Bangladesh

Target 7: Have halted by 2015 and begun to reverse the spread of HIV/AIDS.

Indicator 19: Condom use rate

Indicator 21: Prevalence and death rates associated with malaria

Indicator 22: Proportion of population in malaria risk areas using effective malaria prevention and treatment measures

Indicator 23: Prevalence and death rates associated with tuberculosis

Indicator 24: Proportion of tuberculosis cases detected and cured under Directly Observed Treatment Short Course (DOTS)

Situational Analysis

It is estimated that the prevalence rate of HIV infection among adults (15-49 years) is less than 0.1 percent. The Ministry of Health and Family Welfare reported a total of 363 cases at the end of November 2003. However, as there is no functional reporting system on HIV/AIDS and the information remains incomplete, Bangladesh is classified as a low HIV prevalence country. Nevertheless, latest surveys indicate a rapid increase of HIV positivity among injecting drug users (IDUs) from 1.7 percent in 2000 to four percent in 2002. Such concentrated HIV epidemic can have far reaching implications on HIV transmission to other vulnerable populations in the community.

Based on the HIV/AIDS situation in the country, and because of the absence of data on global indicators of HIV pregnancy age and HIV/AIDS orphans, additional indicators have been selected for monitoring this target in Bangladesh. These are:

     Percentage of HIV positivity among the most vulnerable groups: IDUs, female sex workers (SW), and men who have sex with men (MSM).

     Percentage of condom use among most vulnerable groups: SW, MSM, rickshaw­-pullers, and truck drivers.

     Percentage of needle sharing among IDUs.

     Percentage of blood being screened for HIV before transfusion.

     Percentage of health facilities at the different levels (tertiary, district and sub-district) with adequate capacity for screening blood for HIV before transfusion.

Percentage of HIV positivity among the most vulnerable groups[1]

Among IDUs surveyed in Central-A Bangladesh, the HIV sero prevalence has risen from 1.7 percent in 2000 to four percent in 2002. There was no HIV detected in IDUs surveyed from other sites.

The HIV infection rate among sex workers surveyed was 0.2, 0.7 and 0.5 percent in Brothel SW in Central-B, Central-D and Southwest-B respectively. Furthermore, 0.2 percent of Street and Hotel based SW in Central-A were found HIV positive.

Of the MSMs tested in Central-A, 0.2 percent were positive during the fourth round of surveillance.

Percentage of condom use among most vulnerable groups

Consistent condom use is only two and four percent for brothel and street based sex workers, respectively. Among their clients, 75 percent of truckers reported that they did not use condoms the last time they purchased sex, and only 2 percent of rickshaw-pullers reported using condoms consistently when having sex with sex workers. The majority (two thirds) reported that they had never used a condom. Out of 101 college/university students, 30 percent reported consistent condom use during the past year.

Percentage of needle sharing among IDUs

Two thirds of IDUs reported receptive needle sharing (i.e., receiving a shared needle to inject drugs) in Central Bangladesh. The rate was higher (75%) in the southeast. However, in northwest, where there is an active needle exchange programme, only 25 percent reported needle sharing and HIV prevalence at this site remains zero.

Percentage of blood being screened for HIV before transfusion

Although 98 blood transfusion centres have been set up throughout the country, a comprehensive policy and strategy to ensure safety of blood and blood products is yet to be finalized and implemented. There is need to establish the baseline information on percentage of blood being screened in the 98 centres and in all the other facilities that carry out blood transfusion.

Percentage of health facilities at different levels with adequate capacity for screening blood for HIV before transfusion

Minimum standards and requirements for health facilities to qualify and be authorized to screen blood for HIV before transfusion should be defined by the National Policy and Strategy on Blood Safety.

The Government and donor initiatives include developing a National Strategic Plan (NSP) for comprehensive and integrated action in response to HIV/AIDS. The NSP will also elaborate a national Monitoring and Evaluation System that will strengthen follow up of MDG and UNGASS indicators.  Besides these, interventions targeted at most vulnerable groups are being scaled up; HIV/AIDS advocacy and blood safety campaigns are underway; and a Global Funds for Aids Tuberculosis and Malaria (GFATM) assisted project on HIV/AIDS and the Adolescents and Young People is in progress.

Challenges

     While Bangladesh has a relatively low HIV prevalence, there are many factors that make it particularly vulnerable to HIV/AIDS. They include socio-economic and cultural factors that can only be addressed effectively through a multi­sectoral and multi-dimensional approach. Sentinel surveillance remains key to follow trends of HIV infection and behaviour change as well as to monitor the outcome and impact of responses to HIV/AIDS.

     Essential policy review and legal/law reform to enhance enabling environment and the impetus for HIV/AIDS prevention, care and support need to be promoted and facilitated by the different stakeholders.

     Initiatives should be intensified to mainstream HIV/AIDS into different public and private sectors and to ensure effective leadership support and involvement at all levels in advancement of appropriate measures to deal with HIV/AIDS. Since HIV/AIDS is a development concern, all development and health programmes such as PRSP, SWAP and HNPSP are expected to accord due prominence to and coverage of HIV/AIDS.

Target 8: Have halted by 2015 and begun to reverse the incidence of malaria and tuberculosis

To achieve this target, Bangladesh will have to halve the one million people annually afflicted by malaria and reduce the number of deaths from one percent to half a percent by 2015. Also, by 2005, Bangladesh will have to increase the success rate of detection of tuberculosis cases under DOTS from 34 percent in 2000 to 70 percent, and the cure rate from 84 percent to 85 percent.

Situational Analysis

Malaria

Malaria is one of the major public health problems in Bangladesh. Out of 64 administrative districts, 13 belong to the high-risk malaria zone.

Prevalence and death rates associated with malaria

A total of 14.7 million people are at high-risk, and drug resistance to chloroquine and sulphadoxine-pyramethamine is posing a problem. The Malaria and Parasitic Diseases Control Unit in the Directorate General of Health Services implements control interventions based on the Revised Malaria Control Strategies, viz. Early Diagnosis and Prompt Treatment (EDPT), Selective vector control, Promotion of Insecticide Treated Mosquito Nets (ITMN), Epidemic preparedness and response, and community involvement and partnerships with NGOs and private sector. The Roll Back Malaria initiative was piloted in one district and is now being extended to three hill districts. There is an increasing trend of case incidence and deaths in the border districts, particularly in the hard-to-reach areas.

Proportion of population in malaria risk areas using effective malaria prevention and treatment measures

An estimated one million clinical cases of malaria are treated every year. During 2002, the Annual Parasitic Incidence was 4.2 in the high endemic districts, leading to 61,495 laboratory confirmed cases, and 598 reported deaths. Plasmodium falciparum is the predominant infection (61-71%) and Anopheles virus the principal vector. The current programme aims to reduce by 50 percent the incidence of cases and the number of deaths from malaria by the year 2015.

Data on Malaria

     13 out of 64 districts are high endemic.

     14.7 million people are at high risk.

     60,000 - 75,000 lab confirmed cases per year.

     Estimated 1.0 million clinical cases annually.

     Focal outbreaks in eastern border are not infrequent.

     Drug resistance (CO, SP) reported in CHT; Data needs validation; drug policy to be updated.

Challenges

Scaling up ITMN programme to achieve coverage up to 70 percent of 14.7 million high-­risk populations, especially in the remote areas, and poor and tribal families, remains a major challenge. To overcome the problem of drug resistance, effective treatment and rapid diagnostic tests need to be introduced. To be fully effective, the current programme must substantially increase the number of trained manpower and malaria experts, at various levels.

Tuberculosis

Prevalence and incidence

Bangladesh ranks fourth on the list of the 22 highest TB burden countries in the world. In 2002, the incidence of all cases and of new smear-positive cases was estimated to be 233 and 105 per 100,000 respectively.[2] About 70,000 patients die of TB each year. Bangladesh is committed to the 2005 international targets of detecting 70 percent and curing 85 percent of the detected smear-positive patients. To further decrease incidence and prevalence of TB, the momentum must be maintained (or increased) beyond 2005. The survey of 1986-88 found a 0.7 percent prevalence of sputum smear-positive TB in adults. The countrywide prevalence/incidence survey planned for 2004-05 will provide the baseline for monitoring progress towards achievement of the MDG 2015 target. This survey will also provide information on the male/female ratio among TB patients.

Proportion of cases detected and cured under DOTS

Eighty-four percent of cases diagnosed in 2001 were cured under DOTS. In 2002, the case-detection rate of new smear-positive cases was 34 percent. Of the new smear-positive patients, the M/F ratio was 1:0.44, which indicated an under-diagnosis of female cases. Increased detection and cure of females will have a considerable impact on maternal mortality as TB has been found to be a major cause of maternal death in high TB burden, low income countries.

Challenges

The major challenge is to simultaneously increase case detection, maintain a high cure rate, and improve the quality of the diagnostic services. This calls for strengthening the management of National TB Control Programme (NTP) at central, divisional and district levels, intensifying effective partnerships and collaboration, expanding diagnostic and treatment services, implementing quality assurance of smear microscopy and BCG strategies, and strengthening monitoring and evaluation. Other essentials include human resources development and uninterrupted supply of drugs and laboratory provisions.

It is estimated that $ 33 million will be needed to achieve the 2005 international targets of 70 percent case-detection and 85 percent cure. Of this, $ 12 million is expected to be Government contribution, $ 4 million NGO contribution, and $ 17 million must come from external resources.

GOAL 7: ENSURE ENVIRONMENTAL SUSTAINABILITY

Target 10: Halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation.

Indicator 29: Proportion of the population with sustainable access to an improved water source

Indicator 30: Proportion of population with sustainable access to improved sanitation

In the case of Bangladesh, the target is to increase coverage of safe water from 99 percent to 100 percent in urban areas and from 76 percent (arsenic-adjusted estimate) to 96.5 percent in rural areas by 2015.

In addition, access to improved sanitation must be increased from 75 percent to 85.5 percent in urban areas, and from 39 percent to 55.5 percent in rural areas by 2015.

In the case of Bangladesh, MDG 7 - Target 10 was modified to highlight the crucial role that access to water and to sanitation play in maintaining a healthy and productive population. Besides the global indicator of the proportion of population with sustainable access to an improved water source, a second indicator was included, i.e., the proportion of urban and rural population with access to improved sanitation.

Proportion of population with sustainable access to an improved water source

This indicator is defined as the percentage of the population who use any of the following types of water supply for drinking: piped water, public tap, borehole or pump, protected well, protected spring or rainwater. By this definition nearly 100 percent of the population in Bangladesh has access to water. However, over the last few years, thousands of tube-wells have been found to be contaminated with naturally-occurring arsenic at higher than WHO-recommended levels. If quality is taken into account, access to safe water drops to only 72 percent in rural areas. In spite of the fact that this is good coverage by developing country standards, it implies that 30 million people remain without access to safe water.

Proportion of the urban and rural population with access to improved sanitation

In rural areas, access to improved sanitation has increased from 11 percent in 1990 to 29 percent in 2002 to 55 percent in 2004. In the case of urban areas, however, the situation has deteriorated, the coverage dropping from 71 percent to 56 percent in 2002 and in 2004 it is 71 percent. This is mainly due to unbridled and unplanned urbanization that has been taking place in recent years.

Although technologies such as sewers, septic tanks, pour-flush latrines, simple pit latrines, and ventilated improved pit latrines contribute towards the achievement of target 10, additional factors also need to be taken into consideration. For example, it is essential in the case of simple pit latrines that excreta are adequately treated before being discharged into the environment. Even in towns and cities with sewerage systems, discharges are passed untreated directly into the environment. Solid waste disposal remains an environmental sanitation hazard, especially in the urban areas.

The Government recognizes the importance of increasing access to sanitation. Following a major initiative that culminated in the SACOSAN Conference in Dhaka in October 2003, the Government declared its own target of achieving 100 percent sanitation coverage by 2010, and has allocated two percent of its annual development budget for the task.

Challenge 1: Ensuring 100 percent coverage of safe water

To ensure nearly 100 percent coverage by 2015, at least 25 million people must gain access to arsenic-free, safe water over the next 10 years. This is a considerable challenge, since at present there is no effective solution for communities, which are highly affected by arsenic. Technologies for removing arsenic from water are in the process of being introduced on a large scale. However, as each option has some disadvantage, communities and individuals will have to learn to use water from different sources for different purposes, if their water demands are to be met at a viable cost. This requires a level of sophistication by the consumer, which has not been necessary in the past. Resources will therefore be required, not only to support the installation of water sources, but also to raise awareness and train communities in appropriate water use.

In the longer term, other issues are likely to arise in relation to access to safe water. In particular, there is growing concern regarding the availability of groundwater. Currently, groundwater is used widely for irrigation, leading to a lowering of the water table. A proper groundwater management strategy will be necessary to safeguard the resource. Other problems include water salinity in coastal areas.

Challenge 2: Ensuring access to basic sanitation

If the health benefits of sanitation are to be fully realized, good hygiene practices such as hand washing at critical times are crucial. It is important therefore to monitor indicators that include latrine coverage, the condition and use of sanitary facilities, and the adoption of good hygiene practices. Regular national sanitation surveys can be used for tracking these indicators including the treatment of sewage and the collection and disposal of solid waste.

Challenge 3: Resources needed to meet Target 10

It is estimated that US $ 64 million will be required to meet the water and sanitation goals by 2015.

To be most effective, national processes such as Poverty Reduction Strategy, the Pro-Poor Strategy and the Sector Development Framework should coordinate efforts by the Government, NGOs and other stakeholders to achieve and even surpass the targets for water and sanitation under the various development initiatives.

Those sections of population who continue to be excluded from programmes that provide access to safe water and sanitation should be especially targeted. Strategies need to ensure that the poor and marginalized, such as slum dwellers in urban areas, are supported in appropriate ways.

Target 11: Significantly improve the lives of at least 100 million slum dwellers by 2020.

The global indicator for Target 11 is the proportion of households with access to secure tenure. Four additional dimensions of this target[3] have been identified by UN Habitat: i) access to safe water; ii) access to sanitation; iii) durability of housing; and iv) sufficient living area.

Situational Analysis

Access to safe water

In 1999, on average, 45 percent of the urban population had access to safe drinking water. This access varied regionally: 94 percent of households in the capital city of Dhaka had access to drinking water compared to 71 to 85 percent in the three[4] other major cities. Water supply from public sources was better in Dhaka and Chittagong, than in Khulna and Rajshahi where there was a much higher dependency on private water suppliers. The lack of adequate public water supply however has greater negative impact on the poor - 91 percent of poor[5] households in Khulna and 65 percent in Rajshahi used private water suppliers.[6]

Access to sanitation

Access to sanitation and to sanitation services also varies according to region. While 43 percent of urban households use water sealed latrines, only 14 percent of slum households in metropolitan cities have access to any type of sanitary latrines, the majority (85%) using hanging latrines. Regional variations exist, with households in urban metropolitan areas having better access to sanitation than those in the rural areas.

Secure tenure/Durability[7] of housing

In 1999, nearly half the urban population lived in marginal or informal settlements with little or no rights to public services such as water, sanitation and electricity. About 26 percent of urban poor households owned a dwelling unit, although only 18 percent owned any land.[8] The majority (75%) of the houses of the urban poor are built of temporary material, and on average 22 percent have access to electricity.

Challenges

Urban population in 2000 was estimated to be 26 million. Under the assumption that population growth will stabilize by 2035, and that current rate of rural-urban migration is maintained, it is estimated that urban population in 2015 will reach nearly 50 million. The majority will be living in the four major cities of Dhaka, Chittagong, Khulna and Rajshahi. To achieve Target 11 by 2015, health, water and sanitation services must be reached to 50 million urban dwellers, while ensuring that the services also reach urban slum dwellers