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

BACKGROUND: This paper is aimed at critically assessing the extent to which Non-Communicable Disease NCD-related policies introduced in Bangladesh align with the World Health Organization's (WHO) 2013-2020 Action Plan for the Global Strategy for the Prevention and Control of NCDs. METHODS: The authors reviewed all relevant policy documents introduced by the Government of Bangladesh since its independence in 1971. The literature review targeted scientific and grey literature documents involving internet-based search, and expert consultation and snowballing to identify relevant policy documents. Information was extracted from the documents using a specific matrix, mapping each document against the six objectives of the WHO 2013-2020 Action Plan for the Global Strategy for the Prevention and Control of NCDs. RESULTS: A total of 51 documents were identified. Seven (14%) were research and/or surveys, nine were on established policies (17%), while seventeen (33%) were on action programmes. Five (10%) were related to guidelines and thirteen (25%) were strategic planning documents from government and non-government agencies/institutes. The study covered documents produced by the Government of Bangladesh as well as those by quasi-government and non-government organizations irrespective of the extent to which the intended policies were implemented. CONCLUSIONS: The policy analysis findings suggest that although the government has initiated many NCD-related policies or programs, they lacked proper planning, implementation and monitoring. Consequently, Bangladesh over the years had little success in effectively addressing the growing burden of non-communicable diseases. It is imperative that future research critically assess the effectiveness of national NCD policies by monitoring their implementation and level of population coverage.

Schools of public health in low and middle-income countries: an imperative investment for improving the health of populations?

BACKGROUND: Public health has multicultural origins. By the close of the nineteenth century, Schools of Public Health (SPHs) began to emerge in western countries in response to major contemporary public health challenges. The Flexner Report (1910) emphasized the centrality of preventive medicine, sanitation, and public health measures in health professional education. The Alma Ata Declaration on Primary Health Care (PHC) in 1978 was a critical milestone, especially for low and middle-income countries (LMICs), conceptualizing a close working relationship between PHC and public health measures. The Commission on Social Determinants of Health (2005-2008) strengthened the case for SPHs in LMICs as key stakeholders in efforts to reduce global health inequities. This scoping review groups text into public health challenges faced by LMICs and the role of SPHs in addressing these challenges. MAIN TEXT: The challenges faced by LMICs include rapid urbanization, environmental degradation, unfair terms of global trade, limited capacity for equitable growth, mass displacements associated with conflicts and natural disasters, and universal health coverage. Poor governance and externally imposed donor policies and agendas, further strain the fragile health systems of LMICs faced with epidemiological transition. Moreover barriers to education and research imposed by limited resources, political and economic instability, and unbalanced partnerships additionally aggravate the crisis. To address these contextual challenges effectively, SPHs are offering broad based health professional education, conducting multidisciplinary population based research and fostering collaborative partnerships. SPHs are also looked upon as the key drivers to achieve sustainable development goals (SDGs). CONCLUSION: SPHs in LMICs can contribute to overcoming several public health challenges being faced by LMICs, including achieving SDGs. Most importantly they can develop cadres of competent and well-motivated public health professionals: educators, practitioners and researchers who ask questions that address fundamental health determinants, seek solutions as agents of change within their mandates, provide specific services and serve as advocates for multilevel partnerships. Funding support, human resources, and agency are unfortunately often limited or curtailed in LMICs, and this requires constructive collaboration between LMICs and counterpart institutions from high income countries.

Trends in sociodemographic and health-related indicators in Bangladesh, 1993-2007: will inequities persist?

OBJECTIVE: To assess levels, trends and gaps between the poorest and the richest in selected health and human development indicators in Bangladesh. METHODS: Data for selected indicators associated with sociodemographic characteristics among ever-married women, contraception use, child vaccination, antenatal care practices and health conditions were extracted from the Bangladesh Demographic and Health Surveys conducted in 1993-94, 1996-1997, 1999-2000, 2004 and 2007. Results for the whole sample and for the poorest and the richest wealth quintiles are presented. FINDINGS: Positive trends were noted in urbanization, availability of electricity, age at first marriage, use of modern contraception, access to skilled antenatal care, child vaccination, knowledge of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome and overweight and obesity. In contrast, negative trends were seen in factors such as literacy, infant and child mortality, fertility rate, home delivery and malnutrition and underweight. However, changes in these indicators differed between the poorest and richest quintiles. For instance, only the richest quintile experienced rapid urbanization, whereas illiteracy declined more among the poorest. Noteworthy gaps were found in almost all factors. Rich-poor gaps in urbanization, age at marriage, fertility, condom use, home delivery and overweight increased; in contrast, gaps in education, water and sanitation, use of contraception (except condoms) and child vaccination declined. CONCLUSION: Persistent inequities in Bangladesh endanger equitable and sustainable human development in the country. Pro-poor development strategies based on the principles of equity and quality should be implemented to narrow existing gaps and further promote holistic and equitable human development.

Predictors of Self-Reported Health Status of Ready-made Garment Workers in Bangladesh in Post Global Economic Recession Period.

Introduction There has been disagreement within academia in Bangladesh on whether the global economic recession of 2008-2009 came out as a bane or a boon to their economy and for their people, particularly workers in the ready-made garments (RMG) sector; therefore, we sought to conduct a study among currently employed and recently unemployed RMG workers to examine the influence of recession on their self-reported health status. Methods This cross-sectional study was conducted among 200 workers across 20 factories and 108 recently unemployed workers from different locations of Dhaka. Workers were selected based on a systematic sampling method from 20 randomly selected factories. Unemployed respondents were selected via snowball sampling. A questionnaire was prepared to cover different socio-demographic variables, which were then explored against an outcome variable of how the respondents rate their current health status (2009) compared with their past health status during the economic recession period (2008). A simple logistic regression was conducted for each of the independent variables with the outcome variable. Finally, all independent variables were loaded against the outcome variable, and multiple logistic regression was run. Results The only statistically significant predictor of self-reported health status was age, which indicated a 4% decrease (p = 0.05; 95% confidence interval (CI), 0.9203417 to 1.000015) in improved or better health with each year increase in age, holding other variables constant. Respondent health status was unchanged or even improved after the period of recession. The employed group had 1542.061 Taka (approximately $20) more average monthly family income than the unemployed group (two-sample t-test p-value 0.007), their health status was not affected (odds ratio (OR) 0.998; p-value 0.907). Conclusion The absence of an association between self-reported health status and economic recession is not uncommon, and explanations have been proposed for this phenomenon.

Short report: production of recombinant kinesin-related protein of Leishmania donovani and its application in the serodiagnosis of visceral leishmaniasis.

To detect IgG antibody in the serodiagnosis of visceral leishmaniasis (VL), a recombinant antigen rK39, which is part of a Leishmania chagasi kinesin-related protein, has been used successfully and showed high sensitivity and specificity. We report production of a recombinant protein rKRP42, which is part of an L. donovani kinesin-related protein and a homolog of rK39, and its application in an enzyme-linked immunosorbent assay (ELISA) for the diagnosis of VL. When rKRP42 and rK39 were compared, amino acid sequence analysis showed 89.3% identity and 98.7% homology, with rKRP42 having 39 more amino acids than rK39. The ELISA using rKRP42 showed a sensitivity of 94.6% (70 positive samples among 74 from VL patients) and a specificity of 99.3% (148 negative samples among 149 samples from Japanese controls), whereas the sensitivity of the commercial rK39 dipstick test was 93.2% (69 positive samples among 74 from patients with VL). The rKRP42 is a promising new antigen in developing immunodiagnostic methods for VL.

Patients' perspective of disease and medication adherence for type 2 diabetes in an urban area in Bangladesh: a qualitative study.

BACKGROUND: Patients' perspective of diabetes and adherence to its prescribed medications is a significant predictor of glycemic control and overall management of the disease. However, there is a paucity of such information in Bangladesh. This study aimed to explore patients' perspective of diabetes, their experience of taking oral hypoglycemic medications and explore factors that contribute to medication adherence in patients with type 2 diabetes in Bangladesh. METHODS: We conducted in-depth face-to-face interviews with 12 type 2 diabetes patients attending a tertiary hospital in Dhaka city between February and March, 2014. Participants were purposively sampled representing different age groups, education levels, years since diagnosis with diabetes, and glycemic status, to achieve maximum variation sampling. All interviews were conducted using a topic guide and were audio-recorded, transcribed verbatim, checked for errors, coded and analyzed by means of a qualitative content analysis framework. RESULTS: The data analysis generated rich information on the participants' knowledge and perception on diabetes, its causes, self-management, medication use, adverse effects of medication use, medication adherence, and impact of diabetes, Although most of the participants demonstrated substantive knowledge on diabetes and its consequences, they also reported numerous misconceptions about the disease. Knowledge on diabetes medication, their appropriate use and side effects was rather poor. Respondents also reported non-compliance to dietary and physical activity advice by their physicians and concerns on diabetes diabetes-induced psychological stress. High cost of medications, concerns over medication side effects and forgetfulness was noted as factors for non-adherence to medication. CONCLUSION: Participants' knowledge and perception on diabetes are key factors determining their adherence to medications and, thereby, diabetes management. Healthcare providers should explore to better understand patients' perspective on diabetes, medication beliefs, identify psychological stress and provide more effective health education interventions to enhance medication adherence.

Women Empowerment and Its Relation with Health Seeking Behavior in Bangladesh.

OBJECTIVE: Over the last few decades, Bangladesh has made significant progress towards achieving targets for the Millennium Development Goals (MDGs) and women empowerment. This study is aimed at identifying the levels and patterns of women empowerment in relation to health seeking behavior in Bangladesh. MATERIALS AND METHODS: We conducted a cross-sectional study among 200 rural married women in Cox's Bazar district in Bangladesh using multi stage sampling technique and face-to-face interview. Data was collected on socio-economic characteristics, proxy indicators for women empowerment in mobility and health seeking behavior related decision making. Bivariate and multivariate regression analyses were performed to identify associations between women empowerment in relation to health seeking behavior on mobility and decision making, controlling the effect of other independent variables. RESULTS: The results showed that only 12% women were empowered to decide on their own about seeking healthcare and 8.5% in healthcare seeking for their children. In multivariate analysis women empowerment in health seeking behavior was higher among age group 25-34 years (OR 1.76, [CI = 0.82-3.21]), women's education, husband's education, age at marriage > 18 years (OR 6.38, [CI = 0.98-4.21]) and women's working status (OR 16.44, [CI = 0.79-2.71]). CONCLUSION: Women empowerment enhances their decision-making authority regarding health seeking behavior. Acknowledging and adopting the implications of these findings are essential for an integrated health and development strategy for Bangladesh and achieving the MDGs.

Diabetes knowledge and glycemic control among patients with type 2 diabetes in Bangladesh.

AIMS: To explore the association between knowledge on diabetes and glycemic control among patients with type 2 diabetes in Bangladesh. METHODS: A cross-sectional study was conducted among 515 patients with type 2 diabetes attending a tertiary hospital in Dhaka, Bangladesh. Trained interviewers were used to collect data on socioeconomic status, time since the onset of diabetes, co-morbidities, anthropometric measurements, blood tests, knowledge and perceptions about the causes, management, and complications of diabetes through face to face interviewers based on a structured questionnaire. Diabetes knowledge was reported using a composite score. Chi square tests and correlation analysis were performed to measure the association between knowledge on diabetes and glycemic control. RESULTS: Overall, 45.6% participants had good, 37.7% moderate and 16.7% poor knowledge on diabetes. The mean composite score was 0.75 ± 0.28 and the proportion of participants with a score of ≤50% was 16.7%. Only 24.3% participants identified physical inactivity as a risk factor for diabetes. Knowledge on diabetes was significantly associated with education, gender, monthly income, duration of diabetes, body mass index, family history of diabetes, and marital status but not with glycated hemoglobin (HbA1c). Correlation matrix showed weak negative association between diabetes knowledge score and glycemic control (p < 0.001). CONCLUSION: Patients with type 2 diabetes in Bangladesh have limited knowledge on the causes, management and risk factors for diabetes, despite receiving professional health education and care in a tertiary diabetic hospital. Strategies to improve the quality of diabetes education and identifying other potential factors for glycemic control are important for ensuring optimum management of diabetes in Bangladesh.

Health sector reform in South Asia: new challenges and constraints.

In early 1990s, Jamison, Mosley and others concluded that a profound demographic and consequent epidemiological transition is taking place in developing countries. According to this classical model, by the year 2015, infectious diseases will account for only about 20% of deaths in developing countries as chronic diseases become more pronounced. These impending demographic and epidemiological transitions were to dominate the health sector reform agenda in developing countries. Following an analysis of fertility, mortality and other demographic and epidemiological data from South Asian and other developing countries, the paper argues that the classical model is in need of re-evaluation. A number of new 'challenges' have complicated the classical interplay of demographic and epidemiological factors. These new challenges include continuing population growth in some countries, rapid unplanned urbanization, the HIV/AIDS pandemic in Sub-Saharan Africa (and its impending threat in South Asia), and globalization and increasing marginalisation of developing countries. While the traditional lack of investment in human development makes the developing countries more vulnerable to the vicissitudes of globalization, increasing economic weakness of their governments forces them to retreat further from the social sector. Pockets of poverty and deprivation, therefore, persist giving rise to three simultaneous burdens for South Asia and much of the rest of the developing world: continuing communicable diseases, increasing burden of chronic diseases, and increasing demand for both primary and tertiary levels of health care services. While these complex factors, on the one hand, underscore the need for health sector reform, on the other, they make the task much more difficult and challenging. The paper emphasizes the need to revisit the classical model of demographic and epidemiological transition. It is argued that the health sector in developing countries must be aware of and effectively address these 'new challenges'. Although it has included data from many developing countries, the focus is primarily on South Asia.

Effects of Aqueous Extract of Fresh Leaves of Abroma augusta L. on Oral Absorption of Glucose and Metformin Hydrochloride in Experimental Rats.

To get better control in disease conditions, many people take herbs with conventional medicines, therefore, posing a risk of potential pharmacokinetic interactions between herbs and conventional drugs. The aqueous extract of the fresh leaves of Abroma augusta L. (Family: Sterculiaceae, Bengali name: Ulatkambal, English name: Devil's cotton, DC) is viscous and used traditionally to treat diabetes mellitus. This study was done to investigate the probable mechanism by which the aqueous extract of Abroma augusta L. is beneficial in managing type 2 DM and to observe the effects of this extract on absorption of metformin hydrochloride from the gastrointestinal tract. Studies were conducted in healthy Long Evans rats using Na-carboxymethyl cellulose (CMC) as positive control. Both Na-CMC and WSF of DC significantly (P < 0.05) reduced the absorption of glucose administered orally in fasted rats. On the other hand, WSF of DC significantly (P < 0.05) reduced the absorption of metformin hydrochloride in alloxan-induced diabetic rats. The results of this study suggest that WSF of DC may be beneficial in diabetic patients to improve glycemic control but should not be coadministered with metformin HCl for management of type 2 diabetes mellitus.

Water-soluble Fraction of Abelmoschus esculentus L Interacts with Glucose and Metformin Hydrochloride and Alters Their Absorption Kinetics after Coadministration in Rats.

This study was done to investigate the effects of water-soluble fraction (WSF) of the fruits of Abelmoschus esculentus L (okra/lady's fingers) on absorption of oral glucose as well as metformin from the gastrointestinal tract in the Long Evans rats. WSF of A. esculentus significantly (P < 0.05) reduced the absorption of glucose as studied in the 24 hrs fasting rats. The effect of WSF of A. esculentus on metformin absorption was studied in alloxan-induced diabetic rats. Significant differences (P < 0.05) were observed in the average blood glucose level from 2 to 24 hours after metformin therapy in presence (33.6 to 34.2 mmol/L) or absence (15.2 to 20.2 mmol/L) of oral WSF of A. esculentus. In both of the experiments, Na-carboxymethylcellulose (CMC) was used as positive control. The results of this study indicate that A. esculentus may improve glycemic control but should not be taken concurrently with metformin hydrochloride in controlling diabetes mellitus.

Enzyme-linked immunosorbent assay to detect urinary antibody against recombinant rKRP42 antigen made from Leishmania donovani for the diagnosis of visceral leishmaniasis.

We recently reported the production of the recombinant kinesin-related protein of Leishmania donovani with a molecular weight of 42 kd (rKRP42) and the value of the antigen in serum-based ELISA for the diagnosis of visceral leishmaniasis (VL). In this study, the rKRP42 antigen was validated with ELISA using urine samples (rKRP42 urine ELISA). The urine-based ELISA showed 94% sensitivity (108 positives among 115 VL samples) and 99.6% specificity (239 negatives among 240 non-VL samples). The sensitivity and specificity are almost similar to our previous results by ELISA with acetone-treated L. donovani promastigote antigen and direct agglutination test, both methods being done by use of urine samples. A comparison of the rKRP42 urine ELISA with the commercially available urinary antigen detection kit (KAtex) using 108 VL samples showed much higher sensitivity of the ELISA (96.3%) than KAtex (55.6%). The use of the rKRP42 antigen with urine samples will facilitate epidemiologic studies.

Good governance and sustainability: a case study from Pakistan.

OBJECTIVE: On the basis of a case study in Pakistan, the paper argues that good governance, characterized by transparency, accountability and meaningful community participation, plays a critical role in the sustainability of donor-funded health systems projects in the public health sector. METHODS: The Family Health Project (FHP) (1992-1999), funded by the World Bank, has been used as a case study. Critical analysis of secondary data mainly obtained from the Department of Health (DoH) in the province of Sindh in Pakistan is the major tool used for the study. Data from other sources including the World Bank have also been used. RESULTS: The analysis reveals that the existing health care system could not fully absorb and sustain major "sociopolitical" thrusts of the project, meaningful community participation and "democratic" decision-making processes being the most important ones. The hierarchical structure and management process made it difficult to produce a sense of ownership of the project among all managers and the rank and file staff. The Provincial Health Development Center (PHDC) and District Health Development Centers (DHDCs) established by the FHP did not receive adequate financial and political support from DoH and the Ministry of Health to have much control of the project at the local level. Consequently, these Centers largely failed to institutionalize a continuing training program for district level health officials/professionals. Due to lack of political support, the District Health Management Teams (DHMTs) could not be institutionalized. Community participation in the DHMTs was symbolic rather than forceful. Improved coordination among all stakeholders, more stable and competent leadership, more meaningful community participation, greater devolution of project management to the district level, and better management of resources would have resulted in more effective and efficient implementation of the project. Based on these findings, the paper introduces a Sustainable Management Approach (SMA) as a tool that can be used to ensure the sustainability of health systems projects, particularly those funded by international organizations in developing countries. CONCLUSIONS: Good governance and a conducive organizational culture are important prerequisites for incorporating any new project within an existing system. This includes prior consensus building among all stakeholders, a meaningful and inclusive participatory planning, implementation and evaluation process involving communities, political commitment, and the identification and use of appropriate leadership for project management.