Masters in health care Leadership.

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