Bangladesh policy on prevention and control of non-communicable diseases: a policy analysis

Non-communicable diseases (NCDs) are the most prominent cause of morbidity and mortality worldwide [1]. According to the Global Burden of Disease study, NCDs were responsible for the deaths of 38 million people in 2013 [2]. Forty-two percent of NCD deaths occurred among people under 70 years of age and of those deaths, 82% were in the low- and middle-income countries (LMICs). The burden of NCDs are projected to exceed the combined burden posed by communicable, maternal, perinatal, and nutritional diseases by 2030 and would emerge as the most common cause of death taking more lives than all other causes combined if appropriate measures are not taken without delay [3, 4].

In order to tackle the burden of NCDs, there is a need for comprehensive, coherent and multi-sectoral policies and strategies at international, national and local levels [5, 6]. This has already been recognized by the World Health Organization (WHO) in its 2013–2020 Action Plan for the Global Strategy for the Prevention and Control of NCDs (hereafter referred to as the Action Plan) [7]. This action plan has set six objectives for the prevention and control of NCDs. While this has increased awareness regarding the growing burden posed by NCDs and the need for effective policy response, it remains unclear how far it has led to the development and implementation of appropriate policies, particularly in developing countries [8].

The developed countries, in most cases, have already undertaken broad policy and programmatic analysis to address the challenges posed by the NCDs. However, effective application of such policy analysis seems to remain limited [8, 9]. It may be noted that while more than 70 % (72%) of research on the burden of NCDs are conducted in high income countries, Low and Middle-income countries (LMICs) are home to only 57% of such research is conducted in low and middle income countries [10]. Nevertheless, seldom such research translates into concrete policy actions in LMCs. Moreover, there is an acknowledged lack of theoretical and conceptual framework that could be used to design appropriate healthy public policy in LMICs [11].

Like many other developing countries, in Bangladesh also non-communicable diseases (NCDs) are emerging as major cause of morbidity and mortality, accounting for 61% of deaths [12]. The most common NCDs include cardiovascular diseases, diabetes mellitus, cancer, and chronic respiratory diseases. As the prevalence of these diseases increase, they will impose an even greater burden in the near future [13]. In response to these emerging trends, the Government of Bangladesh has designed and introduced some innovative initiatives. A substantial number of policy documents have been published to address the critical issues related to the prevention and control of NCDs; however, little effort has been made to conduct a comprehensive analysis of the past and current policy instruments with a view to learn from the experience. The study uses the WHO Action Plan framework and six objectives for the prevention and control of NCDs. Since Global Action Plans provide a guide to developing national policy framework and also guide health care systems on how to manage NCDS and in comparing it by region. This analysis of national NCD policies in low-income Bangladesh allows for an assessment of the extent to which the objectives of the WHO Action Plan have been met at a policy level. It could also be useful in better understanding the operational dynamics of the Ministry of Health’s planning cycle.

Although the study is aimed at comprehensively review and analyze the NCD policies and plans of Bangladesh following the framework of the WHO Action Plan, due to the paucity of available data, it could not cover all the NCDs.

Of the 51 documents analyzed, seven (13.7%) were research/survey, nine were on policies (17.7%), while seventeen (33.3%) were on acts. On the other hand, five (9.8%) and thirteen (25.5%) were related to guidelines and/or strategic plans/documents respectively from government institutes and non-government institutes (Table 1). Table 2 presents the summary of policy documents against objectives of the action plan. In addition it may be noted that Bangladesh all guideline are usually developed by non-government organization organizations and adopted by the government.

The government of Bangladesh introduced numerous of initiatives to combat chronic NCDs. A total of 51 relevant documents were identified. Seven (14%) were research and/or surveys, nine (18%)were on formulated policies, while seventeen (33%) were on action programmes. Five (10%) were related to guidelines and thirteen (25%) were strategic planning documents from various government organizations or institutions.

One of the most effective initiatives was the establishment of NCD corners at the Upazila Health Complexes. The 2013 ban on tobacco product advertisements and the more recent introduction of plain packaging for tobacco product materials by the government also make evident to be effective initiative in combating NCDs [18]. The National Safe Food Act of 2013 was aimed at safeguarding the health of the general population by ensuring food safety. The Act empowered regulatory bodies in conducting research on food, standardizing the quality of food, and controlling the production, import and sale of food products. However, effective enforcement of these policies and acts remains problematic. Close monitoring and supervision of the system is lacking making it difficult to ensure proper implementation of these policies at the ground level. A multi-sectoral approach is also lacking that could maximize the positive output of these policies and acts. Bangladesh has introduced a National Drug Policy (NDP), however the health system is not fully prepared to understand and effectively address the epidemiological and demographic transitions that affect the efficacy of the National Drug Policy. There is a critical need to reform the NDP with a view to accommodate medicines and supporting resources for handling NCDs. Similarly, while the National Women Development Policy recognizes that during every stage of a woman’s life she has the right to receive the highest level of nutrition, physical, and mental health care, it remains silent on pregnancy related health issues including hypertension, diabetes, and epilepsy. Bangladesh adopted the National Children’s Policy and educational policy to promote good physical and mental health for children by ensuring proper nutrition, healthy psychological development and the opportunity for physical exercise. However, there is little serious effort in properly implementing the said policy. With a view to promote health and prevent NCDs through physical exercise, WHO outlined various guidelines for creating opportunities for games and physical activities in educational institutions [19]. Unfortunately, educational institutions in Bangladesh, especially in urban areas, lack adequate space or playground for physical activity. The National Sports Policy also emphasized establishing and maintaining open space or fields in all educational institutions. Again, the policy may be remains poorly implemented. There are also directions to establish sports facilities, swimming pools and gymnasium in educational institutions - from village to the city level. However, little attention is being paid to operationalize these directives.

The national agricultural policy clearly emphasized the need to diversify the agriculture sector and produce agricultural products with higher quality of nutrition to satisfy the nutritional needs of the general population. However, in this case too there are no clear directions in ensuring the availability of fresh vegetables and fruits for the city dwellers. The National Integrated Multimodal Transport Policy emphasized on walking and cycling as mode of primary commute. The policy also emphasized the need to prevent air pollution and that of using good quality fuel in vehicles. The policy, therefore, put a ban on two-stroke engines. Nevertheless, there is little effort in enforcing these policy guidelines.

A recent study in Bangladesh entitled “A scorecard for tracking actions to reduce the burden of non-communicable diseases” reported that among the four domains of governance, risk factor surveillance, research, and health system response, the country’s performance score was low in three domains, except for the governance domain (moderate performance) [20]. It means that although the government initiated many policies or programs, there was a clear lack of forceful implementation and monitoring of these policies and programs. On the other hand, the country lacks any integrated community public health program focused on monitoring NCDs on a regular basis. Bangladesh also lacks any national surveillance program focused on NCDs. Unfortunately, only a few tertiary hospitals maintain such NCD surveillance systems [21]. Another study identified a total of 11 NCD programs in Bangladesh focusing on tobacco-related illnesses, diabetes or cardiovascular diseases [22].

In short, Bangladesh designed and introduced numerous policies and programs aimed at addressing challenges posed by surging chronic non-communicable diseases. However, serious efforts may be improperly implementing these policies and programs were critically lacking.

Similar to the resent one, a study in Mongolia using WHO 2008–2013 NCD Action Plan came out with similar findings the Mongolian government had a well-developed action plan on NCDs that lacked forceful implementation [23]. Sadly, many other developing countries also suffer from similar failures in forcefully implementing NCD policies and programs.

Although the analysis is limited to electronically available policy document, government of Bangladesh successfully demonstrated a positive response toward global action plan through institutional recognition of NCDs, high level coordination mechanism like designated line director, management and information system for NCDs and treatment corner in the primary health care facilities, integrated NCD programs in the community level, inclusion of NCDs in the sector health program. Beside the maternal and child health issues, the government increased the readiness of health workforce in NCDs due to high and dual burden. Largely, a number of policy documents on NCDs are available, but significant effort is required for implementation and evaluation how these policies or acts can be effectively implemented in the health system further strengthened to effectively address the NCDs. Needless to say, this policy analysis could also guide monitoring, opportunities and challenges for assessing the success of the health system in tackling NCDs and will aid for corrective measures at an early stage within the resource poor context.