Hypertension and Type 2 Diabetes in Bangladesh Continuum of Care Assessment and Opportunities For Action

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HYPERTENSION AND
TYPE-2 DIABETES
IN BANGLADESH:
CONTINUUM OF CARE
ASSESSMENT AND
OPPORTUNITIES
FOR ACTION
JUNE 2019
This page is for collation purposes
TABLE OF CONTENTS
1.1 Aim of this report ........................................................................................................................................... 1

1.2 Global context.................................................................................................................................................. 2
1.3 Bangladesh health transition .................................................................................................................... 3
2.1 Hypertension cascade, breakpoints and outcomes .......................................................................... 5

2.2 Type-2 diabetes cascade, breakpoints and outcomes ..................................................................... 7
3.1 Policies, strategies and plans on NCD control.................................................................................. 11

3.2 Financing and resources for NCD control ......................................................................................... 12
3.3 Health infrastructure relevant to NCD control ................................................................................ 14
3.4 NCD interventions and costs .................................................................................................................. 16
4.1 Overview of selected care models implemented in Bangladesh .............................................. 21

4.2 Principles and examples of NCD and chronic care models implemented elsewhere....... 23
5.1 NCD policy and resource allocation ..................................................................................................... 39

5.2 NCD burden and risk factors .................................................................................................................. 39
5.3 Major NCD cascade breakpoints ........................................................................................................... 40
5.4 Integrated chronic care models............................................................................................................. 41
5.5 Surveillance, monitoring and evaluation ........................................................................................... 42
CITATION AND NOTES................................................................................................................................................ 63
ANNEXES
v
FIGURES
ES 1 Schematic of continuum of care for chronic conditions ...................................................................xiii
ES 2 Models of care as per NCD Control Operational Plan 2017‒22 ..................................................... xiv
ES 4 Hypertension cascade Bangladesh ........................................................................................................... xvi
ES 5 Diabetes cascade Bangladesh.................................................................................................................... xvii
1.1 NCDs as cause of all deaths by country group, % (2000, 2015) ....................................................... 2
2.1 Hypertension cascade for rural and urban residents aged 35 years and above ........................ 6
2.2 Diabetes cascade for rural and urban residents aged 35 years and above .................................. 8
3.1 Division of funding amongst the health service programmes in 2017‒22 ............................... 13
3.2 Reported medication use by diabetes patients (in percentages, 2014 data) ........................... 18
4.1 Percentage of health facilities providing diabetes and CVD services and respective
medications in rural and urban Bangladesh ......................................................................................... 22
A 1.1 Disability-Adjusted Life Years by cause, Bangladesh, 2016 ............................................................ 45
A 1.2 Distribution of population reporting chronic illness in preceding 12 months by
type of illness, HIES2016 .............................................................................................................................. 46
A 1.3 Prevalence of reported diabetes by sub-population, 2016 HIES .................................................. 46
A 1.4 Death attributable to risk factors, Bangladesh, 2016 ........................................................................ 47
A 3.1 Estimated total burden of hypertension in adults aged 18 years and above
in Bangladesh Divisions ................................................................................................................................ 50
A 3.2 Estimated total burden of diabetes in adults aged 18 years and above in Bangladesh
Divisions .............................................................................................................................................................. 50
A 4.1 Reported hospital admissions for hypertension by Bangladesh Division ................................. 51
A 4.2 Reported hospital admissions for diabetes by Bangladesh Division ........................................... 52
A 6.2 Diagnosis rates of diabetes across countries ........................................................................................ 55
A 7.1 Bangladesh NCD policy context compared to countries with similar GNI per capita ........... 56
A 7.2 Bangladesh NCD score card results in international comparison ................................................ 56
A 8.1 Bangladesh total health spending, 2014................................................................................................. 57
A 8.2 Allocations and level of expenditure of HPNSDP in FY 2015‒16.................................................. 57
A 8.3 Share of government funding across health implementation plans, 2017‒22........................ 58
A 9.1 Unit cost distribution for hypertension management, diabetes mellitus, stroke
and acute ischemic heart disease .............................................................................................................. 59
A 9.2 Estimated cost of interventions to reduce NCD risk factors in three countries ...................... 59
A 11.1 Infographic: New model of NCD care in A) Urban and B) Rural Bangladesh ........................... 61
vi
TABLES
3.1 Public sector health facilities visiting numbers per year ................................................................ 15
4.1 Highlighted hypertension and diabetes care models in Bangladesh across
the care cascade .............................................................................................................................................. 24
4.2 Bangladesh’s new model for the continuum of care for hypertension and
type-2 diabetes................................................................................................................................................ 29
A 2.1 Benchmarking Bangladesh with countries with similar GNI per capita ................................... 48
A 2.2 Benchmarking Bangladesh with countries in the South Asia Region ........................................ 48
A 2.3 Benchmarking Bangladesh with countries with similar GNI per capita ................................... 49
A 2.4 Benchmarking Bangladesh with countries in the South Asia Region ........................................ 49
A 5.1 Hypertension care: Overview of patient and provider barriers to the
continuum of care .......................................................................................................................................... 53
A 5.2 Diabetes care: Overview of patient and provider barriers to the
continuum of care .......................................................................................................................................... 54
A 8.1 Facility distribution in rural areas of Bangladesh ............................................................................. 58
A 10.1 Drug list for Diabetes Mellitus ................................................................................................................... 60
A 10.2 List of medicines for Hypertension ......................................................................................................... 60
vii
This page is for collation purposes.
ACRONYMS
BADAS Bangladesh Diabetic Somiti (Diabetic Association of Bangladesh)
BDHS Bangladesh Demographic and Health Survey
BDT Bangladeshi Taka
BIRDEM Bangladesh Institute of Research & Rehabilitation in Diabetes,
Endocrine and Metabolic Disorders
BP Blood pressure
CBHC Community Based Health Care
CC Community clinic
CHW Community health worker
CKD Chronic kidney disease
COBRA-BPS Control of Blood Pressure and Risk Attenuation-rural Bangladesh,
Pakistan, Sri Lanka
COPD Chronic obstructive pulmonary disease
CVD Cardiovascular disease
DALY Disability-adjusted life years
DGHS Directorate General of Health Services
DHIS2 District Health Information System version 2
ESP Essential services package
FBG Fasting blood glucose
GBD Global burden of disease
GoB Government of Bangladesh
HIES Household Income and Expenditure Survey
HPNSDP Health, Population and Nutrition Sector Development Plan
HPNSP Health, Population and Nutrition Sector Programme
HRH Human resources for health
HTN Hypertension
icddr,b International Centre for Diarrhoeal Disease Research, Bangladesh
LIC Low income country
LMIC Lower middle income country
MCH Mother & child health
mHealth Mobile health
MNCAH Maternal, Neonatal, Child and Adolescent Health
MO Medical officer
MOHFW Ministry of Health and Family Welfare
NCD Non-communicable disease
NCDC Non-communicable disease control
NHF National Heart Foundation
NIPSOM National Institute of Preventive and Social Medicine
OGTT Oral Glucose Tolerance Test
OOP Out-of-pocket
PEN Package of Essential Non-Communicable Disease
PHC Primary Health Care
ix
PPP Purchasing Power Parity
RADP Revised annual development programme
RBG Random Blood Glucose
SACMO Sub-assistant Community Medical Officer
SLT Smokeless tobacco
T2DM Type-2 diabetes mellitus
UHFWC Union Health and Family Welfare Centres
UZHC Upazila Health Complex
WHO World Health Organisation
x
ACKNOWLEDGEMENTS
This report was prepared under the overall guidance of Prof .David Wilson ( Program Director
and Global Lead, Decision & Delivery Science, World Bank) by Bushra Binte Alam and Anna
Koziel (Senior Health Specialists, World Bank), Nicole Fraser-Hurt, Zara Shubber, Adetayo
Olabiran and Jil Billy Mamza(Consultants, World Bank).
The team is deeply appreciative of the guidance received from. Prof Abul Kalam Azad, DG,
Director General of Health Services(DGHS); Dr. Mohiuddin Osmani, Joint Chief, Ministry of Health
and Family Welfare, Government of Bangladesh.
The study team is grateful for the technical input of key stakeholders and resource persons. This
includes the following experts and teams:
Prof. Enayet Hussain, ADG, DGHS and Line Director, NCD OP; Prof. A K Azad Khan, President, and
his management team at the Bangladesh Diabetic Association; National Prof. Brig. (Retd.)M.A.
Malek, Founder and President, and his team at the National Heart Foundation, Prof. Liaquat Ali,
Vice Chancellor, Bangladesh University of Health Sciences associated with Bangladesh Diabetic
Association, Dr. Mostafa Zaman, Dr. Tara Kessaram and NCD team, WHO, Prof. M. Abul Faiz,
former-DGHS , Mr. Muhammad Abdul Hannan Khan, Team Leader HISP Bangladesh Foundation,
Dr. Aliya Naheed and NCD team, ICDDR,B, and Ms. Rie Ozaki, JICA .
Special thanks go to Mr Shyfuddin Ahmed, Scientist at the ICDDR,B, for accompanying the study
team to Munshiganj District for a field visit, and to the health facilities visited on this occasion. Dr.
Mohibur Nirob, Medical Officer, DGHS, provided insights from practice and document translation.
The team appreciates the contribution of Dr. Muhammod Abdus Sabur and Dr. Asib Nasim
(Consultants ,WB) who supported in collection of data and visits to different sites.
The team also acknowledges the valuable information provided by Tekabe Ayalew Belay
(Program Leader, World Bank). The authors would also like to thank the World Bank peer
reviewers Mickey Chopra (Lead Health Specialist & Global Solutions Lead) and Marelize Görgens
(Senior Monitoring & Evaluation Specialist) for their comments.
xi
“Self-management of chronic diseases
can be challenging for patients, as it
likely needs daily and lifelong changes
to lifestyle, and therefore requires
tailored education and additional and
ongoing support.”
EXECUTIVE SUMMARY
Bangladesh needs to transition from a disease-specific public health care system designed for
infectious diseases and mother & child health (MCH) to an integrated primary health care
(PHC) system with strong out-patient care and community health promotion components.
The non-communicable disease (NCD) burden is very large and new solutions are needed to
reduce NCD risk factors, prevent or slow the progression to disease, and manage complications
sustainably. Bangladesh’s NCD Control (NCDC) Operational Plan 2017‒22 provides a
framework to instigate change to better cater for NCD prevention, care and support.
This analysis was carried out to provide input into the dialogue on how to improve NCD
integrated care and outcomes in Bangladesh. The objectives were to a) Assess the
hypertension (HTN) and type-2 diabetes burden in Bangladesh, including benchmarking, b)
Review Bangladesh’s policy and health care delivery environment for NCDs, c) Determine the
continuum of care for hypertension and diabetes, d) Assess models of NCD and chronic care in
Bangladesh as well as other countries to identify common principles and promising practices,
and e) Identify opportunities for strengthening primary level care for HTN and diabetes. The
methodology consisted of literature review, consultations with experts, data triangulation,
benchmarking against comparable economies, and synthesis of the evidence. For the continuum
of care, the cascade framework was used to assess the stages from screening and diagnosis to
treatment initiation, adherence and disease control (Fig. ES 1).
Figure ES 1 Schematic of continuum of care for chronic conditions
Source: Author’s illustration based on the concept of the chronic care cascade.
xiii
HYPERTENSION AND TYPE-2 DIABETES IN BANGLADESH: CONTINUUM OF CARE ASSESSMENT AND OPPORTUNITIES FOR ACTION
NCD BURDEN IN BANGLADESH AND BENCHMARKING

In 2016, NCDs were The NCD burden in Bangladesh is very large. In 2016, NCDs were
responsible for almost responsible for almost two-thirds (63%) of Disability-adjusted life
years (DALYs) in Bangladesh, while communicable, maternal, neonatal
two-thirds (63%) of
and nutritional diseases accounted for 27% and injuries for 11% of
Disability-adjusted life
DALYs. Ischemic heart disease (IHD), stroke and type 2 diabetes are
years (DALYs) in the main contributors to the NCD burden. In the 2016 Household
Bangladesh, while Income and Expenditure Survey (HIES), HTN, chronic heart disease
communicable, maternal, and diabetes were among the most reported illnesses with rising levels
neonatal and nutritional of reported diabetes in females between 2010 and 2016.
diseases accounted for
27% and injuries for 11% Bangladesh has achieved great success in reducing all-cause mortality
of DALYs. and pre-mature death and improving life expectancy. However,
benchmarking across countries with similar GNI per capita
income levels revealed poor rankings for NCD-attributable premature death for
Bangladesh (rank 11 of 12 for all NCD mortality). Poor rankings were also observed for
premature death due to cerebrovascular disease, chronic kidney disease and chronic obstructive
pulmonary disease (all rank 12), diabetes (rank 11) and ischaemic heart disease (rank 9).
Furthermore, the 12-country benchmarking analysis demonstrates the high share of all-cause
death and disability attributable to major NCD risk factors such as high systolic blood
pressure, high fasting plasma glucose and tobacco smoking.
NCD POLICY, FINANCING AND SERVICE DELIVERY

Bangladesh scores well internationally on NCD policy.1 The government of Bangladesh has
initiated many NCD-related policies or programmes. For example, the country has defined a
NCD-specific Operational Plan and NCD clinical guidelines and has increased excise taxes and
prices for tobacco demand reduction. However, NCD interventions “lack proper planning,
implementation and monitoring”2 according to a recent NCD policy review.
In order to address the challenges and bottlenecks in public sector NCD service delivery, the
Operational Plan proposes the implementation of NCD models of care (Fig. ES 2, see also
Fig. A ll.1).
Figure ES 2 Models of care as per NCD Control Operational Plan 2017‒22 (left: urban model, right: rural model)
Source: Author’s drawings based on NCDC Operational Plan 2017‒22.
xiv
EXECUTIVE SUMMARY
While the models of care are promising, the public sector NCD The annual point-of-
budget is relatively small (<5% of public health sector funding) service payments that
compared to the NCD burden (63% of DALYs). The resulting per
an individual with
capita NCD allocation of US$0.08 is also very low compared to the
diabetes makes each
estimated cost of implementing WHO’s recommended set of “best buy”
interventions in Low and Middle Income Countries (US$ 1.50 per
year represents 27% of
person and year). The Bangladesh Copenhagen Project, in its
the annual
assessment of the benefit of reducing NCD burden through targeted consumption
investment, found HTN medication had an exceptionally high level expenditure average in
of return on investment (BDT 37 benefit for every BDT spent).3 Bangladesh and
Diabetes treatment also showed positive returns, albeit at a much illustrates the
lower ratio, at BDT 3 benefit per BDT spent.4 potential of NCDs
impoverishing
Due to insufficient public sector delivery, out-of-pocket expenditure
patients and their
for NCD care is large in Bangladesh. Chronic care patients face
recurrent expenditures to manage their disease, and disease
families.
complications can lead to expensive hospital stays. Annual payments for anti-diabetes
medication are on average BDT 35,385 (US$ 429), an expense 22 times higher than average
medication costs for non-diabetic patients.5 A diabetic’s annual point-of-service payments
averages at BDT 49,538 (US$ 600). This is 27% of the 2016 HIES reported annual consumption
expenditure average of BDT 185,000 and illustrates the potential of NCDs impoverishing
patients and their families.
Regarding service delivery for NCDs, key challenges include the health system’s orientation
towards MCH and communicable diseases at PHC level at the expense of NCDs, poor NCD
screening, the lack of availability of a tier-specific essential services package to patients, the weak
patient referral system, and the inadequate coordination of NCD control across health and non-
health sectors and between state and non-state actors. These and other factors lead to a sub-
optimal continuum of NCD care.
CONTINUUM OF CARE CASCADE FOR HYPERTENSION AND

DIABETES
Hypertension Cascade
A published meta-analysis assessing the prevalence of hypertension across diverse age groups
and populations in Bangladesh estimated overall HTN prevalence at 14%.6 There is a
significantly higher HTN burden in urban settings and among females. Using data from
Bangladesh’s Demographic and Health Survey (DHS), this analysis estimated that in 2016, about
4.1 million adults aged 35+ years had stage 27 HTN regardless of treatment status, with rural
females most affected. The HTN continuum of care for adults aged 35+ years in Bangladesh
highlights significant breakpoints (Fig. ES 3).
xv
Figure ES 3 Hypertension cascade Bangladesh
Sources: BDHS 2011 and 2016 UN population estimates.
The 2013 National HTN Guidelines8 focus on the PHC level and provide much relevant guidance.
However, the guidelines do not provide sufficient information on HTN screening, such as
screening strategies and targeting of specific populations. Furthermore, despite HTN treatment
adherence being a major challenge, insufficient guidance is provided on treatment adherence
support.
The analysis estimated that identifying 50% (or 7.1 M) of undiagnosed hypertensive people aged
35+ years by 2022 (a NCD Plan target) would cost about BDT 1140 M (US$ 13.8 M). Treating the
currently diagnosed 7.3 M hypertensives aged 35+ translates into a cost of approximately BDT
7800 M (US$ 95 M).
Diabetes cascade
Bangladesh is among the top 10 countries with the highest number of people living with
diabetes, and has a relatively low diagnosis rate.9 A meta-analysis including studies conducted
across a diversity of age groups and populations estimated the prevalence
Bangladesh is among
of diabetes at 6% in Bangladesh.10 A study conducted at a tertiary diabetes
the top 10 countries
hospital in Dhaka estimated that only 20% of DALYs forgone due to diabetes
with the highest were due to diabetes episodes and 80% were due to diabetes complications.
number of people The diabetes continuum of care for adults aged 35+ years in Bangladesh
living with diabetes. also highlights significant breakpoints along the cascade (Fig. ES 4).
The 2013 National diabetes Guidelines for the PHC level11have deficiencies regarding these
breakpoints in the continuum of care. The guidelines don’t provide much directive on diabetes
screening and risk factor scoring. Information on the choice of diagnostic tests is scarce (HbA1C
testing is included for gestational and type-1 diabetes but not for type-2 diabetes). The
guidelines are also deficient in respect to glucose monitoring during treatment, drug refill at
PHCs, and patient self-monitoring.
xvi
EXECUTIVE SUMMARY
Figure ES 4 Diabetes cascade Bangladesh
Sources: BDHS 2011 and 2016 UN population estimates.
This analysis estimated that finding 50% of the currently undiagnosed 3.8 M diabetic adults aged
35+ years would cost approximately BDT 780 M (US$ 9.5 M). Treating the currently diagnosed
2.33 M diabetic adults aged 35+ years would cost approximately BDT 9860 M (US$ 119 M).
MODELS FOR CHRONIC CARE

The Government of Bangladesh has defined models for NCD care for urban and rural settings
(Fig. ES 2, Fig. A 11.1). This review also scanned the literature on models of chronic care with the
aim to identify international good practices and principles of such models of care. PHC-level care
models often share some of the following five features:
1. Simplification, standardisation and monitoring of healthcare delivery processes
2. Decentralisation
3. Task-shifting
4. Peer and community involvement in programming
5. Support for self-management
Simplifying healthcare management aims to strike a balance between While there are
what is desirable and what is currently feasible in resource-limited settings. currently no
It allows a wider range of providers to be involved in patient management national standard
while minimising risks to patients. It can also help patients directly with operating
self-management and treatment adherence (for example if the treatment procedures for the
regimen is simplified). Standardising health care management helps management of
maintain patient safety and high-quality healthcare service provision.
NCD in Bangladesh,
Indeed, a key objective of WHO’s Package of Essential NCD (PEN)
the country is in the
Interventions for Primary Health Care is “standardisation of diagnostic and
investigation procedures and drug prescription” as well as “formulation of
process of
referral criteria for further assessment or hospitalisation”. While there are developing these
currently no national standard operating procedures for the with the support of
management of NCD in Bangladesh, the country is in the process of WHO.
developing these with the support of WHO. These will be based on
simplified algorithms and the use of standard drug prescriptions based on generic
formulations. The use of standardised indicators, electronic records and a unique client
xvii
identifier number will help with referrals, linking client data in all facilities, easier tracking,
better understanding of defaulting and better data-driven management processes.
Bangladesh has strongly advocated for a decentralised health system, however, there are
several barriers to full decentralisation including administrative issues, institutional mandates
and decision-making roles. Practical applications of decentralisation could include for instance
drug dispensing via adherence clubs with the aim to decongest clinics and facilitate drug refill for
patients. Bangladesh’s new NCD care model for rural areas—where access to diabetes and
cardiovascular disease services is particularly poor in Bangladesh—is an attempt to decentralise
NCD service delivery. Furthermore, many providers organise community outreach or health
‘camps’ and the country has been piloting and scaling up a wide variety of decentralised models
of care for NCDs.
Peer and community involvement in service delivery is an important feature of PHC-level

care models. Community participation can serve to raise awareness, design appropriate
interventions and thus increase acceptance, advocate for political action, provide informal and
formal support to patients, mobilise resources, and support sustainability of programmes. Peer
support care models, where peers are used to provide social and emotional support, assistance
with disease management, and linkage to clinical care and community
Considering the huge resources, have been widely applied in health and are starting to gain
burden of NCDs and the momentum in NCD care. Considering the huge burden of NCDs and the
critical shortages of critical shortages of healthcare staff in rural areas in Bangladesh, there is
healthcare staff in rural a need to tap into the community itself to support NCD programmes.
areas in Bangladesh, This could include using community volunteers or peers to help with
there is a need to tap into NCD prevention, screening and client navigation through the health
the community itself to system.
support NCD programs. Task-shifting and involvement of a full range of health providers
This could include using can be indispensable in a context of shortages and/or unequal
community volunteers or distribution of healthcare staff. Task shifting has been shown to be
peers to help with NCD effective in improving process outcomes (such as successfully screening
prevention, screening for HTN and diabetes) and health outcomes (such as achieving HTN and
and client navigation diabetes control) and achieving treatment concordance with doctors.
through the health Enablers of task-shifting include appropriate training and provision of
system. standard algorithms and protocols while the principal barriers are
linked to legislative prescribing restrictions and availability of
medicines. Bangladesh’s new NCD care model includes task-shifting of NCD screening to
healthcare workers in community clinics. Further task-shifting could involve trained lay
workers or volunteers, drug sellers, pharmacists or informal village doctors performing
screening, or the expansion of the prescribing list of community healthcare workers if
feasible.
The active participation of patients in their own treatments through self-management has
considerable scope. Interventions to improve self-management can include education, peer
support, identification of barriers to treatment adherence, problem-solving to overcome
barriers, provision of self-monitoring tools, reminders, goal setting and incentives. However, self-
management of chronic diseases can be challenging for patients, as it likely needs daily and
lifelong changes to lifestyle, and therefore requires tailored education (regarding content,
delivery and frequency) and ongoing support. A 2017 systematic review assessing the
effectiveness of self-management interventions for diabetes found that diabetics who
xviii
EXECUTIVE SUMMARY
participated in self-management interventions improved their diabetes knowledge, glucose

control, body-mass index, lipid profile and quality of life.12 Elsewhere, chronic care passports
have been found to lead to better diabetes and HTN control and better quality service provision.
While some self-management is already happening in Bangladesh (including BIRDEM diabetic
clients), there are opportunities to promote such approaches further - for example by using
different, culturally sensitive patient education material, and by improving access to monitoring
tools and peer support.
Among the case studies illustrating these five elements of care models, the report also describes
South Africa’s Integrated Chronic Disease Management (ICDM) model. While this model speaks
to all five elements, it represents a more wide-ranging re-design of service delivery. Important
aspects are patient flow in a health facility and early triaging; the use of a chronic care patient
record and simplified evidence-based PHC guidelines; task-shifting; decentralisation of health
promotion, tracing and support services to outreach teams; and “assisted” self-management
within the community. Such a model however requires a radical overhaul of PHC-level service
delivery, including appointment systems, a designated chronic patient ‘track’ in facilities and
consultation area, and pre-dispensed medication among others. Early evaluation findings based
on health care worker reports suggest that South Africa’s ICDM model has improved patient care
and interaction, level of knowledge, teamwork and work satisfaction.
OPPORTUNITIES FOR STRENGTHENING PRIMARY LEVEL

CARE FOR HTN AND DIABETES
Based on the review of the evidence and cascade analyses, the report provides the following key
recommendations:
1. Coordinate NCD control - An effective coordination mechanism for NCD control is

urgently required, with a strong mandate for coordination, measurable targets and
clear reporting processes. The coordinating body should have cross-sectoral reach with
pluralistic provision.
2. Adequately finance NCD control - It is advisable that the Government consider
alternate financing mechanisms. Households need to be protected from
impoverishment due to NCD costs.
3. Incorporate NCD needs in human resources for health strategy - Taking into
consideration the increasing burden of NCDs, a long-term human resources strategy is
required which responds to the changing service needs, and adequate budget
allocations need to be made.
4. Address NCD risk factors - Bangladesh needs to raise awareness and risk perception
in the population through the implementation of tested communication strategies and
promotion of healthier lifestyles to reduce exposure. A substantive focus on preventative
and promotive care is urgent, especially in the rapidly urbanising areas. Stronger and
additional tax policies should be considered.
5. Mainstream NCD prevention and management - Existing programmes and initiatives,
such as MCH, community health and UPHCP, should integrate NCD prevention and care
into their activities.
6. Find NCD cases through improved screening capacity - Bangladesh needs to train its
health workers to better identify NCD risks and set screening targets at local level to
xix
help meet, by 2022, the end-of-plan national screening targets for diabetes and
hypertension. Protocols and guidelines should be explicit on screening and linkage to care,
and be accompanied by job aids for community health workers.
7. Focus on treatment adherence - Essential drugs
need to be made available at PHC level at all times
as this is a vital part of improving treatment adherence.
Guidance on hypertension and diabetes care needs to
be explicit about treatment monitoring and adherence
support. Health care professionals need to be educated
on the guidelines and on the importance to focus on
high-risk patients. Assisted self-monitoring and
mHealth technology should be promoted.
8. Fully involve the Community Clinics for NCD care -
It is vital that the CCs can lead the NCD case finding,
linkage to care and management of uncomplicated
cases, while facilitating referral as per their mandate.
The CCs' outreach function needs to be
appropriately resourced for health promotion and
NCD screening at scale. Low cost, low technology tools could be considered, such as the
“string test for obesity”.
9. Harness existing health work force/structures to address NCD burden - Bangladesh
should consider task shifting within its health cadres in order to accommodate the
changing needs for long-term monitoring and treatments, and involve paramedics and
SACMOs where possible. MCH services could provide nutritional education and support
to pregnant women beyond the usual nutritional advice relevant to pregnancy itself.
10. Expand human capacity - Bangladesh should adopt good practices from elsewhere on
harnessing community support for the care continuum, the mobilisation of volunteers
and lay workers, and the use of peer approaches.
11. Pilot an integrated Chronic Care Passport – Akin to BADAS’ diabetic book, such a
patient-held passport is recommended in order to facilitate medication refill at community
clinics and support self-monitoring of patients. Such a passport would also help
referrals and continuity of care and likely improve the quality of care.
12. Build in NCDs into existing surveillance systems - Bangladesh should incorporate NCDs
into existing disease surveillance systems. This will enable the Government to better
assess trends and its progress towards SDG Target 3.4 (reducing the premature NCD
mortality by one-third by 2030).
13. Strengthen NCD M&E for better decision-making – Bangladesh should roll out the
Unique Patient Identifier as a prerequisite for a powerful M&E system, and set NCD
service delivery targets to measure progress. The country should document the
experiences with the new MOH NCDC model and share the learning.
xx
INTRODUCTION
1.1 Aim of this report

Bangladesh faces a health transition challenge as its health outcomes improve and it
transitions from a health system dominated by infectious disease and maternal and child health
challenges to one confronted increasingly by non-communicable diseases (NCDs). The country’s
NCD statistics highlight the urgent need to re-configure service delivery,
The new NCD
make more strategic investments, and find new solutions to reduce NCD
Operational Plan
risk factors, prevent disease sustainably, and manage complications. The
provides a 5-year window new NCD Operational Plan provides a 5-year window to redress the
to redress the NCD situation by moving the public health care system from a disease-
situation by moving the specific one designed for infectious disease and mother & child health
public health care system (MCH) to an integrated care system emphasising integrated primary
from a disease-specific health care (PHC), out-patient care and community health promotion.
one designed for
This report aims to provide a review of the NCD situation by using the
infectious disease and
“cascade” framework—drawing on the indicators diagnosed, treated,
mother & child health
controlled—to determine the continuum of care for hypertension and
(MCH) to an integrated type-2 diabetes mellitus in Bangladesh (section 2). It then
care system emphasising summarises the country’s policy and health care delivery
integrated primary environment for NCDs (section 3) followed by an assessment of
health care (PHC), out- models of NCD and chronic care in Bangladesh and elsewhere
patient care and (section 4). Based on the evidence reviewed and analyses conducted, the
community health report then provides conclusions and recommendations (section 5).
promotion.
The methodology consisted of literature review, consultations with
experts, data triangulation, benchmarking, and synthesis of the published evidence. For the
continuum of care, the cascade framework was used to assess the stages from screening to
diagnosis, treatment initiation, adherence and disease control. PHC-level models from other
countries were selected opportunistically to capture promising practices.
The objective of this technical assistance is to provide input into the dialogue on how to
improve NCD integrated care and outcomes in Bangladesh. The support is provided within
the World Bank’s assistance to countries to strengthen NCD care through data-driven resource
allocation and decision-making.
1
1.2 Global context

NCDs now account for more than half of the global burden of disease, and cardiovascular
diseases (CVD) alone are responsible for half of NCD-attributable deaths of which the majority
occur in low- and middle-income countries (LMICs).13 Death and disease due to NCDs matter in
their own right, but they also act as important barriers to poverty reduction and sustainable
development. The global call for action was strongly made in the 2011 High-level Meeting of the
UN General Assembly on the Prevention and Control of NCDs.14 This Political
Declaration was followed by two NCD-specific targets in 2015 in Sustainable
Development Goal 3 “Ensuring healthy lives and promote well-being for all at
all ages”, with targets to i) Reduce by one third premature mortality from NCDs
through prevention and treatment and promote mental health and well-being
(target 3.4), and ii) Support the research and development of vaccines and
medicines for the communicable and non-communicable diseases that primarily affect
developing countries and provide access to affordable essential medicines and vaccines (target
3.b).15
Despite these high-level endorsements, progress in addressing NCDs is uneven and does not
match the growing need. NCDs as cause of death has between 2000 and 2015 increased
significantly in country groups Bangladesh belongs to: the lower middle income countries
(LMICs), the International Development Association (IDA)-eligible countries, and countries in the
South Asia region (Fig. 1.1).
Figure 1.1 NCDs as cause of all deaths by country group, % (2000, 2015)
Source: World Development Indicators, indicator ‘cause of death, by NCD (% of total)’.

Note: Bangladesh is part of the Lower middle income level countries, in IDA country group, and in South Asia region.
Since many health systems in lower income economies have been focusing on infectious and
childhood diseases, there is often low capacity to confront the emerging disease pattern
dominated by NCDs. The implications of the poorly addressed NCD epidemics are vast: There
is a social burden which is multifaceted and ranges from prolonged disability of NCD cases, to
diminished resources within families due to out-of-pocket payments for services and drugs,
reduced productivity due to illness, and a tremendous demand on health systems for acute and
long-term NCD care. This translates into a staggering economic burden. It has been estimated
that during 2011–25, cumulative economic losses due to NCDs under a “business as usual”
scenario in LMICs amounts to US$ 7 trillion.16 This far outweighs the annual US$ 11.2 billion
2
INTRODUCTION
cost of implementing a set of high-impact interventions to reduce the NCD burden.17 The
economic case for NCD investments is therefore clear.
The 2013 global survey on national capacity for the prevention and control of NCDs18
identified a number of missed opportunities and made two overarching recommendations to
address the NCD challenge: 1) To strengthen NCD governance, prevention, health care, and
surveillance and monitoring; and 2) To support NCD-related research and evaluation of the
impact of interventions and policies. The World Health Organisation (WHO) provided in its 2014
NCD report several key recommendations to guide the national and global NCD response.19 It
emphasised the importance for better tracking of financial resources for NCDs. Also, it called on
programmes to prioritise cost-effective population-wide and individual interventions, including
the “best buys” identified in 2011.20,21 Supporting implementation research and its translation
into practice was also highlighted, and the necessity to produce high-quality case-studies to
better understand why progress has not been made.
1.3 Bangladesh health transition

Bangladesh has a population of 162.95 million.22 Currently, about 65% of In the 2016
the population live in rural areas but the country is rapidly urbanising. The Household Income
demographic and epidemiological transition leads to an ageing population and Expenditure
and shifting disease burden from infectious, communicable diseases to Survey (HIES) ,
chronic NCDs (Annex 1, Fig. A 1.1). In 2016, NCDs were responsible for hypertension,
62.7% of Disability-adjusted life years (DALYs) while communicable, chronic heart
maternal, neonatal and nutritional diseases accounted for 26.8% and disease and
injuries for 10.6% of DALYs respectively.23 Ischemic heart disease (IHD), diabetes were
stroke and type 2 diabetes are the main contributors to the NCD burden. In among the most
the 2016 Household Income and Expenditure Survey (HIES)24,
reported illnesses
hypertension, chronic heart disease and diabetes were among the most
with rising levels of
reported illnesses with rising levels of reported diabetes in females between
2010 and 2016 (Fig. A 1.2, A 1.3).
reported diabetes in
females between
Benchmarking Bangladesh health indicators with comparison countries: 2010 and 2016.
 Bangladesh has overall achieved great success in reducing mortality, pre-mature
death and improving life expectancy. This is especially compelling when comparing
across countries with similar per capita income levels (Annex 2, Table A 2.1), but even
within the South Asia Region, Bangladesh compares well (Table A 2.2): Life expectancy at
birth has increased to 73 years (2016) from 58 years in 1994.25 Large gains have been
made in child survival, and maternal mortality has seen important improvements.26
 However, Bangladesh is ranking poorly in comparisons on premature death due to

NCDs. Among 12 countries with similar per capita income levels, Bangladesh takes rank
11 for pre-mature death due to all NCDs combined, rank 9 for IHD, rank 11 for diabetes
mellitus, and rank 12 for cerebrovascular disease, chronic kidney disease (CKD) and
chronic obstructive pulmonary disease (COPD) (Table A 2.3). Benchmarking within the
South Asia Region, the poor rankings on pre-mature mortality remain for overall NCD
burden, cerebrovascular disease, and COPD, but not for diabetes, IHD and CKD (Table A
2.4).
Most of Bangladesh’s premature deaths from IHD, stroke, COPD and diabetes are attributable to
risk factors (Annex 1, Fig. A 1.4). High systolic blood pressure is estimated to be responsible for
3
18% of all deaths in Bangladesh, and smoking for an estimated 17%. High fasting plasma glucose
may be responsible for about 11% of deaths. The Global Burden of Disease (GBD) analysis for
Bangladesh notes that the greatest disease risk factors are now NCD risk factors: “Overall, the
three risk factors that account for the most disease burden in Bangladesh are tobacco smoking,
household air pollution from solid fuels, and dietary risks”.27
Regarding smoking, Bangladesh has actually had progress in tobacco control in recent years.
Tobacco excise taxes have been raised, but, at 62%, fall short of the WHO-recommended 70%
minimum.28 Nicotine replacement therapy and cessation services are partially available, but
patient costs are not covered. Although it is recommended that all public places are completely
smoke-free, restaurants and public transport are not yet smoke-free, and funds for smoke-free
enforcement are insufficient. Bangladesh has exceptionally high use of ‘smokeless tobacco’
(SLT); a quarter of adults use SLT.29,30 SLT products are cheap and readily available, and
misconceptions regarding its deleterious health effects, lack of
The country needs the comprehensive tobacco control regulations and weak enforcement of
right service delivery existing regulations are contributors.31 One WHO study found that
systems to reduce tobacco was a major risk factor in Bangladesh and cost the economy
population exposure to about $44 million annually.32
behavioural risk factors,
slow the progression to For many people in Bangladesh, NCD risks are already set in
childhood:33 22% of babies are born with low birthweight, 36% of
disease in exposed people,
children under five are stunted, and 33% are underweight.34 This,
and address
compounded by lifestyle factors such as air pollution, poor diet and
complications to prevent
nutrition, high salt intake, tobacco use and insufficient physical activity,
disability and premature precipitates NCDs often at a relatively young age. The underlying social
death. determinants like poverty, low education and urbanisation are complex
to change, and the interplay of the NCD determinants can have long-lasting, transgenerational
impacts. Many of these underlying factors are of course outside the direct influence of the health
sector and rely on a “comprehensive government” approach.
In summary, Bangladesh’s health transition with the rising NCD burden and the associated costs
requires a reorientation of the health care system. The country needs the right service
delivery systems to reduce population exposure to behavioural risk factors, slow the progression
to disease in exposed people, and address complications to prevent disability and premature
death.
"One WHO study found

that tobacco was a
major risk factor in
Bangladesh and cost
the economy about
$44 million annually.”
4
THE CONTINUUM OF CARE
FOR HYPERTENSION AND DIABETES
This analysis used the cascade framework and applied it to male and female adults in urban and
rural areas, respectively. It focused on hypertension as a tracer condition and type-2 diabetes as
a cost-driving NCD, in order to devise the continuum of care for chronic NCDs in Bangladesh.
The simple concept of the continuum or cascade of care provides a useful lens to assess the
delivery of chronic care, and help re-orientate health systems for improved chronic care
outcomes. The continuum or cascade of care asks four questions about a patient’s health journey
and trajectory:
 First, is a patient diagnosed if he/she has a health condition?
 Second, is the patient linked to appropriate health care?
 Third, is the patient adherent to the required care regimen?
 Fourth, does the patient achieve disease control?
Failure at each stage of the cascade precludes success at the next, which Failure at each stage
means the cascade of care may tumble rapidly with the breakpoints at of the cascade
each stage adding to the final outcome. For hypertension and diabetes
precludes success at
care in Bangladesh, cascades are presented separately for adult female
the next, which means
and male residents in rural and urban areas. The most comprehensive
national data came from the 2011 Demographic and Health Survey (DHS)
the cascade of care
which measured blood pressure (BP) and blood glucose in a subset of may tumble rapidly
survey participants aged 35 years and above. These population-based with the breakpoints
biomarker data from 2011 were applied to 2016 population estimates in at each stage adding
order to generate estimations along the continua of care. to the final outcome.
2.1 Hypertension cascade, breakpoints and outcomes

Hypertension prevalence has been reported from various studies conducted in Bangladesh.35 A
recent meta-analysis reported an overall hypertension prevalence of 14.0% (95% CI: 11.0%–
16.0%), across a diversity of age groups and populations.36 2016 estimates of adults with
hypertension in each of the eight Divisions are provided in Annex 3, suggesting that the
hypertension burden varies by a factor 5 across Divisions, and diabetes burden by a factor 4.
The only national data source providing all the key data for the cascade analysis was the 2011
DHS in which blood pressure measurements were done in a sample of participants aged 35 years
and above. Hypertension prevalence in these DHS participants aged 35+ was 26%37. Based on
this, we estimated that in 2016, 14.36 million adults aged 35+ had hypertension and another
15.35 million were pre-hypertensive38 - see Fig. ES 3 for the national cascade, and Fig. 2.1 for
5
rural and urban female and male residents. The prevalence of hypertension was highest in
females living in urban (40.2%) and rural (29.4%) areas, followed by urban males (25.2%), and
lowest in rural males (17.6%). Overall, 51% had been diagnosed. Therefore, about 7.25 million
adults aged 35+ years are undiagnosed hypertensives. The absolute gap to diagnosis was
largest in rural females (2.5 million undiagnosed, or a relative gap of 46% of all hypertensives)
and lowest in urban males (1.2 million undiagnosed, or 50% of hypertensives). Treatment
among those diagnosed was high based on self-reported taking of hypertension medicine,
however, only 38.2% (urban males) to 49.2% (rural males) actually had treatment success by
achieving normal BP. This means that only 2.8 million adults aged 35+ years have their
hypertension controlled, and over 12 million have uncontrolled hypertension. Other
analyses of the same data showed that the risk of hypertension is significantly associated with
older age, being female, higher educational attainment, higher wealth, urban residency, higher
body mass index (BMI) and having diabetes.39 Community and facility based NCD screening in
Jessore District found 27% hypertension prevalence (Nov. 2013 – Jan. 2016, 14,023
participants).40 Overall, 48% were aware of being hypertensive, which is similar to the levels
observed in the 2011 DHS. A study among university students in Dhaka showed that
hypertension is also an issue among younger people. It reported a 6.5% prevalence (12.1% in
males, 3.4% in females).41
Figure 2.1 Hypertension cascade for rural and urban residents aged 35 years and above
Sources: DHS 2011; Rahman et al 2017; 2016 UN population estimates; World Bank data for rural residency.
In the same 2011 DHS data, one in 10 females had stage 2 hypertension.42 It can be estimated
that in 2016, about 4.1 million adults aged 35+ years had stage 2 hypertension either on
treatment or without treatment, with the largest share among rural women (40% of all stage
2). Hypertension is the most important risk factor for stroke and heart attacks (see Fig. A 1.4 for
deaths attributable to risks). But hypertension also leads in itself to hospital admissions. In a 12-
month period up to end October 2017, the District Health Information System (DHIS2) counted
6
CONTINUUM OF CARE FOR HYPERTENSION AND TYPE-2 DIABETES
22,805 hospital admissions for primary hypertension and 8,322 admissions for
hypertensive disease. Annex 4 shows the hospital in-patient admission rates for each division
(the health information system does not collect outpatient data disaggregated by reason for
clinic visit/ disease).
In order to improve the continuum of care for hypertension, an understanding of the main
barriers on the patient and the provider sides is helpful to plan relevant interventions (see Annex
5 for an overview). Based on the literature, chief barriers to diagnosis are the low priority given
to case finding at community level (see also Box 2.1 on screening), combined with insufficient
population awareness of the risk and symptoms of hypertension, whereas barriers to treatment
and treatment adherence are the recurrent drug costs, the weak capacity for supporting patients
in chronic care at PHC level and poor risk perception regarding life-threatening complications of
hypertension.
Box 2.1 What do the National Hypertension Guidelines say regarding the cascade stages?
WHO in collaboration with the Directorate General of Health Services (DGHS) and the National
Heart Foundation published hypertension guidelines in 2013.43 Hypertension treatment is
mostly provided by general practitioners and specialist physicians, including cardiologists,
through government and private healthcare services. This guideline wants to be relevant and
applicable to the primary care setting, where primary care physicians often work with limited
resources. The guideline places emphasis on the affordability of the treatment for
hypertensive patients. It promotes the importance of lifestyle modifications (as health-
supporting and as a way to limit medication need), and encourages the use of the cheapest
generic drugs if equivalent. Given the low cost and availability, it also endorses beta-blockers
as first line therapy for resource constrained settings in Bangladesh. The guideline provides
specific information about stepping up and stepping down treatment depending on a patient’s
response to therapy. There are also instructions regarding follow up and target BP levels. If a
patient fails to achieve the BP target after 3–6 months of treatment, the guideline advises
referral to a secondary or tertiary center for further evaluation.
The guideline does not provide operational detail on screening for hypertension, and
provides little guidance on treatment adherence support.
2.2 Type-2 diabetes cascade, breakpoints and outcomes

The prevalence of diabetes has risen rapidly from about 0.7% in 1980.44 Globally, Bangladesh
Diabetes prevalence in the 2011 DHS participants aged 35+ years with
is among the top 10
glucose measurement was 11.0%. The meta-analysis by Islam et al.
countries for number
(2016) reported an overall diabetes prevalence of 6.0% (95% CI: 5.0%–
7.0%) across a variety of studies on different age groups and populations,
of diabetes cases, and
and the 2017 Diabetes Atlas reports 6.8% prevalence for Bangladeshi
has a relatively low
adults aged 18 years and above.45 Globally, Bangladesh is among the top diagnosis rate in
10 countries for number of diabetes cases, and has a relatively low international
diagnosis rate in international comparison (rank 45 of 221, see Annex 6). comparison.
Again, the only national data source providing key data for the diabetes cascade analysis was the
2011 DHS. No population level data were available on the coverage of diabetes screening. Based
on our estimations, 6.13 million adults aged 35+ years had diabetes46 in 2016, and 13.73
million were pre-diabetic (Fig. ES 4)47. The prevalence of diabetes was highest in urban females
7
(17.3%) followed by urban males (14.9%), and virtually the same in rural females (9.5%) and
males (9.3%) (Fig. 2.2). The lower diabetes prevalence in rural areas is consistent across studies,
however, representative epidemiological data is scant and the ranges found across studies are
quite large.48 Based on the same DHS 2011 data, about 3.8 million adults 35+ years are
undiagnosed diabetics. The absolute gap to diagnosis was largest in rural males (1.2 million
undiagnosed, or a relative gap of 73% undiagnosed diabetics) and lowest in urban males (0.72
million undiagnosed, or 49% of diabetics). Undiagnosed diabetes prevalence in adults 35+ years
was therefore 6.7%. This matches results from a survey reporting a 6.6% prevalence of
undiagnosed diabetes in adults aged 20+ years (urban 12.2%, rural 2.6%).49
Figure 2.2 Diabetes cascade for rural and urban residents aged 35 years and above
Sources: DHS 2011 (with secondary data analysis); 2016 UN population estimates; World Bank data for rural residency.
Similar to hypertension, treatment among those diagnosed with diabetes was high based on self-
reported taking of medicine and treatment control was poor with only 29.2% (rural males) to
42.9% (rural females) having treatment success by achieving normal fasting plasma glucose
while taking medication. This means that only 12.3% of adults aged
…significant inequality 35+ years have their diabetes controlled, and close to 5.4 million
in diabetes are diabetic without controlling their fasting plasma glucose. Other
management was analyses of the same data suggested that participants who had a lower
found between poor education and lower economic condition were less likely to be aware of
and wealthy their diabetes.50 Poor management was observed among non-educated
and low-income groups. Furthermore, significant inequality in diabetes
households.
management was found between poor and wealthy households: 18.2%
vs. 63.2% (awareness), 15.8% vs. 56.6% (treatment), and 8.2% vs. 18.4% (control). In the survey
described by Alam et al. (2016), urban residence, higher age, overweight and abdominal obesity
were significant predictors of diabetes. The 2010 STEPS survey asked about the type of
treatment people were taking: 21% of diabetics on treatment reported receiving insulin and
8
CONTINUUM OF CARE FOR HYPERTENSION AND TYPE-2 DIABETES
61% oral anti diabetic drugs.51 In another study, 46% reported using metformin, 41% reported
insulin, and 39% reported sulfonylurea use.52
Undiagnosed as well as treated but poorly controlled diabetes can lead to hospital admissions. In
the 12 months to October 2017, the DHIS2 system53 counted 5,070 hospital admissions for
type-2 diabetes and 937 admissions for diabetes-related complications. Annex 4 shows the
rates for each division. A study conducted at a tertiary diabetes hospital in Dhaka estimated that
of 473.43 DALYs forgone due to diabetes, only 20.5% were due to diabetes itself while the rest
(79.5%) was due to its complications. The study also estimated that the most number of DALYs
forgone were incurred by diabetes with CVDs (38%), followed by diabetes with retinopathy
(20%), and diabetes with nephropathy (13%).54
The barriers across the diabetes care continuum were also reviewed and summarised (see
Annex 5). Limited availability of diabetes services is most marked in rural and peri-urban slum
areas where patients report that effective diabetes services are scarce.55 Diabetes is often an
incidental finding when people seek medical care for other problems such as TB, or as a result of
severe complications of diabetes. Likewise, continuity of diabetes care is poor in peri-urban slum
areas with high costs, meaning that people delay follow-up visits. In rural areas, patients at
community clinics (CCs) need to travel to the local sub-district hospital for basic diabetes care,
and to a specialist hospital of the Diabetic Association of Bangladesh (BADAS) for comprehensive
services.
For diabetes cases, disease-specific knowledge and attitudes are Patients’ non-
important factors throughout the continuum. Several studies report that adherence to
males show higher levels of relevant knowledge, but females showed
treatment is
better attitudes and practice towards diabetes compared to
correlated with poor
males.56,57,58,59 Diabetes knowledge is strongly associated with education
and income.60 In turn, better disease control i.e., normal fasting plasma
understanding of the
glucose (FPG) while on medication is seen in persons with higher disease management
education and higher wealth (2011 BDHS). One study found that about due to lack of
80% of patients monitored their blood sugar at least once every 3 adequate education
months.61 In Fatema’s report (2017), 38% of diabetes patients measured from health staff.
their blood sugar once in a month either at home or at the hospital and
37% checked their blood sugar at least once in 3 months.62 Only 3% tested their blood sugar
once in a year, and 2% never got checked. Difficulties in attending regular or monthly check-ups
can stem from lack of family support for such monitoring visits. Patients’ non-adherence to
treatment is correlated with poor understanding of the disease management due to lack of
adequate education from health staff. The below quotes, selected from a qualitative study carried
out among diabetic out-patients at the Bangladesh Institute of Health Science hospital in Dhaka,
highlight this point:
“I have diabetes, I take five different medicines, but I am not sure which ones are specifically
for diabetes and the dose of each medicine”
“ … nobody ever informed me about the side effects of the medicines and what I should do
if I have any problem” (Diabetes patients)63
In one multi-site study in Bangladesh, 72% of prescriptions did not have directions on how to
take the medication and 62% did not specify the duration of treatment.64 An assessment among
medical officers working in BADAS hospitals found that physicians with certificate course on
9
diabetology, and junior physicians had significantly better prescribing practices than physicians
without the course and Senior Medical Officers/consultants, respectively.65
Medication costs are another chief reason for non-adherence, as these can put strains on families,
as is highlighted in the below quote from a diabetic patient who took part in another qualitative
study, conducted in urban centres.
“I only take medicines when I can afford them; it is too much to pay for them all the time
… I have to think of my family” (Diabetes patient)66
Box 2.2 What do the National Diabetes Guidelines say regarding the cascade stages?
The 2013 National Guidelines for the Management of Diabetes Mellitus at Primary Health Care
by DGHS, BIRDEM and WHO67 is published in Bangla to guide diabetes management at
primary care level. Regarding screening, the document provides the risk factors for T2DM and
gestational diabetes, but no detail on targeting of screening or screening strategies is given.
Three tests are mentioned for the primary care level (OGTT, FPG, RBG). However, more
implementation guidance could be provided and HbA1C testing included as a diagnostic
method for T2DM (it is included for type-1 and gestational diabetes). No risk factor scoring is
referred to. Diagnosis of gestational diabetes and type-1 diabetes in young people is well
covered. Guidance on treatment maintenance and refill is not given, although antidiabetic
drugs should be supplied at the PHC level. Another area which is not well addressed is glucose
monitoring, and how patients can be supported for self-monitoring. Acute, delayed and
chronic complications of diabetes and how to prevent these, and the need for clinical
consultation along with laboratory tests, are however mentioned in the guideline. The 2003
Guidelines for care of type-2 diabetes mellitus in Bangladesh are more widely disseminated.
They provide comprehensive guidance across the continuum of care, including targeting and
frequency of screening, diagnostic tests and case definitions (with flowchart), initiation of
non-pharmacological and pharmacological treatments, follow-up visits during treatment
consolidation, the use of patient self-monitoring data by the physician, and criteria for referral.
Section 3 summarises the policy and care provision environment relevant to the delivery of
hypertension and diabetes services.
“Medication costs are another chief

reason for non-adherence, as these
can put strains on families…”
10
NCD SERVICE PROVISION AND
COSTS ACROSS THE CONTINUUM
OF CARE
3.1 Policies, strategies and plans on NCD control
To address the NCD epidemic and shifting demands on the health sector, the Government of
Bangladesh and several non-government organisations (NGOs) have published a number of
policy documents, strategies and plans. This has provided a conducive policy environment for
NCD control in Bangladesh, but has not necessarily been harnessed for NCD control activities
(Box 3.1). A recent comprehensive NCD policy analysis68 states that “although the government
has initiated many NCD-related policies or programmes, they lacked proper planning,
implementation and monitoring” and concludes that the growing burden of NCDs has not been
effectively addressed (the analysis covered 51 NCD-related policy documents that have been
published since Bangladesh’s independence in 1971).
Box 3.1 Bangladesh's NCD policy context in international comparison

Using the 2017 Global NCD Monitor data to compare across 12 similar economies:69
We compared the WHO-reported data on NCD policies, targets, guidelines and action plans, as
well as on targeted policies for demand-reduction (tobacco, alcohol, salt, unhealthy diet)
across 12 countries with similar GNI per capita. Bangladesh came out with the highest overall
score among this country group, suggesting a comparatively strong NCD policy environment.
The scores, however, showed gaps in addressing unhealthy diet and food marketing in
Bangladesh, among other gaps (Annex 7).
Using the 2014 ‘NCD scorecard’ data to compare across countries in different income
groups:70
The NCD scorecard study assessed countries’ performance on tackling NCDs across the four
domains of governance (which included national plans and leadership), action on reducing
risk factors, conducting research and surveillance, and responding to NCDs through the health
system. The study scored Bangladesh as a medium performer with regards to governance and
a poor performer across the remaining three domains. The health systems response for NCDs
in particular was far better developed in upper-middle and high income countries,
presumably due to a longer history of NCD burden and management (Annex 7).
The current Operational Plan for NCDs within the 4th Health, Population and Nutrition Sector
Programme (2017‒22) relates that during the 3rd sector programme (2011‒16), “control of NCDs
was given priority but with inadequate resource allocation...[and] most of the resources were used
in purchasing equipment, training of manpower and arsenicosis and emergency related activities”.
11
Four NCDs—CVDs, cancer, diabetes mellitus, and arsenicosis—are being treated as major public
health concerns. Key activities were the 2010 STEPS survey, the piloting of the Package of
Essential NCD (PEN) interventions in 2013 at Satkhira in Debhata Upazilla Health Complex
(UZHC), establishment of Health Promotion Model villages for NCD control in a few areas, and
the model school initiatives in 91 schools. Other measures were the creation of health literacy by
courtyard meetings, facility based education, use of mass media, and establishment of the “NCD
corner” in health facilities.
…the better coordination The 2014 mid-term review made clear recommendations on how
of non-state-actors in NCD NCDs need to be better addressed in a comprehensive manner and
with effective regulatory mechanisms. The current NCD Operational
control with the public
Plan (Box 3.2) aims to address the barriers to effective action. There
sector is critical to achieve
is awareness that the better coordination of non-state-actors in
NCD objectives, as is a NCD control with the public sector is critical to achieve these
stronger focus of the public objectives, as is a stronger focus of the public sector on prevention
sector on prevention and and health promotion, with investment in intensive care units and
health promotion... tertiary care largely left to the burgeoning private sector.
Box 3.2 Objectives of the NCD Control Operational Plan 2017‒22

The current Operational Plan for NCDs has as its objective to reduce mortality and morbidity
from NCDs in Bangladesh through strengthening of evidence-based measures for control of
risk factors, and health service delivery options for early detection and management. Its
specific objectives are:
a. To promote development and implementation of effective, integrated, sustainable, and

evidence-based public policies for chronic NCDs, their risk factors, and determinants
b. To develop and strengthen capacity for surveillance of chronic NCDs, their

consequences, their risk factors, and the impact of public health interventions
c. To foster, support, and promote social and economic conditions that address the
determinants of chronic NCDs and empower people to increase control over their health
and to adopt healthy behaviours
d. To strengthen the capacity and competencies of the health system for the integrated
early detection and management of chronic NCDs and their risk factors
3.2 Financing and resources for NCD control

It is estimated that total health spending in Bangladesh in 2014 was $14.7 billion (2015
Purchasing Power Parity (PPP)) (Annex 8 Fig. A 8.1). Government contribution was about 22%,
while Out-of-pocket (OOP) expenditure by households was about 65% and development
assistance for health was about 12% of all spending.71
In fiscal year 2015‒16, the total allocation under the revised annual development programme
(RADP) for the DGHS was BDT 237,590.00 lakh. Among all the 19 operational plans of the Health,
Population and Nutrition Sector Development Plan (HPNSDP) 2011‒16, the Non-
Communicable Diseases Control (NCDC) Operational Plan was allocated 1.73% of the total
budget and 65% of this allocation to NCDs was spent over the Plan period (Fig. A 8.2 for
allocations and level of expenditure).72
12
NCD SERVICE PROVISION AND COSTS ACROSS THE CONTINUUM OF CARE
Budgets for the current HPNSP period of 2017‒22 foresee funding for the provision of health
services (61.5% of total), health system strengthening (37.0%), but also governance and
stewardship, training, education, and some research, which all have relevance to NCD control.73
In this 5-year budget, the NCDC Operational Plan itself obtains 4.2% of the total funding or
BDT 111,827.27 lakh. (Fig. 3.1). This translates to BDT 6.8 per capita (or 8.2 U.S. cents).
Depending on the operational plan, there are different sources of funding. The NCDC
operational plan is funded by 65% from government sources and 35% other sources (Fig.
A 8.3).
Figure 3.1 Division of funding amongst the health service programmes in 2017‒22
Source: Operational plans ,Programme Implementation Plan, 4th Health, Population and Nutrition Sector Program
2017‒22.
Notes: MNCAH=Maternal, Neonatal, Child and Adolescent Health; HSM=Hospital Services Management; CCSDP=Clinical
Contraception Services Delivery Program; MCRAH-Maternal, Child, Reproductive and Adolescent Health; CDC-
Communicable Disease Control; AMC=Alternative Medical Care; LHEP=Lifestyle and Health Education & Promotion;
CBHC=Community Based Health Care; TB-L&ASP=Tuberculosis- Leprosy and AIDS/ STD Program; FP-FSD=Family
Planning-Field Services Delivery; NCDC=Non Communicable Diseases Control; NNS=National Nutrition Services;
IEC=Information, Education & Communication; NEC=National Eye Care.
As mentioned above, the total amount allocated for the implementation of the NCDC program in
2017‒22 is BTD 111,827.27 lakh. The bulk of this budget is for supplies and services costs (BDT
101,378.45 lakh), including vaccines and medications (20.6% of the total budget),
conferences/workshops (16.3%), training (12%) and survey costs (5.2%). Advertising and
publicity costs are 8% of the total budget estimates, printing and binding another 5.6%, and
research expenses are 3% (NCDC Program 2017‒22).
It is worth noting that NCD-related health services are also benefiting from support through
other operational plans like the Community Based Health Care (CBHC) Operational
Programme and the Urban Primary Health Care Services Delivery Project, a project of
Ministry of Local Government and Rural Development. In those programmes and projects,
some elements of NCD control accrue, from capacity building, education, training or facilities’
development to the provision of health services. The cross cutting issues like air pollution,
poverty, mother and child or gender issues are being tackled in all operational programmes.
Furthermore, it is important to state that an estimated two-thirds of health spending comes
from households through out-of-pocket (OOP) payments (section 3.4. for further detail). This
13
OOP contribution amounted to $9.6 billion in 2014 (2015 PPP)74—see Annex 8, Fig. A 8.1. Public
sector contribution to health was about 22%, and development assistance close to 12%.75
3.3 Health infrastructure relevant to NCD control

The Ministry of Health and Family Welfare (MOHFW) is responsible for health service delivery
through various implementing authorities. Different directorates are responsible for 29 health
operational programmes. Box 3.3 provides an overview of the public sector health care system.
Community Clinics (CCs), one of the governmental flagship programmes, are providing a limited
amount of services related to NCDs. The role of CCs is to provide basic curative care but also
some health promotion and prevention (as per CBHC 2017‒22). Diagnosis and disease
management for hypertension and diabetes is carried out by medical doctors which limits these
activities to occur at the Sub-district level facilities and above only.
Box 3.3 Public sector health system in Bangladesh

The health care infrastructure under the DGHS has six levels: national, divisional, district,
upazila (subdistrict), union, and ward. The national level service delivery system is organised
around public health functions, and postgraduate medical education and training and
specialised treatment for patients. Tertiary health care is provided at national or divisional
level, secondary care is provided in district or general hospitals, and primary care is provided
at upazila level and below down to CCs.
Primary care: Nationally, there were 13,336 CCs in operation by 31 July 2016. On average,
there is one clinic per 7,000‒10,000 citizens (CBHC 2017‒22). From July 2015, all the
activities of CCs are being carried out based on the DGHS’s CBHC Operational Plan. Emergency
and complicated cases are referred to higher level facilities. There are about 4.3 Government
community health workers per 10,000 population and they are distributed fairly evenly
whereas those supported by NGOs are concentrated in certain areas. At the union level, there
are 51 primary-care hospitals with 830 beds and 3,083 health facilities for outpatient services
only (3,134 PHC level facilities at the union level in total). Overall there are 482 primary-care
government hospitals at the Upazila level, which have 19,508 hospital beds (see Annex 8
Table A 8.1. for facility distribution and beds in rural areas). In total there are 16,968 public
health facilities including all hospitals and ambulatory care centers at primary care level.
Higher-level care: There are 131 public hospitals and facilities (secondary and tertiary under
DGHS), out of which there are 14 hospitals and 117 secondary and tertiary facilities, with a
total of 29,426 beds. The specialised public sector hospitals are located in urban settings, and
there are also 35 urban dispensaries and 23 school health clinics in some of the bigger cities.
Since the establishment of CCs in 2009, the number of CC clients has been increasing and is now
reaching approximately ten million visits every month. Women and children are the ones
seeking help most frequently (80% of all visits between 2009–16, CBHC 2017‒22). Table 3.1
summarises the visiting frequency in the public health sector. Within the public sector, the
highest number of service use is ambulatory visits at outpatient departments (OPDs), yet the
reporting within the DHIS2 does not provide disease-specific statistics from OPDs which could
be used for analysis of NCD caseloads.
14
Table 3.1 Public sector health facilities visiting numbers per year
APPROXIMATE NUMBER VISITS PER 1,000
FACILITY TYPE OF VISITS PER YEAR POPULATION
Community clinics 120 million 736
Ambulatory care at outpatient departments 178.7 million 1,097
Emergency departments of different types of facilities 7.4 million 45
District hospitals under DGHS 5.71 million 35
Tertiary level hospitals 620,000 3.8
Sources: Health Bulletin 2016; CBHC 2017‒11.
Notes: Bangladesh also has a large private health care sector with 2,630 private hospitals and clinics, including 40
private medical colleges (compared with 120 secondary and tertiary public sector hospitals and 482 UZHCs in the public
sector);76 The number of registered private hospitals and clinics in 2016 was 4,596 and that of registered private
diagnostic centers was 9,741, with a total of 78,426 beds in hospitals and clinics.
The country also hosts the world’s largest and most dynamic NGOs, The health workforce in
supporting health care delivery in a very significant way (see section 4 Bangladesh is
for some NGOs working on hypertension and diabetes). The traditional substantially smaller
and community health workers in rural areas are a legacy of village- than in other
based care systems, but also reflect the growth of informal markets. countries...well below
These workers fill a void in healthcare service delivery due to the WHO’s minimum
inadequate numbers of and incentives for more formally trained public
recommended numbers
sector health workers to serve in those communities. Each village in
of doctors, midwives
Bangladesh has “village doctors,” and in the village and sub-district
markets, drug vendors (often the same person) at unregistered drug
and nurses required to
retail outlets. provide basic services.
Human resources in the health care sector are overall relatively constrained, creating challenges
for the health system and patients themselves. The health workforce in Bangladesh is
substantially smaller than in other countries, which at 0.58 per 1000 population is well below
WHO’s minimum recommended numbers of doctors, midwives and nurses required to provide
basic services (2.28 per 1000 population).77 In 2011–12, Bangladesh also had about 219,000
CHWs (i.e., 13.7 per 10,000). Of these workers, about 56,000 were government workers (23,500
family welfare assistants, 19,300 health assistants, and 12,991 community health care providers)
and about 163,000 were supported by NGOs (over 100,000 supported by BRAC).78
The urban health care system is dominated by the private sector while the urban health services
is controlled by local government institutes (City Corporations and Municipalities). Local
government bodies have executed several projects with development partners to strengthen
urban health care especially to reach the poor (Box 3.4).
Box 3.4 Urban health care initiatives

The Local Government Division has over the years implemented three health projects: The
Urban Primary Health Care Project (1998‒2005), the Second Urban Primary Health Care
Project (2005–2011)79, and, evolving from these projects, the Urban Primary Health Care
Services Delivery Project (July 2012 to June 2017) with the financial support of the Asian
Development Bank, Swedish International Development Cooperation Agency and the United
Nations Population Fund. MOHFW provides services to the urban population through their
outdoor dispensaries and secondary and tertiary hospitals. In total, there are around 4,000
satellite centers to reach the urban population. A total of 35 urban dispensaries under the
DGHS are providing outdoor patient services including an expanded programme on
immunisation (EPI) and MCH interventions to the urban population.
15
3.4 NCD interventions and costs

Controlling hypertension
Key issues in hypertension Diagnosis and control of raised blood pressure is a cornerstone
of the prevention of stroke, IHD and peripheral vascular disease
control include the efficiency
and is cost-effective in all regions of the world.80 Key issues in
of identifying those who
hypertension control include the efficiency of identifying those
would most benefit from who would most benefit from treatment, how to improve access
treatment, how to improve to medications and treatment adherence, and how best to deliver
access to medications and medications. One trend has been to evaluate the overall NCD risk
treatment adherence, and of a patient rather than just BP, and several studies have shown
how best to deliver that it is more cost-effective to determine overall CVD risk
medications. instead of focusing on BP (or cholesterol) levels alone.81
Controlling diabetes
Early detection of diabetes confers opportunities to slow disease progression, address
comorbidities like hypertension, and lower the costs of managing advanced diabetes and its
complications. Diabetes meets key criteria for screening with reliable tests to identify elevated
glucose, a precursor phase (prediabetes), and interventions to delay onset and manage the
disease.82 Given that interventions to prevent diabetes among
Given that interventions to persons with prediabetes are cost-effective,83 screening should
prevent diabetes among always also take into account the prediabetes range of results.84
persons with prediabetes are Equally, regular screening to detect and treat diabetes
cost-effective, screening complications in their early stages is generally recommended,
should always also take into before irreversible clinical manifestations and disability set in.85
Since there is a preclinical phase before each complication sets
account the prediabetes range
in, diagnosed diabetes cases should undergo regular eye, foot,
of results.
and urine checks.
The following sections give broad estimates of costs, using best available data from Bangladesh
or elsewhere. The clinical heterogeneity of hypertensive and diabetic patients makes overall case
management costs highly variable.
Screening and diagnosis costs

Hypertension: The average screening cost is approximately US$ 3.90 for LMICs (BDT 322).86
This includes the cost of performing a NCD risk assessment and BP measurement at the primary
care level.
Diabetes: The average cost of screening is approximately US$5 (BDT 411).87 This estimate is for
glucose screening at PHC level, and includes documentation, setting up referrals and organising
screening events.
Relevance for Banladesh: Finding 50% of the currently undiagnosed 7.1 million hypertensive
people aged 35+ years would cost about US$ 13.8 million (BDT 1140 million), and finding 50% of
the currently undiagnosed 3.8 million diabetic adults aged 35+ years would cost about US$ 9.5
million (BDT 780 million).
Patients cover a large part of the screening and diagnosis costs out of their own pockets. A single
blood sugar test can cost a patient BDT 120.88 Test costs can be higher in urban areas than rural
16
settings.89 Total diagnosis costs to the patient, including the investigations, consultation fee and
indirect costs, amount to an average costs of BDT 1700 (US$ 20).90
Treatment costs
Hypertension: Using WHO data, it has been estimated that hypertension treatment would cost
about US$ 13 (BDT 1,070) per patient per year.91
Diabetes: For Bangladesh, IDF estimates treatment costs of approximately US$ 51 (BDT 4,200)
per patient per year.92 Costs can however be much higher depending on the treatment regimen
(Annex 9 Fig. A 9.1 illustrates the wide range of costs from a systematic review of LIC/LMIC
data). In one study, the average annual cost of diabetes care was estimated at US$ 25,900
(US$314, direct cost US$283 and indirect cost US$31).93
Treating the currently diagnosed 7.3 million hypertensive adults aged 35+ years translates into a
cost of approximately US$ 95 million (BDT 7800 million). Treating the currently diagnosed 2.33
million diabetic adults aged 35+ years would cost approximately US$ 119 million (BDT 9860
million).
The Bangladesh Copenhagen Project assessed the benefit of averting The Bangladesh
NCD burden through targeted investment. It found hypertension Copenhagen Project
medication highly beneficial at BDT 37 benefit for every BDT spent. assessed the benefit of
Diabetes treatment also showed positive returns, albeit at a much averting NCD burden
lower ratio, of BDT 3 per BDT spent. through targeted
investment. It found
Much of the long-term treatment and monitoring costs are borne by
hypertension
patients (e.g., BDT 2,486 annual payment per person for glucose testing
strips). These high costs repeatedly lead patients to delay treatment
medication highly
seeking, prevent them from accessing comprehensive and continued beneficial at BDT 37
care, and severely hinder their ability to manage their illness benefit for every BDT
effectively.94 Often, patients require several different medications. In spent. Diabetes
one Bangladesh study, diabetic patients took on average 3.6 different treatment also showed
medications.95 Figure 3.2 shows the medication patterns of diabetic positive returns...
patients at the OPD of the Bangladesh Institute of Health Science
Hospital.
Complications can also quickly lead to high care costs. The average costs of retinopathy alone
were reported to be US$140 per patient in Bangladesh in 2012.96 According to studies in India,
up to 30% of people with newly diagnosed diabetes already had evidence of retinopathy,
nephropathy, and CVD at the time of diagnosis.97 Diabetes is of course also associated with
substantial indirect costs of lost productivity attributable to absenteeism and suboptimal work
performance.98
17
Figure 3.2 Reported medication use by diabetes patients (in percentages, 2014 data)
Source: Islam SMS et al. (2017). Healthcare use and expenditure for diabetes in Bangladesh. BMJ Global Health
2017;2:e000033.
The medicines for hypertension and diabetes listed in the NCD Control Operational Plan are
provided in Annex 10.
Costs for diabetes care from a study comparing patients with and without diabetes are
summarised in Box 3.5.
Box 3.5 Average excess costs for people needing diabetes care
Annual payments for medicines: BDT 35,385 (US$ 429) or 22 times higher than non-
diabetic patients
Annual out-patient care: BDT 5,075 (US$ 62) or 50% higher than non-diabetic patients
Annual in-patient care: BDT 6,592 (US$80) or twice as high as non-diabetic patients
Total annual point-of-service payments: BDT 49,538 (US$ 600) or six times higher than
non-diabetic patients. This is also 27% of the HIES 2016-reported annual consumption
expenditure average of BDT 185,000.
Sources: Islam SMS et al. 2017, HIES 2016.
For low-income groups, direct costs associated with diabetic care are therefore a dramatic drain
on the annual household income (Box 3.5). This highlights the need to address financing and
equity issues. Future treatment costs for hypertension and diabetes will further escalate with
population growth and aging unless effective prevention and health promotion interventions are
scaled-up.
18
Costs of preventive and health promotion interventions

According to WHO,99 population-based measures that address tobacco and harmful alcohol use,
as well as unhealthy diet and physical inactivity, account for a very small fraction of the total
price tag of intervening against NCDs. Promoting public awareness
about diet and physical activity costs approximately US$ 0.038 per In the Bangladesh
person per year, interventions to reduce people’s salt intake cost about Copenhagen Project,
US$ 0.030, and replacing trans-fat with polyunsaturated fat through smokeless tobacco
population-level interventions cost about US$ 0.009. Figure A 9.2 in cessation and tobacco
Annex 9 presents cost estimates for these three interventions in China, tax interventions
India and the Russian Federation, which are higher than WHO’s global showed positive returns
cost estimates but still regarded as “best buys” in these countries. In of BDT 9 and 8 per BDT
the Bangladesh Copenhagen Project, smokeless tobacco cessation and spent, respectively.
tobacco tax interventions showed positive returns of BDT 9 and 8 per
BDT spent, respectively.
The combination of population-based and individual-based best buy interventions for NCDs and
their underlying risk factors amounts to an annual per capita investment of about US$1.50 in
LMICs based on WHO estimates.100
Section 4 provides an overview of care models in Bangladesh focusing on diabetes and

hypertension. It highlights some innovative and expanded models of care, both in Bangladesh
and beyond.
19
“For low-income
groups, direct costs
associated with
diabetic care are a
dramatic drain on the
annual household
income. This highlights
the need to address
financing and equity
issues.”
NCD MODELS OF
HEALTHCARE SERVICE DELIVERY
4.1 Overview of selected care models implemented in
Bangladesh
Available NCD services in Bangladesh are primarily concentrated in urban areas and provided by
the private sector. In Dhaka, NCD service provision is for the most part through private for-profit
and non-profit organisations, through general and specialised tertiary hospitals, such as The
Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic
Disorders (BIRDEM)—the largest institute of the Bangladesh Diabetic Samiti (BADAS, previously
known as Diabetic Association of Bangladesh)—and The National Heart Foundation of
Bangladesh (NHFB). From the public sector, the National Institute of Cardiovascular Disease, a
tertiary hospital that provides cardiovascular specialist care, has an outpatient department,
including a hypertension clinic.
Moving outside Dhaka, the Ministry of Health and Family Welfare (MoHFW) is scaling up ‘NCD
corners’, which were initially piloted in three Upazila (sub-district) UZHCs in 2012 and are now
planned to be available in 300/491 UZHCs; there is one UZHC in each Upazila. A NCD service
capacity assessment carried out in an UZHC with a newly established NCD corner reported that
the “NCD corner was not able to function adequately” due to stock-outs of a substantial number
of essential NCD medications and inadequate record taking of consultations and referrals among
others101.
Box 4.1 Key findings from the 2014 Bangladesh Health Facility Survey
The Bangladesh Health Facility Survey of 2014, funded by the Government of Bangladesh and
USAID, assessed the health care system capacity to appropriately diagnose and treat NCDs.102
The survey reported that less than one in five (18%) health facilities offer services for
diabetes, increasing to around one in four (26%) if excluding the community clinics. For CVD
diagnosis, care and treatment services, this is provided by 16% of all health facilities and 28%
of facilities if excluding community clinics. Unsurprisingly, higher level facilities are more
likely to provide diabetes or CVD services with almost all district hospitals (95%) and 81% of
UZHCs providing such services. In addition, more than three quarters of facilities do not have
guidelines for the diagnosis and management of diabetes and CVDs and 80% or more
(depending on condition) of health facilities don’t have any staff member recently trained
(defined as in the last two years) to provide services for either diabetes or CVDs. The majority
of facilities are ill-prepared to provide quality services for diabetes or CVDs and, in particular,
lack the essential medicines for treating diabetes and CVDs, especially in rural areas (see
Figure 4.1).
21
Figure 4.1 Percentage of health facilities providing diabetes and CVD services and respective medications in
rural and urban Bangladesh
Sources: National Institute of Population Research and Training (NIPORT), Associates for Community and Population
Research (ACPR), and ICF International. 2016; Bangladesh Health Facility Survey 2014. Dhaka, Bangladesh: NIPORT,
ACPR, and ICF International.
Despite these shortfalls in NCD service delivery, a NCD-related PHC level situation assessment
conducted in 2015 confirmed the potential that is in the country to address the NCD burden.103
For instance, the human resources including doctors, nurses,
Despite shortfalls in NCD technologists and field level workers, are present (albeit not at
service delivery, a NCD- sufficient levels). It however also demonstrated that detection
related PHC level situation and referral of cases from the community level by health
assessment conducted in 2015 workers is weak and training limited.104
confirmed the potential that is
in the country to address the To help improve this situation, the Ministry of Health is piloting,
through its NCDC project 2017–22, a community-based, primary
NCD burden.
healthcare model that utilises the country’s CCs. This model of
care is based on WHO’s Package for Essential NCD (PEN, Box 4.2) and includes screening of NCDs
at the CC, a referral to the UZHC for screen positive patients, diagnosis and treatment initiation at
the UZHC, and treatment maintenance back at the CC. The aim is to reach 20 (200) UZHCs and
200 (2000) CCs by 2020 (2022). It would allow further involvement of the community level and
non-physicians to screen for risk factors for CVD and participate in managing uncomplicated
NCDs according to established protocols, under the supervision of medical officers. In some rural
areas NCD services are also provided by small community-based intervention pilots. Table 4.1
provides an overview of hypertension and diabetes care models in Bangladesh by care cascade
stage.
22
NCD MODELS OF HEALTHCARE SERVICE DELIVERY
Box 4.2 WHO’s Package for Essential NCDs (PEN)

WHO’s Package for Essential NCDs (PEN) is a conceptual framework that aims to strengthen
equity and efficiency of primary health care in low-resource settings. The package includes a
prioritised list of cost-effective interventions that can be applied to an acceptable quality even
in resource-poor settings. Furthermore, the package includes core medicines and
technologies, risk prediction tools, tools for planning, implementation and assessment of
capacity, and guidance and protocols on how interventions should be implemented. It also
addresses technical and operational issues on how the essential NCD interventions can be
integrated into primary care and evaluated for impact. According to the WHO, PEN “should not
be considered as yet another package of basic services” but, rather, an important "first step for
integration of NCD into PHC and for reforms that need to cut across the established
boundaries of the building blocks of national health systems”. WHO’s PEN is the minimum
standard for NCDs to strengthen national capacity to integrate and scale up care of heart
disease, stroke, cardiovascular risk, diabetes, cancer, asthma and chronic obstructive
pulmonary disease in primary health care in low-resource settings. The package has already
been implemented in a number of countries, including Bangladesh, Sri Lanka, Bahrain, Kuwait,
Indonesia, Palestine, Malawi, Bhutan, the Philippines and the Democratic People’s Republic of
Korea, among others.
4.2 Principles and examples of NCD and chronic care

models implemented elsewhere
The response to major infectious diseases with long-term treatment needs (such as HIV and TB)
has provided some important lessons for the long-term management of chronic diseases. While
there are certainly lessons to be learned from NCD management in high-income settings, the
rapid scale-up of health services in resource-constrained settings where health systems are
generally much weaker than high-income settings and there are critical shortages of health
professionals, requires a “public health approach”. In HIV, this approach, described by WHO in
2003105, prioritised large-scale access to treatment over maximising individualised care, the
usual hallmark of chronic disease care in high-income settings. The main principles of the
successful public health approach in generalised HIV epidemics, particularly in Sub-Saharan
Africa, are simplification and standardisation of healthcare delivery processes, decentralisation,
task-shifting, peer and community involvement in programming and support for self-
management.106 Some of these elements have been applied to other chronic diseases - including
NCDs - in Bangladesh and other resource-constrained settings, through innovative service
delivery models of care.
23
24
Table 4.1 Highlighted hypertension and diabetes care models in Bangladesh across the care cascade
INSTITUTE/ FUNDING; 1 TARGET GENERAL MODEL/ PATIENT SCREENING/ ADHERENCE/
PROJECT TARGET POP DISEASE SCALE PAYMENT DIAGNOSIS LINKAGE/REFERRAL TREATMENT MONITORING OTHER
NCDC Government; HTN & Community-based “Free/subsidised Screen in CC by Those with +ve screen or Initiated in Unclear Future plan is to
project of rural DM PHC model. No treatment for trained CHW. complications referred up to UZHC and use multi-
DGHS baseline on current NCDS at least for Some home UZHC for diagnosis & refill planned purpose
scale (new the poor screening in treatment (no formal to be volunteer/
programme). (identified) will be selected pilot referral/ follow up currently). available workers to work
Programme target= provided.” areas. CC to be However, the country is from CC in communities
20 (200) UZHC and provided BP working on establishing “a to motivate
200 (2000) CC by machine, strong referral linkage with people to
2020 (2022) glucometer, urine feedback…from CC to UZHC attend
sugar strip. and further referral to CC/UZHC for
Diagnosis by MO DH/MCH/ Specialised screening,
at UZHC, which institutes” diagnosis &
are to be management of
provided X-ray, NCD as
ECG, glucometer, appropriate.
BP machine,
measuring tape,
weighing scale
NCD corner Government; HTN & Community-based As above At NCD corner in If complications, advise At NCD Unclear
rural DM PHC model, based on UZHC patients to go to district corner in
PEN intervention. 1st hospital or above. Currently, UZHC.
piloted in 2012 in 3 no formal referral/ follow up.
UZHCs in the SW Patients who attend UZHC
districts of Khulna are often not triaged at
Division. Now scaled- UZHC and thus queue to see
up plan in 300 UZHC a GP who subsequently
in country refers patient to NCD corner,
also manned by a GP.
Table 4.1 Highlighted hypertension and diabetes care models in Bangladesh across the care cascade (continued)
INSTITUTE/ FUNDING; 1 TARGET GENERAL MODEL/ PATIENT SCREENING/ ADHERENCE/
PROJECT TARGET POP DISEASE SCALE PAYMENT DIAGNOSIS LINKAGE/REFERRAL TREATMENT MONITORING OTHER
BRAC NGO; rural HTN & Community-based Unclear Screen at home Screen +ve patients at home At hospital by At regular home visit by
DM model. Pilot in 11 by trained CHW; referred for diagnosis and MO CHW. Importance of a
sub-districts in 7 diagnosis in management in hospital. healthy lifestyle emphasised.
districts hospital by MO Unclear exact referral
mechanism
COBRA-BPS Research HTN Home community- Subsidies, in the Screen at home Stepped-up referral from the By trained Adherence to lifestyle advice Currently being
institute; rural based model utilising form of a travel by CHW. CHW to a trained GP using a public and through HHE. Follow-up at evaluated for
CHW. Currently voucher for clinic Diagnosis checklist; HTN care private home by CHW impact as part
piloted in some areas visit and a free confirmed by coordinators facilitate the providers in of a RCT,
of Tangail and supply of antiHTN trained GP in tracking of referrals in HTN triage including in
Munshiganj Districts medications, designated HTN government clinics counters Pakistan and Sri
provided to low triage counter in using HTN Lanka.
income health facility checklist
individuals with
poorly controlled
HTN.
BIRDEM Private, non- All, but 700-bed GH, largest 30% of the On-site and Patients referred up to & On-site by On site DM & nutrition The hospital
profit; urban DM and institute of BADAS. hospital’s beds during diabetes down from BIRDEM, MO. education available. All has the largest

endocrin All expected GH are free, including camps & street particularly from/to affiliated Pharmacy patients have DM book. OP turnover in
e services, including OP investigation & screening associations. This is usually also available the world
disorder and IP services, treatment, for initiatives in done in form of on-site. under a single
s priority providing poorest patients Dhaka during DM recommending patient to roof
comprehensive special days attend without formal
primary, secondary referral & follow up
and tertiary care.
25
26
Table 4.1 Highlighted hypertension and diabetes care models in Bangladesh across the care cascade (continued)
INSTITUTE/ FUNDING; 1 TARGET GENERAL PATIENT SCREENING/ ADHERENCE/
PROJECT TARGET POP DISEASE MODEL/SCALE PAYMENT DIAGNOSIS LINKAGE/REFERRAL TREATMENT MONITORING OTHER
The Private; urban HTN & Subscription-based Monthly Unclear DM patients with SMS Patients able to transfer data The programme
Telemedicin DM membership subscription fees complications/ in-need of in- prescriptions from home monitoring was able to
e Reference organisation that range from patient services are referred provided devices (glucometers & BP increase client
Centre links DM patients US$0.60 to to BADAS. Unclear for HTN. monitors). Home visits by adherence to
Limited with healthcare US$20.00. qualified providers also treatment plans
(TRCL)/ providers (qualified available (US$10–20/ by 62% and
AMCARE doctors & nurses) month). Patients also receive reduce doctor/
through a call centre. relevant information & hospital visits
medical alerts via SMS. from 5–6 per
Patients have direct access year to 1–2 per
to their patient file. year.
National Private, non- CVD, 300-bed specialist 30% of the On-site and Patients referred up to & After acute
Heart profit; urban including hospital, provides hospital’s beds during free down from hospital, hospital
Foundation HTN invasive and non- are free for hypertension particularly from/to affiliated episode and
Hospital and invasive cardiac poorest patients camps associations. This is usually in HTN clinic
Research diagnostics and done in form of
Institute investigations. recommending patient to
(part of Includes OP, ED & IP attend without formal
NHFB) specialist services, referral & follow up
including a cardiac
surgery unit. In 2015,
the provided services
for 88343 OP and
21704 IP.
Sources: Key informant interviews and site visits; 4th HPNSP NCDC Operational Plan 2017–22; BADAS website and Annual report 2016; NHF website and Annual Report 2016 and 2015; Bangladesh Health Watch Report
2016; World Bank NCD report 2013; Jafar et al, 2017. Multicomponent intervention versus usual care for management of hypertension in rural Bangladesh, Pakistan and Sri Lanka: study protocol for a cluster
randomized controlled trial. 18:272. DOI 10.1186/s13063-017-2018-0. BADAS The Diabetic Association of Bangladesh; BIRDEM Bangladesh Institute of Research & Rehabilitation in Diabetes, Endocrine and Metabolic
Disorders; BP blood pressure; CC Community Clinic; CHW community health worker; COBRA-BPS Control of Blood Pressure and Risk Attenuation-rural Bangladesh, Pakistan, Sri Lanka, Feasibility Study; CVD
cardiovascular disease; DGHS Directorate General of Health Services; DH District Hospital; DM type 2 diabetes mellitus; ECG electrocardiogram; ED Emergency Department; GH General Hospital; GP General Practitioner;
HTN hypertension; IP inpatient; MCH Maternal and Child Health; MO Medical Officer; NCD Non-communicable diseases; NCDC Non-Communicable Disease Control; NGO non-governmental organisation; NHFB National
Heart Foundation Bangladesh; OP outpatient; PEN Package for Essential NCDs; PHC primary health care; RCT Randomised controlled trial; UZHC Upazila Health Complex.
The following section briefly describes the underlying principles of the aforementioned
strategies and provides some examples of their use in chronic diseases, primarily focusing on
NCDs in other low- and middle-income countries.
As will be highlighted, these principles can be complimentary and NCD programmes will often
use more than one of these principles in their programme design. At the same time, an approach
can be used across the different principles. For instance, mobile health
or mHealth solutions relate to the principles of self-monitoring, In Bangladesh,
decentralisation and task shifting. Interventions using mHealth standardisation,
technology can enhance or replace the in-person, face-to-face and decentralisation and
group-based service delivery, and has been found to improve limited task-shifting
outcomes, be cost effective, and culturally relevant. According to (primary prevention
Mallow et al. (2015), "mHealth technology has been used to improve and screening) and self-
outcomes include seeking out health information via the web, access to management has been
appointment scheduling and medication refills, secure messaging, the predominant
computerised interventions to manage a chronic condition, use of a
strategy.
personal health record, use of remote monitoring devices, and seeking
support from others with similar health concerns through social networks".107Evidence on the
potential of mHealth applications especially in diabetes care is accumulating rapidly, for
instance: A telephone-delivered intervention after discharge from diabetes rehabilitation in
Germany demonstrated improvements in patients' level of activity and health status after 12-
months.108 A two-way text messaging program in Utah, USA that provided behavioral coaching,
education, and testing reminders to diabetes patients who were failing to achieve their self-
management goals, saw high satisfaction among patients and frequent use in a sub-set of
them.109
mHealth interventions may however not always be superior to traditional approaches. For
instance, mHealth mobile phone messaging and participatory community mobilisation were both
tested in a large trial involving 96 villages in Bangladesh. The mHealth intervention increased
knowledge and awareness of T2DM and its risk factors but had no detectable impact on disease
outcomes. In contrast, the community mobilisation using a participatory learning and action
approach not only increased knowledge and awareness of disease, but also significantly reduced
population prevalence of T2DM and intermediate hyperglycaemia, and T2DM incidence among
an intermediate hyperglycaemic cohort.110
In Bangladesh, standardisation, decentralisation and limited task-shifting (primary prevention

and screening) and self-management has been the predominant strategy (Table 4.1 highlights
the key components of some of the models). In upcoming sections, we provide examples of
models that have used a more extensive task-shifting strategy as well as peer support,
community involvement and self-management strategies.
Simplification, standardisation and monitoring of healthcare delivery

processes
Simplifying healthcare management approaches aim to strike a balance between what is
desirable and what is currently feasible in resource-limited settings.111 It allows a wider range of
providers to be involved in patient management while minimising risks to patients. They can
also help patients directly with self-management and treatment adherence (for example if
treatment regimen is simplified). Standardisation is “the process of developing, agreeing upon
and implementing uniform technical specifications, criteria, methods, processes, designs or
27
practices that can increase compatibility, interoperability, safety, repeatability and quality112.”
Simplifying decision-making and defining clear and simple standards based on evidence-based
interventions, including standard operating procedures (SOPs), help maintain patient safety and
high-quality healthcare service provision. One of the key objectives of WHO’s PEN Interventions
(Box 4.2) is “standardisation of diagnostic and investigation procedures and drug prescription”
as well as “formulation of referral criteria for further assessment or hospitalisation”113.
Relevance for Bangladesh: While there are currently no national standard operating
procedures for the management of NCD in Bangladesh114, the country is currently in the process
of developing these with the support of WHO. These will be based on simplified algorithms and
the use of standard drug prescriptions based on generic formulations.
Decentralisation including “Care closer to home”

In health service delivery decentralisation encompasses the transfer of service delivery from
higher levels, such as hospitals, to lower levels of the healthcare system, which are often closer to
patients (“Care closer to home”), saving patients time and money and allowing individuals living
in rural and remote locations to access care. A 2017 systematic review of primary care models
for NCD interventions in Sub-Saharan Africa found that 10/12 studies incorporated the use of
rural locations for implementation of their clinics.115 Box 4.3 provides a case study from Sri
Lanka, which implemented a decentralised PHC NCD model. This model is similar to
Bangladesh’s new NCDC care model (Table 4.2 provides an overview of Bangladesh’s model by
tier of health care and cascade stage while Figure A 11.1 Annex 11 provides infographics on the
NCDC care model in urban and rural settings of Bangladesh).
Box 4.3 Decentralising primary NCD care: Sri Lanka’s Healthy Lifestyle Centres
The development of Sri Lanka’s Healthy Lifestyle Centres (HLCs) was based on a decentralised
primary care model using the lessons learnt from a WHO PEN intervention pilot, as well as
two other pilots.116 The HLCs were initiated in 2011 to address the lack of NCD screening in
Sri Lanka’s primary health care. They were set up within primary medical care institutions
(PMCUs)—the lowest level of curative institutions offering only outpatient services provided
by one medical officer and one health assistant and/or a dispenser—and the Healthy Life
Centre was expected to be open on at least one weekday morning, serving 20 adults aged
between 40 and 65 years per session. Services are provided in the HLCs using standardised
protocols for NCD and risk factor screening, lifestyle management of screen positive patients,
referral to the specialised medical clinics conducted at the same PMCU or another institution
for those with a 10-year CVD risk higher than 30%, and group health education.
Implementation of the Sri Lanka programme highlights a few lessons that can be drawn.
Firstly, the importance of carrying out monitoring and using that data for programming,
including to redesign the programme as needed, is highlighted. The project noted low
participation in some areas and of men overall in the programme, which led the country to
expand the opening hours of the HLC and consider expanding it further to include weekends
and public holidays. The country also initiated “outreach” screening in geographical locations
where participation was low and in workplace settings to target those previously not reached
by the programme. Secondly, to improve health system capacity for NCD provision, the
country is considering the development of a separate community-level cadre dedicated to
NCD-related activities that would work in their communities to encourage people to attend for
screening, follow-up NCD patients in the community, and provide ongoing health and lifestyle
education to the population.
28
Table 4.2 Bangladesh’s new model for the continuum of care for hypertension and type-2 diabetes
PRIMARY SCREENING TREATMENT TREATMENT
PROVIDER PREVENTION (BP, NCD RISK) DIAGNOSIS INITIATION MONITORING
Outreach Education on Clinical screening Patient self-
risks & of CVD risk factors monitoring
healthy life including BG & BP
style Partial
determination of
10-year CVD risk &
refer
Community Education on Clinical screening No but policy is for refills Patient self-
Clinic risks & of CVD risk factors to be obtained once monitoring
healthy life including BG & BP patients are initiated on Regular BP & BG
style Partial treatment check at facility
determination of (unclear frequency)
10-year CVD risk &
refer
Union Education on Clinical screening Both HTN Yes, by doctor (available Patient self-
risks & healthy of CVD risk factors (serial BP) & only in few unions), using monitoring
life style including BG & BP DM2 (FPG/ both biomedical (generic
Partial OGTT) drug or insulin
determination of formulations) and lifestyle
10-year CVD risk & advice.
refer
Manage conditions
and I&R
complications
Upazila Education on Clinical screening Both HTN Yes, by doctor, using both Screening,
Health risks & healthy of CVD risk factors (serial BP) & biomedical (generic drug identification &
Complex life style including BG & BP DM2 (FPG/ or insulin formulations) referral/
Laboratory OGTT) and lifestyle advice. management of
screening complications
Full determination Laboratory follow-up
of determination of of HTN and DM
10-year CVD risk cases
Manage conditions Down-referral to CC
and I&R once disease
complications controlled
District Education on Clinical screening Both HTN Yes, by doctor, using both Screening,
Hospital risks & healthy of CVD risk factors (serial BP) & biomedical (generic drug identification &
life style including BG & BP DM2 (FPG/ or insulin formulations) management or up-
Laboratory OGTT) and lifestyle advice. referral of
screening complications
Full determination Laboratory follow-up
of determination of of HTN and DM
10-year CVD risk cases
Manage conditions Down-referral to CC
and I&R once disease
complications controlled
29
Table 4.2 Bangladesh’s new model for the continuum of care for hypertension and type-2 diabetes (continued)
PRIMARY SCREENING TREATMENT TREATMENT

PROVIDER PREVENTION (BP, NCD RISK) DIAGNOSIS INITIATION MONITORING
Urban: Education on Screening of CVD Both HTN Yes, by doctor, using both Screening,
CRHCC risks & healthy risk factors (serial BP) & biomedical (generic drug identification &
(unclear if includes OGTT) and lifestyle advice. referral of
laboratory or complications
clinical only) Laboratory follow-up
Full determination of HTN and DM
of determination of cases
10-year CVD risk
Manage conditions
and I&R
complications
Urban: Education on Screening of CVD Both HTN Yes, by doctor, using both Screening,
PHCC risks & healthy risk factors (serial BP) & biomedical (generic drug identification &
(unclear if includes OGTT) and lifestyle advice. referral of
laboratory or complications
clinical only) Laboratory follow-up
Full determination of HTN and DM
of determination of cases
10-year CVD risk
Manage conditions
and I&R
complications
Private Yes, in selected Yes, more so if Yes, more so if doctor Yes, in selected
pharmacies pharmacies upon doctor associated with pharmacy pharmacies upon
client request associated patient request
with
pharmacy
Sources: NCDC Operational Plan 2017‒22; In-country observations and key informant interviews.
Notes: BG=blood glucose; BP=blood pressure; CC=community clinic; CVD=cardiovascular disease; CRHCC=
Comprehensive Reproductive Health Care Centre; DM2=diabetes mellitus type 2; FPG=fasting plasma glucose; HTN=
hypertension; I&R=Identify and refer; NCD=non-communicable disease; OGTT=Oral Glucose Tolerance Test; PHCC=
Primary Health Care Clinic.
Relevance for Bangladesh: The new NCDC care model is an attempt to decentralise NCD
service delivery, based on a decentralised primary care model whereby the first point of contact
for NCD patients with the healthcare system is at the CC, the lowest level tier of the healthcare
system. In addition, many healthcare providers, such as BIRDEM, organise community outreach
or health ‘camps’ whereby health services are brought to the people. The country is also
introducing a new cadre of community healthcare staff, the Multipurpose Health Volunteers, who
would be able to carry out education, screening and follow-up of patients in the community itself
with referral of screen positive patients to healthcare facilities. The approach used is similar to
Sri Lanka’s experience and some lessons that can be drawn for Bangladesh have been highlighted
above.
Task-shifting and involvement of a full range of healthcare providers

In a context of shortages and/or unequal distribution of healthcare staff in low- and middle-
income countries, many countries have introduced task-shifting strategies for a variety of
healthcare services.117 Task-shifting refers to the reallocation or shifting of tasks from the
30
responsibility of one cadre (a qualified person such as a doctor) to another, usually lower, cadre
(such as a nurse or even a person with no health qualification). This practice has been
particularly prevalent and successful in MCH,118 and, as previously mentioned, in the context of
HIV/AIDS, where the impressive scale up of antiretroviral therapy coverage among people living
with HIV can at least be partly attributed to task-shifting of treatment initiation to nurses.119
Training, the use of clearly defined SOPs and appropriate supervision and mentorship helps
maintain patient safety and service quality.
In recent years, task-shifting approaches have expanded to NCDs in low- and middle-income
countries. A 2014 systematic review assessing the effectiveness, cost-effectiveness and barriers
of task-shifting to non-physician healthcare workers for the management and prevention of
NCDs in LMICs identified 22 published studies, including seven studies for hypertension and
CDVs and five studies for diabetes120. The systematic review found that task-shifting was
effective in improving process outcomes (such as successfully screening for hypertension and
diabetes) and health outcomes (such as achieving hypertension and diabetes control) and
achieving treatment concordance with doctors. Two studies, both conducted in India, reported
on the cost-effectiveness of task-shifting strategies for oral cancer and anxiety and depression,
finding the intervention to be cost-effective and cost-saving respectively. Task-shifting enablers
were appropriate training and provision of standard algorithms and protocols while the main
identified barriers were linked to legislative prescribing restrictions and availability of
medicines. Boxes 4.4, 4.5 and 4.6 provide task-shifting case studies from Kenya, Rwanda and
Indonesia respectively.
Box 4.4 Task shifting for patient management and medication adherence clubs: Kenya
Five years after launching a NCD programme in Kibera slum in Nairobi, Kenya, Médecins Sans
Frontiéres—in response to an overwhelming NCD patient volume load for clinical officers—
began to shift the management of stable patients with five NCDs to nurses, as an extension of
its task-shifting approach already used for HIV and TB121. The nurses underwent a week-long
training on the five NCDs (hypertension, diabetes, epilepsy, sickle cell disease and asthma) as
well as how to use structured clinical decision support protocols. A retrospective review of
routinely collected clinic data from the two PHC facilities carried out in 2014 found that
nurses’ adherence to NCD protocols and process indicators was 69% for routine screening
questions, 81% for routine laboratory monitoring and >90% for weight checks, BP monitoring
and review of laboratory results. Seventeen (2%) of consultations were referred back to
clinical officers for uncontrolled disease, medication side effects, and NCD-associated
complications. The programme also used medication adherence clubs for stable NCD patients,
who are able to collect their chronic medication every three months through a club, rather
than through individual clinic appointments122. These clubs also provide an opportunity for
monitoring, health education and peer support. Furthermore, by having the clubs at different
times (including Saturday) and avoiding the need to queue at the clinic, the saved opportunity
cost for patients can be considerable.
31
Box 4.5 Nurse-led NCD care: Rwanda’s integrated model for rural settings
In Rwanda, an integrated, nurse-led NCD care model implemented in rural areas has been
providing comprehensive care services for a wide range of NCDs including heart failure,
chronic cancer pain, hypertension, diabetes, and chronic respiratory diseases123. Services are
led by nurses and are provided on disease specific clinic days. Training, on-going mentorship
from specialist doctors and standardised diagnosis and treatment protocols are provided to
nurses. Nurses working in health centres are also provided mentorship from district hospital
nurses. The nurses use point-of-care diagnostics including HbA1c and are able to perform
simplified echocardiography to inform initial management of heart failure. Standardised
forms are used to record clinical information and kept in individual patient files that are later
captured in an electronic medical records system. Patients are also offered group education
sessions and socioeconomic support and those identified as high-risk are provided support
from community health workers. By Deptember 30, 2014, 3367 patients had been enrolled in
three district hospitals and seven health centres with 30% and 16% having hypertension and
diabetes respectively. The outcomes assessments for hypertension and diabetes are ongoing.
Box 4.6 Village health workers for community awareness and screening: Indonesia
Indonesia implemented a primary care level diabetes and hypertension screening and
treatment programme based on the WHO PEN programme in 2011124. The country used
trained village health care volunteers to conduct ‘Posbindu’ (community engagement,
community-based awareness, monitoring, and screening activities) for diabetes and
hypertension, in various community areas including the homes of the volunteers and
designated Posbindu facilities. Posbindu activities are carried out on the same day monthly
whereby the village volunteers carry out general health history check-ups, take weight and
height measurements, and screen for hypertension and diabetes mellitus using a BP monitor
and a glucometer for random capillary blood glucose for any attending person aged 15 years
and older. Persons who are screened positive are referred to PHC facilities where doctors or
nurses confirm the diagnosis and provide treatment. Individuals may also present directly to
the PHC facility for screening and diagnosis. An economic analysis of the community screening
strategy found that the programme averts 0.04 DALYs per individual screened for diabetes or
hypertension and is cost-saving (14.22 million Indonesian rupiah savings for every DALY
averted, around US$ 1052). The study also reported that a more targeted screening policy
(screening of those aged 40 years and older as opposed to screening for 15 years old and
above as is the current practice) and the use of a more accurate screening test for diabetes
(fasting versus random capillary glucose) would be even more cost-effective.
Relevance for Bangladesh: The new NCDC care model is focused on task-shifting of NCD
screening to community healthcare workers working in CCs. Diagnosis and treatment initiation
remains the responsibility of physicians. There is a critical shortage of nurses in Bangladesh and
task-shifting to nurses would not be feasible. Community healthcare workers are also already
overstretched. The country may consider further task-shifting of screening to trained lay
workers or volunteers, drug sellers or pharmacists or informal village doctors as well as
expanding the prescribing list of community healthcare workers if feasible.
Peer and community involvement in service delivery

Peer and community involvement is critical for large-scale roll out of healthcare programmes.125
At its strongest and most transformative, community participation encompasses empowerment
of the community the programme serves, where the community is involved in considering
options, making decisions, and taking collective action.126 Community participation can serve to
32
raise awareness, design appropriate interventions and thus increase acceptance, advocate for
political action, provide informal and formal support to patients, mobilise resources, and support
sustainability of programmes.
Peer support care models, where peers are used to provide social and emotional support,
assistance with disease management, and linkage to clinical care and community resources, have
been widely applied in health and are starting to gain wider momentum in NCD care. Boxes 4.7
and 4.8 provide case studies from NCD peer support care models in Cambodia, Cameroon, South
Africa, Thailand and Uganda.
Box 4.7 Peer support care models for diabetes management

Peers for Progress, a peer support programme for diabetes management of the American
Academy of Family Physicians Foundation, was implemented in Cameroon, South Africa,
Thailand and Uganda127. Each country team developed its own programme based on the local
context. However, the programmes shared the same general approach with peers providing:
1) assistance in daily self-management; 2) social and emotional support; 3) linkage to clinical
care; and 4) ongoing support. Depending on country context, the support involved individual
and group meetings, text messaging, home visits, exercise sessions, cooking classes, and
accompanying patients to clinical care as required. Peers were based in diabetes clinics
(Cameroon and Uganda), non-health community organisations (South Africa), and a health
volunteer service (Thailand). In Cameroon, the programme observed significantly decreases
in participants’ average body mass index (from 28.6 to 25.5 kg/m 2), systolic (from 142 to
124.4 mmHg) and diastolic (from 84.4 to 77.7 mmHg) blood pressure, and HbA1c (from 9.6%
to 6.7%) in only six months. Before the project the number of diabetics with a HbA1c greater
than 8% was 85/96; six months later only 4 had a HbA1c greater than 8% and 65 had a HbA1c
less than 7%. In Thailand, evaluation data were available for fifty-three adults with type 2
diabetes; after six months the study reported a significant decline in average HbA1c (from
8.6% to 7.9%) and a borderline significant decline in body mass index (from 26.7 to 25.2,
p=0.07). In Uganda, the project also observed a decline in participants’ average diastolic blood
pressure (from 85.4 to 76.3 mmHg) and average HbA1c (from 11.1% to 8.3%) while the
number of diabetics with HbA1c values less than 7% almost doubled (from 17% to 32%).
While the evaluation results are impressive, it must be noted that sample sizes were relatively
small.
33
Box 4.8 Peer educators for diabetes screening, education and patient navigation: Cambodia
The MoPoTsyo Patient Information Centre, a Cambodian NGO, has been implementing an
innovative care model for diabetes using peer educators.128 129 The NGO created networks of
‘informed’ and ‘empowered’ patients organised around a team of peer educators that also
have diabetes. To become a peer educator, a person obtains six weeks of training, after which
they receive basic equipment and supplies and are able to use their homes as a ‘Patient
Information Centre’ for weekly patient meetings and education sessions. Peer educators
screen adult patients in the community using urine strips and those with a positive urine
screen are further screened using a glucometer. Newly identified diabetic patients receive
classes at the peer educator home with an emphasis on self-monitoring of urine glucose levels
(strips are provided monthly) and lifestyle adaptation, including better nutrition and daily
exercise. The NGO also supplies medication to its networks through a Revolving Drug Fund
whereby the NGO procures a set of diabetes and hypertension medicines on the international
market to sell to patients at a fixed price via contracted pharmacies. Medical consultations and
laboratory services are provided by a diabetes specialist contracted by the NGO in district
hospitals twice a month. During the consultation days, the peer educator is responsible for
crowd control and registers patients and takes blood pressure, blood glucose and weight
measurements. Other services, such as retinopathy screening, are organised via external
private, non-profit clinics where a modest fee applies for those not eligible for a Health Equity
Fund. The role of the peer educator here is to guide the patients through the available services
including when and where to access them. Peer educator travel costs are reimbursed and, for
each activity (screening, monitoring and education sessions), an incentive is provided. The
peer educator is also eligible for a bonus based upon the evaluation of their work through the
NGO’s monitoring and evaluation system. Results after 18-months of programme implementation
showed that peer educators had reached more than 80% of adults in the pilot district with 474
confirmed as having diabetes. Of these, 67% were newly diagnosed. Almost 90% of patients
reported having increased their activity level after the programme and 84% had reduced the
amount of white rice in their diet. A review of patient self-management books showed that 71%
had recorded more than two urine glucose results in the past month (this average was
depressed by one new peer educator area where rates were only 5% compared to more than
80% in the remaining seven areas). The study also documented short-term improvements in
blood glucose and BP control as well as low referrals for medical consultations, expenditures
and drop-out rates.130
Relevance for Bangladesh: Considering the huge burden of NCDs and the critical shortages of
healthcare staff in rural areas, there is an opportunity to tap into the community itself to help
with NCD programming. This could include using trained community volunteers or peers to help
with NCD prevention, screening and client navigation through the health system.
Self-management
Due to the large burden of NCDs and its chronicity, requiring lifelong management, experts have
argued that there is a strong need to educate and support patients towards full self-management
of their chronic condition131. The term self-management in relation to diseases was first coined
by Thomas Creer who described self-management as the active participation of patients in their
own treatments132. While there is a wide variety of definitions and conceptualisations for disease
self-management today the term more broadly refers to the day-to-day management of chronic
conditions by individuals over the course of an illness133.
34
…self-management of chronic Self-management is a key component of the Chronic Care Model

(CCM)—perhaps the most well-known and influential chronic
diseases can be challenging
disease management model134. Interventions to improve self-
for patients, as it requires
management can include education, peer support, identification
daily and lifelong changes to of barriers to adherence to treatment (lifestyle and/or
lifestyle, and therefore biomedical), problem-solving to overcome barriers, provision of
requires tailored education self-monitoring tools, reminders, goal setting and incentives. In
(both content, delivery and one of its most basic forms, the provision of educational material
frequency) and additional and such as leaflets to patients that describe their disease and
ongoing support. management can already decrease information asymmetry
between provider and patient and help the patient on the path to empowerment and self-
management of his or her disease. However, self-management of chronic diseases can be
challenging for patients, as it requires daily and lifelong changes to lifestyle, and therefore
requires tailored education (both content, delivery and frequency) and additional and ongoing
support. In Bangladesh, for example, patients with type 2 diabetes who had received professional
health education and care in an urban tertiary health facility were still found to have limited
knowledge of the risk factors, causes, and management of their condition135.
There is a wide literature on the use and effectiveness of self-management strategies in NCDs,
particularly from high-income countries. In 1996, the Center for the Advancement of Health
reported that “there is substantial evidence (from over 400 studies of self-management) that
programmes providing counselling, education, information feedback, and other supports to
patients with chronic conditions are associated with improved outcomes136.” Evaluation
evidence of the self-management component of the Chronic Care Model mentioned above points
to three key interventions that are effective: distribution of educational material; patient
motivational counselling; and patient educational sessions137.One simple tool that patients can
be given to support their empowerment and self-management is a booklet that includes tailored
and appropriate information on their condition and treatment, their care plan, and specific
patient goals. The Chronic Care Passport, which has been successfully piloted in 13 countries in
Latin America and the Caribbean, is one such example.138 The passport, a patient held card used
by patients with chronic conditions including diabetes and hypertension, promotes integration
between different levels of care and includes a care plan to be followed by providers and clients
along with goals and meal plans. Preliminary results from the demonstration projects have found
that that the use of these passports is associated with better diabetes (% of patients with
HbA1c<7% increased from 32% to 40%) and hypertension control (from 45% to 49%). It has
also been associated with better quality service provision; there was a reported increase in the
proportion of patients who had received nutritional advice (12% to 52%), a foot exam (28% to
68%) or an eye exam (21% to 61%) while the proportion of patients meeting 3 or more quality
of care measures, increased from 12% to 56%. A similar patient-held ‘passport’ for diabetes has
been used in other contexts for NCD management and was also observed to be in use in the
BIRDEM institute in Dhaka.
35
A 2017 systematic review of peer-reviewed articles assessing the effectiveness of self-

management interventions for type 2 diabetes identified 14 studies with a wide-range of self-
management interventions139. While all had some form of education
… people with type 2
intervention involved, how these were delivered, by who, the material
diabetes who
used, duration and frequency, and their content differed. Overall,
however, the review found that people with type 2 diabetes who participate in self-
participated in self-management interventions improved their management
knowledge of diabetes (3 studies; all found positive statistically interventions improve
significant results), blood glucose control (8/9 studies reporting their knowledge of
varying improvements in HbA1c levels, ranging from 0.7% to 1.7%), diabetes…, blood
BMI (2 studies both showing significant improvements), lipid profile glucose control…, BMI...,
(3/4 studies reporting statistically significant improvements) and lipid profile… and
quality of life (all 3 studies reporting on quality of life reporting
quality of life…
significant improvement).
Relevance for Bangladesh: Despite the high prevalence of NCDs in Bangladesh, NCD
knowledge among Bangladeshis is still relatively poor. Self-management of NCDs, in particular
diabetes, can be complex and challenging for patients. The country may consider additional
approaches to support patients and their families to manage and control their disease, for
example using different, culturally sensitive education material, monitoring tools and peer
support, among others. Approaches should be evaluated to ensure that they are appropriate for
the population served.
Comprehensive change towards delivery system redesign

The above five principles are often combined when health services get reoriented in response to
changing health care needs. One model which speaks to all the principles is the Integrated
Chronic Disease Management (ICDM) model140, however, the model represents a more wide-
ranging re-design of service delivery or a “diagonal health system strengthening” intervention.
Box 4.9 Delivery system redesign: Integrated Chronic Disease Management in South Africa
In South Africa, an integrated approach to the management of chronic diseases derived from
Wagner’s Chronic Care Model141 and WHO’s improved care for chronic conditions
framework142 was developed and modified according to local conditions.143 The main aim was
to attain efficient, integrated services for chronic communicable (HIV, TB) and chronic non-
communicable (hypertension, diabetes, COPD, asthma, epilepsy, mental health) diseases. This
Box 4.9 Delivery system redesign: Integrated Chronic Disease Management in South Africa (continued)
required a complex intervention directed at each of the health system building blocks and
along the continuum of care.144
Since the introduction of the ICDM model in South Africa meant a radical overhaul of PHC-
level service delivery, several preparatory steps were required, such as pre-implementation
preparedness at province, district and facility level, baseline assessments, and facility re-
organisation. In the latter, key elements were: Re-organisation of patient flow; Introduction of
appointment scheduling; Scheduling of nurses; Pre-appointment retrieval of clinical records;
Creation of a designated consultation area for chronic patients; A single administrative point;
Integration of clinical records; and Pre-dispensing of chronic medication. Much consideration
was given to improving patient flow for chronic patients with two levels of triage. Firstly, a
designated waiting area for chronic patients was created (with MCH and acute patients
36
triaged elsewhere). An additional vital signs station for chronic patients was conveniently
located between the waiting area and consulting room. Secondly, after completing the vital
signs, the chronic patients were further triaged and directed appropriately, into a) Repeat
medication with normal vital signs, b) Repeat medication with abnormal vital signs, c) Six
month full examination, and d) Doctor referral. A chronic patient record was designed, and
easy-to-read evidence-based PHC clinical guidelines were made available (simplification and
standardisation principle). At facility level, implementation was the responsibility of the “ICDM
model champion” instead of the head of the facility, and lower level cadre such as adherence
counsellors and pharmacist assistants assumed certain functions of higher level cadre (task
shifting principle). Also, the guidelines offered a practical and acceptable tool to help expand
the scope of practice of non-physician clinicians to include NCD care.145 Health promotion and
patient tracing and support services were moved to ward-based outreach teams consisting of
professional nurses, enrolled nurses and CHWs, as well as integrated school health teams
(decentralisation principle). One of the main aims of the ICDM model is also to empower
health care clients to take responsibility for their own health, through “assisted” self-
management within the community with CHW support and point of care testing of BP and
glucose (self-management and community involvement principles).
The ICDM illustrates well the shift in the management of chronic disease patients from a
disease-centred to a patient-centred care approach in which patients are informed and
educated to participate in their own care. Early evaluation findings suggest that
implementation experiences have been positive, with health staff noting improved patient
care, better interaction with patients, improved level of knowledge and better teamwork
coupled with an improved level of satisfaction with the work environment at the clinic.146
Although a third of the professional nurses perceived that the ICDM would increase their
workload, this did not affect their experience and attitudes negatively towards the model.
Relevance for Bangladesh: NCD corners have been established in UZHCs, however, tracks for
MCH, acute and chronic patients as in the ICDM, and explicit triaging of patients, could further
help to improve patient flow and appropriate care. The vital sign station along the track may
improve compliance with routine measurement of weight, BP and glucose. Appointment
scheduling combined with staff scheduling would help maximise resources, but appointment
scheduling requires good data systems and strong cooperation by patients to honour the
appointments. Pre-dispensing is another area with potential efficiency gains.
37
CONCLUSIONS AND
RECOMMENDATIONS
5.1 NCD policy and resource allocation
While Bangladesh has made important strides towards a policy
environment which is conducive to NCD control, our review confirms
While Bangladesh has
that further focus on NCDs is required. Positive change includes made important strides
policies on tobacco taxes, cigarette packaging and alcohol advertising, towards a policy
while policies addressing dietary risks are especially weak. Within the environment which is
Health Sector Programme, it is commendable that NCD control has its conducive to NCD
own operational plan and budget and that diabetes and CVDs are control, our review
classified as priority diseases of major public health concern. However, confirms that further
the dedicated NCDC budget is small (4.2% of health sector programme, focus on NCDs is
or BDT 6.8/US cents 8.2 per capita) compared to the NCD burden (63% required..
of DALYs), even if several other health plans’ budgets contribute to
overall health sector capacity to address NCDs. The per capita NCD allocation is also
incommensurately small compared to the estimated cost of implementing the full set of “best
buy” interventions in LMIC settings (US$ 1.50 per person and year). As a consequence of low
government spending, OOP expenditure for NCD care is very large, likely exceeding the OOP
across all diseases (which is 66% of all health spend). Human resources in the health care sector
are comparatively few compared to the recommended WHO standard of 2.28 doctors, midwives
and nurses per 1000 population.
RECOMMENDATIONS
1. Coordinate NCD control - An effective coordination mechanism for NCD control is

urgently required, with a strong mandate for coordination, measurable targets and clear
reporting processes. The coordinating body should have cross-sectoral reach with
pluralistic provision.
2. Adequately finance NCD response - It is advisable that the Government consider
alternate financing mechanisms. Households need to be protected from impoverishment
due to NCD costs.
3. Incorporate NCD needs in Human Resources for Health Strategy - Taking into
consideration the increasing burden of NCDs, a long term human resources strategy is
required which responds to the changing service needs, and adequate budget
allocations need to be made.
5.2 NCD burden and risk factors

Our benchmarking of Bangladesh’s NCD health indicators confirms the poor performance of its
health system in preventing premature death due to NCDs, especially IHD, stroke, diabetes,
39
COPD, CKD and hypertension. A large proportion of the NCD burden is attributable to common
risk factors, of which the main ones are high blood pressure, smoking and high fasting plasma
glucose.
RECOMMENDATIONS
4. Address NCD risk factors - Bangladesh needs to raise awareness and risk perception in
the population through the implementation of tested communication strategies and
promotion of healthier lifestyles to reduce exposure. The health system needs to ensure a
substantive focus on preventative and promotive care in the future, and a particular
geographic focus on the rapidly urbanising areas. Stronger and additional tax policies
should be considered.
5. Mainstream NCD prevention and management - Existing programmes and initiatives,
such as MCH, community health and UPHCP, should integrate NCD prevention and care
into their activities.
5.3 Major NCD cascade breakpoints

Our cascade analysis in adults aged 35+ years using hypertension as a tracer condition and blood
glucose as an indicator of diabetes demonstrates the very large burden of undiagnosed NCDs.
Rural residents and males are especially prone to low diagnosis rates. International comparison
confirms the low diagnosis rate in Bangladesh with the country
Screening and its strategic
in the lowest quartile of the diabetes diagnosis rate. There are
targeting for yield and cost- also an approximately 15 million adults aged 35+ years with pre-
effectiveness is not prominent hypertension and about 14 million with pre-diabetes, whereby
in policy and practice in the the two conditions will overlap in many of them. Screening and
public health system, resulting its strategic targeting for yield and cost-effectiveness is not
in underdiagnoses, late case prominent in policy and practice in the public health system,
detection, disability and excess resulting in underdiagnoses, late case detection, disability and
costs to the care system and excess costs to the care system and the patients. The NCD plan
the patients. suggests that 50% of adults should be screened by 2022.
Data on linkage to care and treatment initiation after a person’s diagnosis was not covered in the
literature available to the study team. This is surprising given the challenges arising by the weak
referral systems and complex patient pathways in the multifaceted health care system of
Bangladesh. As a proxy, the 2011 BDHS was used to determine the breakpoint between diagnosis
(“aware” of the condition) and getting onto treatment. Since the BDHS used “treatment” and
“taking medicine” interchangeably despite diabetes and hypertension having non-
pharmacological and pharmacological treatment approaches, data interpretation was difficult.
Our cascade analysis in adults aged 35+ years suggested that treatment initiation upon diagnosis
may not be a major breakpoint, but data was limited to self-reported behaviours of 2011 DHS
participants. We could however conclude that an estimated 950,000 hypertensive females (19%
of diagnosed) and 370,000 hypertensive males (15% of diagnosed) who had been diagnosed
were not on medication. For diabetes, we could estimate that about 140,000 diagnosed diabetic
females (11%) and about 100,000 diagnosed diabetic males (9%) were not on medication.
The cascade analysis demonstrates the low effectiveness of treatment among individuals
reporting taking medication for hypertension or diabetes. Only 45% of people taking anti-
hypertensive drugs had normal BP levels, and rates were lower in males especially in urban
areas (only 38% hypertension control). Diabetes treatment had even lower effectiveness with
only 36% of diabetics on medication having a normal glucose reading, again with males showing
40
CONCLUSIONS AND RECOMMENDATIONS
lower success (only 29% of rural males achieving the glucose target level). Patient barriers to
adherence are multiple, but long-term medication costs especially for diabetes are clearly
preventing patients from complying with treatment regimens. Diabetes complications caused by
ineffective treatment increase the use and cost of health care very significantly. Study data
confirm the large additional expenditure of diabetes cases for hospital admissions. Though type-
1 diabetes is not a focus of this report, it is important to note that it occurs earlier in life than
type-2; therefore, if poorly controlled, cases have more years lived with disability and are at risk
for more years of life lost. This is an important consideration for policy and practice.
RECOMMENDATIONS
6. Finding NCD cases - Bangladesh needs to train its health workers to better identify
NCD risks and set screening targets at local level to help meet, by 2022, the end-of-plan
national screening targets for diabetes and hypertension. Local action plans should outline
how the population (especially men and rural populations) can be mobilised and reached
with routine and campaign-based screening including solid referral mechanisms for
screen-positives.Protocols and guidelines should be explicit on screening and linkage to
care, and be accompanied by job aids for community health workers.
7. Focus on treatment adherence - Essential drugs need to be made available at PHC
level at all times as this is a vital part of improving treatment adherence.
Hypertension and diabetes guidelines/ protocols/ SOPs need to be explicit on treatment
monitoring and treatment adherence, and present practical guidance on proven adherence
support activities. These guidance documents should promote the “differentiated care”
approach of focusing health workers efforts on non-adherent and unstable patients while
providing easy refill options and spaced appointments for stable patients, and tracing
cases lost to follow-up to facilitate re-entry into care. Health care professionals need to be
educated on the guidelines and on the importance to focus on patients failing their
treatment. Patients need to receive information, education and be empowered
towards assisted self-monitoring with increasing use of mHealth technology where
appropriate.
5.4 Integrated chronic care models

The data on Bangladesh’s demographic and health transition reviewed for this analysis
emphasise the need to re-orient the health care system towards chronic care and its integration
in practice. The data show the different patient typologies, with
Given the emphasis on
many people being at a pre-disease stage in need of effective
maternal health in
counselling to facilitate healthier lifestyles, while others are either
Bangladesh, the
stable on medication and achieve normal test values, or they
struggle to achieve disease control targets. Some patients are on
engagement of this
multiple medications, often for both diabetes and hypertension. population with the PHC
level also provides an
The term “differentiated care” is increasingly used for chronic opportunity for the
disease management, acknowledging the different needs of development of counselling
patients.147 The concept also puts emphasis on patient-centered mechanisms toward
care and self-management, which are both recognised in curbing the risk of diabetes
Bangladesh as important characteristics of patient care.
through weight loss and
Furthermore, differentiated care takes into account setting
increased physical activity
specificities such as rural versus urban living contexts.
integrated in MCH services.
This review identified principles shared between different
integrated care models, including: Simplification, standardisation and monitoring of healthcare
delivery processes; Decentralisation; Task-shifting and involvement of a full range of healthcare
41
providers; Peer and community involvement in service delivery; and Self-management. Given the
emphasis on maternal health in Bangladesh, the engagement of this population with the PHC
level also provides an opportunity for the development of counselling mechanisms toward
curbing the risk of diabetes through weight loss and increased physical activity integrated in
MCH services.
RECOMMENDATIONS
8. Fully involve the Community Clinics for NCD care - Being at the heart of the
government’s rural NCD model, it is vital that the CCs can lead the local NCD case finding,
linkage to care and management of uncomplicated cases, while facilitating referral as per
their mandate. The CCs' outreach function needs to be appropriately resourced to fulfill the
enormous tasks of health promotion and community-based NCD screening especially
targeting underserved populations such as older men. Low cost, low technology tools could
be considered, such as the “string test for obesity” which measures the waist to height ratio
and is an alternative to BMI (the string method could also be used for self-monitoring of
central obesity while patients pursue lifestyle changes as part of their treatment).
9. Harness existing health work force/structures to address NCD burden –
Bangladesh should consider task shifting within its health cadres in order to
accommodate the changing needs for long-term monitoring and treatments, and involve
paramedics and SACMOs where possible. MCH services could provide nutritional
education and support to pregnant women beyond the usual nutritional advice relevant
to pregnancy itself.
10. Expand human capacity – Bangladesh should adopt good practices from elsewhere on
harnessing community support for the care continuum, the mobilisation of volunteers
and lay workers, and the use of peer approaches.
11. Pilot an integrated Chronic Care Passport – Akin to BADAS’ diabetic book, such a
patient-held passport is recommended in order to facilitate medication refill at
community clinics and support self-monitoring of patients. Such a passport would also
help referrals and continuity of care and likely improve the quality of care.
5.5 Surveillance, monitoring and evaluation

There are various systems collecting data on NCD burden. The DHIS2, which has recently been
strengthened in terms of both coverage of reporting hospitals and capacity to use ICD-10 codes,
is a key system. However, our analysis of the DHIS2 hypertension and diabetes data suggest that
many hospital admissions may not be captured through this system; the incidence of
hospitalisation for T2DM and its complications was only 3.8/100,000 population, and for
primary hypertension and hypertensive disease, it was only 19/100,000 population.
Furthermore, the DHIS2 does not report disease-specific out-patient visits. Data reflecting
disease episodes of hypertension and diabetes that don’t lead to hospital admission are therefore
lacking. The national Sample Vital Registration System of the Bangladesh Bureau of Statistics is
another pillar providing disease-specific estimates of causes of death. The 2011 BDHS remains a
useful data source, including for this study. It collected anthropometry, blood pressure and blood
glucose data, and it did so in older people too (including data of people in their fifties, sixties, and
older ages). The icddr,b Matlab, which has been conducting health and demographic surveillance
since 1966, has provided a wealth of longitudinal data and increasingly on NCD issues. Benefit-
cost analyses have been conducted for hypertension and diabetes interventions, which provide
powerful advocacy for investment. While there is also a wealth of data collection for research
purposes, many studies are very small scale and it is not possible to draw robust conclusions
from them at a population level. The forthcoming STEPS will be a useful source for monitoring
NCD trends, since the same standardised questions will be asked as in the 2010 STEPS.148
42
CONCLUSIONS AND RECOMMENDATIONS
Evaluations like the COBRA-BPS pilot study are central to finding effective care models and
understanding the resource needs.
RECOMMENDATIONS
12. Build in NCD surveillance - Bangladesh should incorporate NCDs into existing disease
surveillance systems. This will enable the Government to better assess trends and its
progress towards SDG Target 3.4 (reducing the premature NCD mortality by one-third by
2030).
13. Strengthen NCD M&E for better decision-making – Bangladesh should roll out the
Unique Patient Identifier as a prerequisite for a powerful M&E system, and set NCD service
delivery targets to measure progress. The country should document the experiences with
the new MOH NCDC model and share the learning.
43
BANGLADESH BURDEN OF
DISEASE – SUMMARY VIEW
Figure A 1.1 Disability-Adjusted Life Years by cause, Bangladesh, 2016
Source: Institute for Health Metrics and Evaluation. Global Burden of Disease, 2016.
45
HYPERTENSION AND TYPE-2 DIABETES IN BANGLADESH | ANNEX 1
Figure A 1.2 Distribution of population reporting chronic illness in preceding 12 months by type of illness,
HIES2016
Source: HIES 2016.
Figure A 1.3 Prevalence of reported diabetes by sub-population, 2016 HIES
Source: HIES 2016.
46
ANNEX 1 | HYPERTENSION AND TYPE-2 DIABETES IN BANGLADESH
Figure A 1.4 Death attributable to risk factors, Bangladesh, 2016
Source: Institute for Health Metrics and Evaluation. Global Burden of Disease, 2016.
47
BENCHMARKING BANGLADESH
WITH COMPARISON COUNTRIES
DEATH, DISABILITY AND LIFE EXPECTANCY
Table A 2.1 Benchmarking Bangladesh with countries with similar GNI per capita (ATLAS method; <20%
difference in GNI per capita)
AGE- AGE- DALYS
STANDARDISED STANDARDISED YLL (DISABILITY- LIFE
GNI PER DEATH RATE RATE ADJUSTED EXPECTANCY AT
CAPITA (PER 100,000) (PER 100,000) LIFE YEARS) BIRTH
2016 2016 2016 2016 2016
COUNTRY $ RATE RANK RATE RANK RATE RANK YEARS RANK
Kyrgyz Republic 1,100 602 5 19,829 2 29,302 2 71.24 3
Tajikistan 1,110 481 1 20,115 3 28,652 3 71.76 2
Mauritania 1,120 492 2 22,807 5 32,254 4 70.16 4
Cambodia 1,140 618 6 22,752 4 32,318 5 68.75 5
Cameroon 1,200 911 11 48,709 11 58,107 11 60.14 9
Lesotho 1,210 1,525 12 67,150 12 78,427 12 50.31 12
Zambia 1,300 904 10 44,772 9 53,887 9 58.62 11
Bangladesh 1,330 524 3 17,177 1 27,552 1 72.62 1
Ghana 1,380 670 7 31,106 8 40,268 8 66.01 8
Kenya 1,380 579 4 26,821 6 35,730 6 66.84 7
Pakistan 1,510 671 8 26,909 7 36,985 7 67.61 6
Cote d'Ivoire 1520 903 9 47,580 10 57,404 10 59.87 10
Sources: World Development Indicators (GNI per capita, Atlas method (current US$), 2016);
https://data.worldbank.org; Institute for Health Metrics and Evaluation. Global Burden of Disease, 2015.
https://vizhub.healthdata.org/gbd-compare/ Accessed 8 Nov, 2017.
Note: YLL = Years of Life Lost.
Table A 2.2 Benchmarking Bangladesh with countries in the South Asia Region
AGE-STANDARDISED AGE-STANDARDISED DALYS (DISABILITY- LIFE
DEATH RATE (PER YLL RATE (PER ADJUSTED EXPECTANCY AT
100,000) 100,000) LIFE YEARS) BIRTH
2016 2016 2016 2016
COUNTRY RATE RANK RATE RANK RATE RANK YEARS RANK
Afghanistan 910 8 44,926 8 55,566 8 58.0 8
Bangladesh 524 3 17,177 4 27,552 4 72.6 4
Bhutan 486 2 16,316 3 27,313 3 73.8 3
India 744 7 23,808 6 35,435 6 68.6 6
Maldives 311 1 7,380 1 16,754 1 77.1 2
Nepal 604 5 20,625 5 30,683 5 70.9 5
Pakistan 671 6 26,909 7 36,985 7 67.6 7
Sri Lanka 592 4 13,656 2 24,134 2 77.4 1
Sources: https://data.worldbank.org; Institute for Health Metrics and Evaluation. Global Burden of Disease, 2015.
https://vizhub.healthdata.org/gbd-compare/ Accessed 6 April, 2018.
48
ANNEX 2 | HYPERTENSION AND TYPE-2 DIABETES IN BANGLADESH
PREMATURE DEATH DUE TO NCDS

Table A 2.3 Benchmarking Bangladesh with countries with similar GNI per capita (ATLAS method; <20%
difference in GNI per capita)
CHRONIC
2016 ISCHEMIC CEREBRO- CHRONIC OBSTRUCTIVE
GNI DIABETES HEART VASCULAR KIDNEY PULMONARY
PER ALL NCDS MELLITUS DISEASE DISEASE DISEASE DISEASE
CAPITA 2016 2016 2016 2016 2016 2016
COUNTRY US$ % Rank % Rank % Rank % Rank % Rank % Rank
Kyrgyz Rep. 1,100 57.0 12 0.6 1 16.0 12 8.3 11 1.5 10 2.2 11
Tajikistan 1,110 42.2 9 1.4 8 10.9 10 5.5 9 1.3 8 1.7 9
Mauritania 1,120 32.0 7 1.0 6 4.3 7 2.8 6 1.1 7 0.6 3
Cambodia 1,140 45.3 10 1.6 9 5.7 8 7.2 10 1.5 9 1.3 8
Cameroon 1,200 22.3 4 0.8 4 1.9 2 1.9 2 0.8 4 0.6 3
Lesotho 1,210 18.3 2 2.2 12 2.2 3 2.4 4 0.6 3 1.2 7
Zambia 1,300 18.9 3 0.8 4 2.4 4 1.7 1 0.5 2 0.5 1
Bangladesh 1,330 51.9 11 1.9 11 10.3 9 9.8 12 1.9 12 4.2 12
Ghana 1,380 29.5 6 1.3 7 3.5 6 3.6 7 1.0 6 0.6 3
Kenya 1,380 16.4 1 0.6 1 1.7 1 1.9 2 0.3 1 0.5 1
Pakistan 1,510 42.1 8 1.7 10 11.1 11 4.9 8 1.8 11 2.0 10
Cote d'Ivoire 1,520 24.3 5 0.9 5 3.2 5 2.7 5 0.9 5 0.6 3
Sources: World Development Indicators (GNI per capita, Atlas method (current US$), 2016); Institute for Health Metrics
and Evaluation. Global Burden of Disease, 2015. https://vizhub.healthdata.org/gbd-compare/ Accessed 8 Nov, 2017.
Table A 2.4 Benchmarking Bangladesh with countries in the South Asia Region
CHRONIC
ISCHEMIC CEREBRO- CHRONIC OBSTRUCTIVE
DIABETES HEART VASCULAR KIDNEY PULMONARY
ALL NCDS MELLITUS DISEASE DISEASE DISEASE DISEASE
2016 2016 2016 2016 2016 2016
COUNTRY % Rank % Rank % Rank % Rank % Rank % Rank
Afghanistan 36.1 1 2.0 5 9.1 1 4.2 1 1.7 1 1.1 1
Bangladesh 51.9 6 1.9 2 10.3 2 9.8 8 1.9 3 4.2 5
Bhutan 50.4 5 2.5 6 10.9 3 4.5 2 2.3 6 4.1 3
India 47.5 4 1.9 2 12.5 6 4.9 3 2.0 5 5.1 8
Maldives 73.2 8 2.9 8 20.2 8 5.9 6 5.6 8 5.0 7
Nepal 45.4 3 1.9 2 10.9 3 5.0 5 1.9 3 4.9 6
Pakistan 42.1 2 1.7 1 11.1 5 4.9 3 1.8 2 2.0 2
Sri Lanka 70.6 7 6.8 7 16.6 7 6.5 7 3.3 7 2.9 3
Sources: World Development Indicators (GNI per capita, Atlas method (current US$), 2016); Institute for Health Metrics
and Evaluation. Global Burden of Disease, 2015. https://vizhub.healthdata.org/gbd-compare/ Accessed 6 April, 2018.
49
HYPERTENSION AND DIABETES
BURDEN BY DIVISION
Figure A 3.1 Estimated total burden of hypertension in adults aged 18 years and above in Bangladesh Divisions
Sources: Data Sources:

Population estimates from
Health Bulletin 2016 and
UN Population data on age
structure; Hypertension
prevalence from 2011 BDHS
in 35+, adjusted for adults
18+ using 2016 meta
analysis of 24 hypertension
prevalence studies by
Fatema et al. 2016 PLoS
ONE 11 (8): e0160180.
Dhaka Division data from
2011 BDHS were used for
the newly demarcated
Dhaka and Mymensingh
Divisions.
Figure A 3.2 Estimated total burden of diabetes in adults aged 18 years and above in Bangladesh Divisions
Sources: Population
estimates from Health
Bulletin 2016 and UN
Population data on age
structure; Diabetes
prevalence from 2011 BDHS
in 35+, adjusted for adults
18+ using 2016 meta
analysis of 24 hypertension
prevalence studies by
Fatema et al. 2016 PLoS
ONE 11 (8): e0160180.
Dhaka Division data from
2011 BDHS were used for
the newly demarcated
Dhaka and Mymensingh
Divisions.
50
HOSPITAL ADMISSIONS FOR
HYPERTENSION AND
TYPE-2 DIABETES
DHIS2 DATA COVERING THE PERIOD FROM
1 NOVEMBER 2016‒31 OCTOBER 2017.
Figure A 4.1 Reported hospital admissions for hypertension by Bangladesh Division
Note: ICD-10 codes included are primary hypertension (I10) and hypertensive disease (I11‒I13)
51
Figure A 4.2 Reported hospital admissions for diabetes by Bangladesh Division
Note: ICD-10 codes included are type-2 diabetes (E10) and diabetes with complications (E100-108)
52
BARRIERS IN THE CONTINUUM
OF CARE ON PATIENT AND
PROVIDER SIDES
Table A 5.1 Hypertension care: Overview of patient and provider barriers to the continuum of cascades
BARRIERS TO… PATIENT SIDE PROVIDER SIDE
Screening/ ▪ Poor understanding of hypertension ▪ Weak integration of hypertension care at
diagnosis control measures primary level
▪ Health seeking and disease ▪ Low capacity and focus to address hypertension
prevention behaviours at PHC levels
▪ Awareness of future treatment costs ▪ Poor referral mechanisms
▪ Lack of risk perception ▪ Poor information flow between level of diagnosis
▪ Lack of symptoms and PHC level
▪ Scepticism about treatment ▪ Non-compliance with screening guidelines at
PHC level due to insufficient training and lack of
equipment
Treatment ▪ Cost of drugs ▪ Poor patient support for linkage to treatment
initiation ▪ Poor knowledge on disease ▪ Consultations too short for proper patient
▪ Non-adherence to lifestyle changes engagement
▪ Uncertainty with drugs availability
Treatment ▪ Non-adherence to regular check-ups ▪ Recall systems missing
monitoring ▪ Improper blood pressure measurement
Treatment ▪ Long-term cost of drugs (low income) ▪ Low capacity to deliver chronic care at PHC level
adherence/ ▪ Poor knowledge on hypertension ▪ Continuity of drug availability at PHC level
disease control impacts, complications and CVDs ▪ Lack of routine system to track BP control
▪ Memory or psychiatric problems ▪ Inadequate drug doses or combinations
▪ Polypharmacy with complicated ▪ Physician inertia with failure to change or
dosing schedules increase dose regimens when not reaching goal
Sources: Das et al. 2017. Health literacy in a community with low levels of education: findings from Chakaria, a rural area
of Bangladesh. BMC Public Health (2017) 17:203; National Guidelines for Management of Hypertension in Bangladesh,
2013. NCDC/National Heart Foundation/WHO; Kasonde et al. (2017). Evaluating medicine prices, availability and
affordability in Bangladesh using WHO and Health Action International methodology; In-country discussions with key
informants.
53
Table A 5.2 Diabetes care: Overview of patient and provider barriers to the continuum of care
BARRIERS TO… HEALTH CARE CLIENT SIDE HEALTH CARE PROVIDER SIDE
Screening/ ▪ Poor understanding of diabetes control ▪ Weak integration of diabetes care at
diagnosis measures public sector primary level
▪ Insufficient knowledge about risk factors ▪ Lack of statistics at PHC level
▪ Religious beliefs of disease etiology ▪ Non-compliance with screening
▪ Health seeking and disease prevention guidelines at PHC level due to insufficient
behaviours training and lack of equipment
▪ Cost of diagnosis (e.g. test strips)
▪ Awareness of future treatment costs
▪ Lack of risk perception
Treatment ▪ Cost of oral anti-diabetes drugs ▪ Poor patient support for linkage to
initiation ▪ Cost of insulin analogs treatment
▪ Poor knowledge on disease ▪ Consultations too short for proper
▪ Non-adherence to lifestyle changes patient engagement
▪ Uncertainty with drugs availability
Treatment ▪ Travel and clinic waiting times affecting ▪ Overburdened specialist facilities able to
monitoring regular blood sugar checks provide comprehensive check-ups with
▪ Cost of travel and cost of testing cardiovascular, renal and eyesight
▪ Low satisfaction with diabetes care provided examinations
▪ Need to pay private laboratory for routine ▪ Lack of availability of basic
HbA1C testing government/NGO medical services
▪ Need to purchase self-monitoring equipment ▪ Low availability of HbA1C test in public
such as glucometer sector (equipment and supplies)
Treatment ▪ Insufficient knowledge about disease control ▪ Insufficient insulin titration

adherence/ and prevention of complications ▪ Continuity of access to oral drugs
disease control ▪ Long-term cost of drugs ▪ Lack of routine system to track ABC
▪ Sub-optimal support to patient from family control
▪ Poor control of obesity for better glycaemic ▪ Lack of diagnostic capacity at PHC level
control and prevention of complications, to detect vascular flow problems
linked to wrong perception of own weight
▪ Misconceptions about disease
▪ Non-compliance to dietary and physical
activity advice
▪ Concerns over medication side effects
▪ Beliefs and prejudices regarding the intake of
food
▪ Fear of hypoglycemia
▪ Episodes of hypoglycemia
Sources: Das et al. 2017. Health literacy in a community with low levels of education: findings from Chakaria,a rural area
of Bangladesh. BMC Public Health (2017) 17:203; Siddique et al 2017; . Fatema et al. 2017; Islam FMA et al 2014.
Knowledge, attitudes and practice of diabetes in rural Bangladesh: the Bangladesh population based diabetes and eye
study (BPDES). PLoS One. 2014;9(10):e110368; Islam SMS et al. 2017. Patients’ perspective of disease and medication
adherence for type 2 diabetes in an urban area in Bangladesh: a qualitative study. BMC Res Notes (2017) 10:131; Munni
US et al. 2017. Nutritional beliefs and practices among diabetic pregnant mothers in a tertiary care hospital in
Bangladesh. Diabetes & Metabolic Syndrome: Clinical Research & Reviews 11, 287–290; Emral R et al 2017 - Self-
reported hypoglycemia in insulin-treated patients with diabetes; Lewis and Newell 2014.
54
INTERNATIONAL COMPARISON
OF DIABETES DIAGNOSIS RATES
Figure A 6.1 Diagnosis rates of diabetes across countries
Source: IDF, 2017.

Note: Only includes countries/ territories with >50,000 adult diabetes cases
55
BANGLADESH’S NCD POLICY
CONTEXT IN COMPARISON
Figure A 7.1 Bangladesh NCD policy context compared to countries with similar GNI per capita
Note: ATLAS method; <20% difference in GNI per capita.
Figure A 7.2 Bangladesh NCD score card results in international comparison
Source: NCD scorecard on http://www.ncdglobalscorecard.org/
56
HEALTH SECTOR
CHARACTERISTICS
Figure A 8.1 Bangladesh total health spending, 2014
Source: http://www.healthdata.org/bangladesh.
Figure A 8.2 Allocations and level of expenditure of HPNSDP in FY 2015‒16
Source: Health Bulletin 2016
57
Figure A 8.3 Share of government funding across health implementation plans, 2017‒22
Source: Programme Implementation Plan, 4 Health, Population and Nutrition Sector Programme 2017‒22.
Table A 8.1 Facility distribution in rural areas of Bangladesh

LEVEL FACILITIES NUMBER OF FACILITIES BEDS
Upazila PHC upazila hospitals 482
19,508
Community centers 13,336
Union PHC hospitals 51 830
Ambulatory care facilities 3,083
Secondary and tertiary level Hospitals 131 29,426
Source: Health Bulletin 2016
58
COSTS OF NCD INTERVENTIONS
Figure A 9.1 Unit cost distribution for hypertension management, diabetes mellitus, stroke and acute ischemic
heart disease
Source: Brouwer et al. BMC Public Health (2015) 15:1183.

Note: Costs per patient, based on a systematic review of LIC and LMIC data.
Figure A 9.2 Estimated cost of interventions to reduce NCD risk factors in three countries
Source: Beaglehole 2011.

Note: Annual cost per person in US$
59
LIST OF MEDICINES FOR
HYPERTENSION AND DIABETES
IN GOVERNMENT NCD
CONTROL PLAN
Table A 10.1 Drug list for Diabetes Mellitus
SL #. PREPARATION NAME OF ITEMS
1 Tablet Glibenclamide 5 mg
2 Tablet Glicalzide 80 mg/30mg
3 Tablet Gilipizide 5 mg
4 Tablet Glimepiride 1 mg
5 Tablet Metformin HCL 850 mg
6 Tablet Metformin 500 mg
7 Tablet Linagliptin 5 mg
8 Tablet Regaglinide
Source: Operational Plan NCD Control 2017‒22 (Plan appendix IX).
Table A 10.2 List of medicines for Hypertension

SL #. PREPARATION NAME OF ITEMS SL #. PREPARATION NAME OF ITEMS
1 Tablet Amlodipine 5 mg 12 Tablet Frusemide 40 mg and
Torasemide 2.5 mg
2 Tablet Propranolol 10 mg/ 13 Tablet Spirolactone 25 mg/ Spirolactone
40 mg 50 mg + Frusemide 20 mg
3 Tablet Atenolol 50 mg 14 Tablet Thiazide 50 mg + Amiloride 5 mg
4 Tablet Carvidolol 6025 mg/12.5 mg 15 Tablet Thiazide 25 mg + Triamtrene 50 mg
5 Injection Frusemide 20 mg/2 ml 16 Injection Manitorl 20% (injectable)
6 Tablet Metoprolol 50 mg 17 Tablet Acetazolamide 250 mg
7 Tablet Captopril 25 mg 18 Tablet Atenolol 50 mg + Amoldipine 5 mg
8 Tablet Emalapril maleate 19 Tablet Benzapril 10 mg +
5 mg/10 mg Amoldipine 5 mg
9 Tablet Losartan potassium 20 Tablet Indapamide 1.25 mg +
25 mg/ 50 mg Perindopril 4 mg
10 Tablet Valsartan 40 mg/80 mg/ 21 Tablet Losartan 50 mg +
160 mg Hydrochlorothiazide 12.5 mg
11 Tablet Thiazide 25 mg/50 mg 22 Tablet Valsartan 80 mg +
Hydrochlorothiazide 12.5 mg
60
THE NEW NCDC CARE MODEL
AND THE CONTINUUM OF CARE
Figure A 11.1 Infographic: New model of NCD care in A) Urban and B) Rural Bangladesh
A. Urban settings
B. Rural settings
61
This page is for collation purposes
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8 DGHS/National Heart Foundation/WHO 2013. National Guidelines for Management of hypertension in
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9 IDF website, 2017
11 Mahatab H, Zaman MM, Ullah AKMJ (2013). National Guidelines for the Management of Diabetes Mellitus in
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HYPERTENSION AND TYPE-2 DIABETES IN BANGLADESH | CITATION AND NOTES
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Cover Image: Rights Usage Permission ©Dreamstime.com/Derivative by Theo Hawkins

1.1 Aim of this report ........................................................................................................................................... 1

2.1 Hypertension cascade, breakpoints and outcomes .......................................................................... 5

3.1 Policies, strategies and plans on NCD control.................................................................................. 11

4.1 Overview of selected care models implemented in Bangladesh .............................................. 21

5.1 NCD policy and resource allocation ..................................................................................................... 39

Figure ES 1 Schematic of continuum of care for chronic conditions

NCD BURDEN IN BANGLADESH AND BENCHMARKING

NCD POLICY, FINANCING AND SERVICE DELIVERY

Source: Author’s drawings based on NCDC Operational Plan 2017‒22.

CONTINUUM OF CARE CASCADE FOR HYPERTENSION AND

Figure ES 3 Hypertension cascade Bangladesh

Sources: BDHS 2011 and 2016 UN population estimates.

Figure ES 4 Diabetes cascade Bangladesh

Sources: BDHS 2011 and 2016 UN population estimates.

MODELS FOR CHRONIC CARE

Peer and community involvement in service delivery is an important feature of PHC-level

participated in self-management interventions improved their diabetes knowledge, glucose

OPPORTUNITIES FOR STRENGTHENING PRIMARY LEVEL

1. Coordinate NCD control - An effective coordination mechanism for NCD control is

1.1 Aim of this report

1.2 Global context

Source: World Development Indicators, indicator ‘cause of death, by NCD (% of total)’.

1.3 Bangladesh health transition

 However, Bangladesh is ranking poorly in comparisons on premature death due to

"One WHO study found

 First, is a patient diagnosed if he/she has a health condition?

 Second, is the patient linked to appropriate health care?

 Third, is the patient adherent to the required care regimen?

 Fourth, does the patient achieve disease control?

2.1 Hypertension cascade, breakpoints and outcomes

2.2 Type-2 diabetes cascade, breakpoints and outcomes

“Medication costs are another chief

Box 3.1 Bangladesh's NCD policy context in international comparison

Box 3.2 Objectives of the NCD Control Operational Plan 2017‒22

a. To promote development and implementation of effective, integrated, sustainable, and

b. To develop and strengthen capacity for surveillance of chronic NCDs, their

3.2 Financing and resources for NCD control

3.3 Health infrastructure relevant to NCD control

Box 3.3 Public sector health system in Bangladesh

Box 3.4 Urban health care initiatives

3.4 NCD interventions and costs

Screening and diagnosis costs

Costs of preventive and health promotion interventions

Section 4 provides an overview of care models in Bangladesh focusing on diabetes and

Box 4.2 WHO’s Package for Essential NCDs (PEN)

4.2 Principles and examples of NCD and chronic care

NCD MODELS OF HEALTHCARE SERVICE DELIVERY

In Bangladesh, standardisation, decentralisation and limited task-shifting (primary prevention

Simplification, standardisation and monitoring of healthcare delivery

Decentralisation including “Care closer to home”

PRIMARY SCREENING TREATMENT TREATMENT

Task-shifting and involvement of a full range of healthcare providers