Lectures MBBS

8. HEALTH PROGRAMS IN
BANGLADESH

9. Overview
• Bangladesh has made significant progress in health of women & children &
achieved MDG4 (to reduce U-5MR) & MDG5a (reduce MMR)
• U-5MR, 1990-2017, fell from 151/1000 to 32/1000 LBs. IMR from 87/1000 to
26/1000 LBs. NMR is now 18. MMR fell by 75%
• Achieved by effective interventions to prevent/treat the most common c/of child
death & with socioeconomic improvements
• ORT & Rx of ARIs, high coverage of vax., IMCI & newborn health interventions,
have been crucial for this achievements
•Malnutrition fell significantly
• Life expectancy 73.4y (>than India & Pakistan)

10. • Remarkable fall in Total Fertility Rate in the last 4 Decades
• We have reduced disparities in U-5MR between urban-rural areas
• We have reduced poverty, done more enrolment at primary schools,
attaining gender parity at primary & secondary
education, contained HIV
• Ensured U-5 children sleeping under insecticide treated bed nets,
detection & cure rate of TB
• Have made remarkable progress reducing underweight children,
improving immunization coverage & reducing communicable d.

11. Successes Stories of Bangladesh
• Success in health sector
• Nobel: Prof. Dr. Yunus
• Sir Fazle Hasan Abed
• Largest NGO
• Cricket
• Everest win
• Garments: 2nd largest
• Drug act, - export
• EPI success
• Agricultural success
• Life expectancy
• Islami banking
• Women empowerment
• Language movement
• Inventor of radio
• One YouTube founder
• FR Rahman
• Channel winner Brozen
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13. Dev. Partners
• HPNSDP (Bangladesh) Consortium, etc.
• WHO. UNICEF. World Bank. UNFPA (UN Population Fund. (formerly UN
Fund for Population Activities)
• DFID (UK. Dept. for International Dev.)
• CIDA (Canadian International Dev. Agency)
• JICA (Japan International Cooperation Agency)
• USAID (US Agency for International Dev.)
• GIZ (Deutsche Gesellschaft für Internationale Zusammenarbeit)
• Kfw (Development Bank of Germany)
• Save The Children USA, SIDA (Swedish Int’l Dev. Authority)
HPNSDP: Health, Popn. & Nutrition Sector Dev. Program (HPNSDP)

14. Millennium Development Goals (MDGs):
Signed in 2000 to achieve by/2015:
1.  To halve undernourished people (achieved)
2. To achieve universal primary education
3. To promote gender equality & empower women
4.  To reduce child mortality (achieved)
5.  To improve maternal health (achieved)
6. To combat HIV/AIDS, malaria, & other diseases
7. To ensure environmental sustainability
8. To develop a global partnership for development
1, 4, 5, 6 are directly health related
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15. 17 Sustainable Dev. Goals (SDGs): 25.9.15-2030
•No Poverty!
• Zero Hunger
• Good Health & Well-being
• Quality Education
• Gender Equality
• Clean Water & Sanitation
• Affordable & Clean Energy
• Decent Work & Economic Growth
• Industry, Innovation & Infrastructure
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• Reduced Inequalities
• Sustainable Cities & Communities
• Responsible Consumption & Production
• Climate Action
• Life Below Water
• Life on Land
• Peace, Justice & Strong Institutions
• Partnerships for the Goals

16. 16

17. Child Status in Bangladesh
•Child population: 40%
• MMR: 176/100,000 LB (569 in 1990)
• NMR 18/1000 LB (BA, NNS, LBW)
• IMR: 26/1000 LB (NMR plus Pn., D, Mn, IDs)
• U-5MR: 32/1000 LB (IMR plus Drowning, accidents)
• U-5 malnutrition: chr. 43%, ac. 13%
• Girls married <18y: 70%
• Child labor: 7%
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18. Problems of our Children
High mortality
• ID, Mn., VADX, anemia, worms
• LBW (22%), prematurity
• Faulty feeding
• Accidents: (drowning, poisoning,
animal bites, fall, RTA)
• Chr. Hemolytic A
• Child labor (7%), no
schooling, drop-out
domestic violence
• Emotional deprivation
• Mutilation, begging,
child trafficking
• Slum, Street children
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• Diarrhea is still high; ORT still low
• Safe water, sanitation, handwashing also inadequate
• VADX is potentially-lethal but preventable. Eating VA-rich
F&V & fortified oil & flour are important

19. Major Programs
• HPNSDP: Health, Popn. & Nutrition
Sector Dev. Program (HPNSDP)
• IMCI: ARI, diarrhea, etc.
• EPI: eradication of NT, polio, measles, …
• Control of TB, leprosy, Kala azar, …
• ,, Malaria
• ,, Filariasis
• ,, Nutrition deficiencies
• ,, Helminthiases
• MMR: Safe motherhood
• Neonatal care
• School health
• Adolescent health
• Injuries
• Poisoning/pollution: arsenic, air
pollution, smoking, food
poisoning/adulteration
• NCD

20. Control of diarrheas
World’s Largest research center!
• ORS
• EBF, safe CF, safe water
• Immunization
• Personal hygiene (hand washing)
• Food safety

21. Control of ARI
• EBF, no bottle, CF from family food
• Immunization
• IMCI
• Rx of pneumonia
• VA, zinc supplementation
• Standard practices: no overcrowding, good housing, clothing, hand
washing, etc.

22. National Tuberculosis Control Program (NTP)
• BD ranks 8th (prev. 5th ) in TB burden & is also a high burden country for DR TB
• <1993: TB services were mainly curative & based in 44 TB clinics, 8 sanatorium &
4 TB hospitals with case detection at 10% & cure rates at 40%. Now under
Mycobacterial D. Control (MBDC) DOTS is available in all Upazilas
• WHO Stop TB strategy targets of 70% case detection & 85% Rx success are now
achieved. It must be sustained & accelerated
• NTP is supported by NGOs
Challenges to TB control:
• Long-term Rx, Rx. failure, MDR, late Dx
• No highly sensitive easy test, new Dx tools are v. complex
DR: drug resistant

23. National Leprosy Elimination Program (NLEP)
Target: “leprosy-free BD”
• BD ranks 5th with >5000 new cases/y
• Control target of <1/10,000 is achieved in 1998
• Prevalence in 2014: 0.23/10,000
• L. in BD decreased over 15y. Now, 46% are MB, 38% female, 5.4% children
• NLEP aims to reduce disability & to increase community awareness, promote
voluntary case reporting, & minimize social stigma
MB: multibacillary

24. • NLEP is integrated into the general health services. Specialized L. staff are
retained for technical support. Health institutes are involved for training
• NLEP provides free MDT. Logistics for Rx of complications & prevention of
disability are inadequate. Expertise is difficult to sustain because of a lack
of training & capacity building because of gradual retirement of senior staff
Major challenges: to reduce incidence to 1000; to reduce Dx & Rx delays.
Leprosy still carries a fairly high stigma
MDT: multidrug treatment

26. Filariasis
• 1/10 in 13 northern districts
In the capital, 4 in 100, mostly in slums
• WHO: to wipe out by 2020. 2 goals: to stop transmission & to treat cases.
National Filariasis Elimination Program since 2001: to eliminate by 2015
• Stop transmission: each person is given a 2-tablet dose albendazole 400 mg plus
diethylcarbamazine (DEC; 6 mg/kg) or albendazole (400 mg) plus ivermectin 200
mcg/kg)/y (total 5) till 2015
• To treat cases: program will focus on decreasing 2y bacterial & fungal inf. of limbs or
genitals

27. Reduction of MMR (240/100,000 LB in 2010; now 176)
ANC, TT, nutrition, hospital delivery
• Detection of preg. complications
• SBA at community level
• 24h emergency service for labor at HCs
• Full functioning referral system
SBA: skilled birth attendant. HCs: health centers
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28. Reducing NMR (BA, NNS, LBW)
ANC, TT, maternal nutrition & Fe & B9
• Steroid for preterm labor. KMC
• Essential NB care (clean place, - catch,- cut, chorhexidine for cord, HBB)
• Prevention & Rx of NNS, birth trauma
• SCaBU at Upazila, district & 3y care hospitals
• BF in first hr (saves 1 million globally)
•EBF
BA: birth asphyxia. HBB: helping babies breathe. KMC: kangaroo mother care. SCaBU: spcl. care baby unit. NNS: neonatal
sepsis. EBF: exclusive breastfeeding 28

29. Reducing U-5 MR (+NMR, +IMR)
(IDs, Drowning, accidents)
• Reduction of NMR, IMR
•Prevent drowning and other injuries
• IMCI (ARI, D, F, Otitis, Mn, Feeding, HPVAC, EPI)
• EBF, CF (IYCF)
• Effective referral system
• New vaccine (pneumococcal, Flue,)
• More trained health workers, more resources
IMCI: integrated management of childhood illness. IYCF: infant & young child feeding. CF: complementary feeding 29

30. Drowning: >97% in L&MICs: 57% 1–2y
• Bangladesh: 45/d or 1/30min. Near D: 182/d
• Mostly in morning (68%), in ponds (69%), mom was busy (70%)
• A silent public health emergency/epidemic
• Preventable but few programs
• Children aged 1-4y, & 5-9 are at highest risk
To Prevent
• Supervision; skills: swimming, CPR, etc.
• Raising awareness
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31. ACTIONS for injuries
• GoB: injury prevention as 1/5 priorities for Child Health
• To make homes, schools & communities safe
Home: awareness; making homes & play-areas child-friendly, swimming, proper
supervision
School: safe learning (physically safe, emotionally secure & psychologically
enabling). Safety risks, injury prevention, basic first-aid
Community: supervise children 1-5y for 4h/d, 6d/w. Supervisors are trained on
ECD, injury Px., healthy practices
After a great progress in ID; child injury must now be
addressed (drowning, RTA, burns, falls, NAI, etc.)
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• NAI: non-accidental injuries. F&V: fruits & vegetables

32. WHO: Ending Preventable U-5MR by ’35
• ANC, nutrition & Fe+B9 in preg, SBA
• Steroid in preterm labor, KMC
• Essential NB care, cord care, Mx. of NNS
• SCANU, EBF/IYCF
•Rx of IDs
• EPI: new vax
• IMCI
• Injury & drowning prevention
• Zn & ORT, management of malnutrition
NNS: neonatal sepsis. KMC: Kangaroo Mother Care
SBA: skilled birth attendant 32

33. EPI
Target Ds in Bangladesh (10)
• TB
• Diphtheria, Pertussis, Tetanus (DPT)
• Poliomyelitis
• HBV
• HIB
• Measles, Rubella (MR)
• S pneumonia
Attempt to add HPV, Rota vax., meningococcus vax)

34. EPI Targets
 Eliminate NT (<1 /1000) 2005
 Measles  95% 2005
Vax. coverage 90% 2005
 Polio eradication 2007
  HBV 80% in U5 2010

35. Children queue to receive HPVAC & de-worming tablets
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36. 36

37. Arsenic (As) Contamination in BD
• <1990 surface water was mainly used for drinking, but it was severely polluted
• So the GoB, UNICEF, etc. decided to use under-ground water
• Ironically, it triggered natural As in the earth to dissolve into water
• As is colorless, tasteless & odorless, so people did not realize contamination
• It is a poison with lethal dose 125mg. It is x4 poisonous as Hg
• Toxicity is acute, sub-acute & chronic. Water contamination causes chr. toxicity
• Most As is excreted in urine, stool, skin, hair, nail & breath. Excessive As is
deposited in tissues & inhibits enzymes
All organs are affected insidiously in 6mo to 2y depending upon intake dose

38. As. Toxicity in Different Organ Systems
System Problems
Skin hyperkeratosis of palms & soles, melanosis or depigmentation,
Bowen's d. (SCC in situ), basal cell Ca. & SCC
Liver Enlargement, jaundice, cirrhosis, non-cirrhotic portal HTN
Nervous System Peripheral neuropathy, hearing loss
CVS Acrocyanosis & Raynaud's Phenomenon
Hemopoietic System Megalobastosis
Respiratory System Lung Ca
Endocrine System DM & goiter

39. Effects on human health
• Cancer
• Melanosis
• Hyperkeratosis

40. PRE-CLINICAL STAGE INITIAL STAGE SECOND STAGE LAST STAGE
No clinical
manifestation
Melanosis, keratosis,
conjunctivitis,
bronchitis,
gastroenteritis
Depigmentation
(leucomelanosis),
hyperkeratosis, non-
pitting edema of legs,
peripheral neuropathy,
hepatopathy
Nephropathy,
hepatopathy,
gangrene, cancer of
skin, bladder & lung
CF of Arsenicosis in Bangladesh
• In Bangladesh, majority of patients are in initial & second stages

41. In BD, De-arsination methods are used:
• Chemical Method
• NIPSOM: based on the principle of iron coagulation with a pre-oxidation step.
Removal of As. is almost 99%
• Alum Method
• Cheap. 70% effective. 300-500g alum in cloth is put in a bucket of water for
12h. Upper 2/3rd of the water is separated using 2 layered clean cloth.
Lower third is discarded
• Ferric oxide-Manganese dioxide clay based filter columns:
attached to tube well outlet; removes significant amount of As. at a flow
rate of 90-110 mL/minute & it can filter up to 5000 L of water before
disposal

42. Control Measures by GoB
• To detect popn. at risk
• Case detection: Rx & Follow-Ups
• Alternate source of drinking water. Distribute de-arsination filters, encourage
people use alum; & digging deep tube wells
• Train staff in the health services
• Appropriate health education campaigns
• Awareness

43. Continued...
Long Term Programs
• Find out c/of As. contamination of soil water & take control measures
• Surveillance to identify, treat, FU cases & conduct water-testing activities
• Establish 10-bed As. hospitals in the affected districts with a view to provide
Rx to Pts. & also do research
• Alternative source of safe drinking water (rain water)
• Rational use of ground water
• Include media people in campaign
• To enhance awareness of the people

44. NCD Prevention & Control in BD
• 50% deaths are due to NCD
• We have the 9th highest NCD mortality: primarily CVD, stroke & DM
• Chr. d, cancer, DM, CVD, & chr. respiratory d. are increasing as the population
becomes more urbanized
• CVD: is the c/of 25.1% deaths
• Tobacco use: more among the poorest men (70%)
• HTN: 1 in 3 women & 1 in 5 men age 35 and older
• DM: Prevalence: 10%, with urban areas having a vastly higher prevalence.
Bangladesh is among top 10 countries

45. Country Activities to NCD
• BD was the first nation to ratify WHO Tobacco Control in 2004 & in March 2005
enacted Smoking & Tobacco Product Usage (Control) Act 2005
• Multiple agencies exist & some have outreach activities (DAB, National Heart
Foundation, BIRDEM). NCD management, esp. for DM is incorporated in
UHC & Community Clinics

46. Health, Popn. & Nutrition Sector Dev. Program (HPNSDP)
To reduce MMR; popn. growth rate & improve nutrition, esp. of W&C
Achievements:
• MMR, IMR & U-5MR declined
• EPI coverage increased. More children receive VA
• Popn. growth rate & total fertility rate (TFR) declined
• Life expectancy at birth is rising
• TB case detection & cure rates achieved MDG targets
• Polio eradicated. Kala azar, leprosy, filariasis virtually eliminated
• Malnutrition & micro-nutrient deficiencies reduced
• HIV prevalence very low
• Remarkable countrywide network of health care infrastructure

47. Main Challenges
• Low rate of deliveries by skilled BA
• High rates of NMR, malnutrition & micronutrient deficiencies
• Low utilization of public health facilities by the poor
• Ineffective urban PHC service delivery
• Emerging & re-emerging d. & impact of climate change
• Rise in NCD including CVD, stroke, DM, Cancer & injury
• Family Planning service: high rate of discontinuation
• Gender sensitive & equity based service delivery
• Inadequate human resources
• Quality assurance system, medical auditing, accreditation & weak legal
framework

48. UNICEF for Disabled Children
• They have many abilities, but are often excluded, mostly invisible, vulnerable.
They face many challenges
• UNICEF brings global attention to them
• Rx for disability is expensive, frustrating
• UNICEF encourages to continue Rx & send them to school as education gives
them confidence
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51. Adolescent Health
22% of population are adolescents
 63% of girls get early marriage, vs. only 3.7% of boys in the same age
 31% of these girls get pregnant within a year of marriage
 Lack of girls mobility - because of Reputation & Security
 Lack of Adolescent Friendly Health Services/Lack of sensitivity among the
service providers
 Lack of appropriate Knowledge on Sexuality & reproductive Health
 In villages, there is v. limited opportunity for paid employment, especially for girls

53. 1992: BRAC started Reading Centres for rural adolescent girls
Purpose: to retain literacy, a safe place to socialize
 Reading books, newspaper, magazine
 Playing indoor games
 Performing cultural program
 BRAC started Adolescent Dev Program (ADP) &
Adolescent Peer Organized Network (APON)

55. Objectives of ADP:
 To empower adolescents, especially girls, to participate meaningfully in
decisions affecting their lives & to be active in social change
 To create & sustain a supportive environment for
adolescent girls
 To reduce child marriage & dowry
Components of ADP:
1. Adolescent Centres
2. Issue based life skills course
3. Livelihood training

57. Issue based Life Skills Course (APON):
• To prepare them about issues related to lives & practice in day to day life
• To enhance their capacity on different life skills
• To develop leadership skill of the adolescents
• To help the adolescents to practice their rights
The course content includes:
 Social, Family & Community Issues
 Sexual & Reproductive Health Issues
(20 books & 1 peer educator guide has been developed for the course.)

58. Issue based Life Skills Course: Con...
Cross-cutting issues
• Child Rights
• Negotiation skills
• Gender sensitive
• Inclusiveness
• Effective Communications

59. Livelihood Training
The livelihood training includes:
• Poultry & livestock
• Sewing & embroidery
• Photography
• Computer
• Journalism etc.
This activities are helping to reduce early marriage from the intervention areas

60. Community Participation:
The activities includes:
• Forum with mothers
• Forum with fathers
• Forum with community leaders
• There is a child marriage & dowry prevention committee, who are
working to reduce the child marriage & dowry from their community

61. Achievements:
• There are 17,000 Adolescent Leaders
under this project & most of them
are continuing their education
• The marriage age has increased by 1-2
years in the intervention areas

62. Activities Beneficiaries
Adolescent Centres (8500) 221100 Girls
APON course for girls 178225 Girls
APON course for Boys 35356 Boys
Sewing & embroidery 8000 Girls
Photography Training 723 Girls
Computer Training 1581 Girls
Journalism 145 Girls
Poultry & livestock 90 Girls

63. Lessons learnt:
• Adolescents are capable of doing a lot more provided if they are
given the opportunities
• Active participation of Community Leaders & Religious Leaders
are essential to prevent early marriage & dowry
• Livelihood program, aside from economic independence, has
been able to change the attitudes of their family & community
towards adolescent girls

64. MCQ
• Fall in NMR is parallel to IMR/U-5MR
• Kala azar is now controlled
• Leprosy is not eradicable
• To control TB case detection is most important
• BCG vax. can contribute to leprosy control
• Surface/rain water are free from arsenic