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6. HEALTH SERVICES
6.1 Health
education and promotion
Educational support to national health programmes
has been provided by the Health Education Bureau (HEB).
Emphasis has been given in recent years to school health education, hospital
health education and coordination with NGOs. Constraints include the lack of
a national IEC strategy, the low priority given to health education by the
health services, underutilization of health education officers, and lack of
opportunities for professional advancement of those working in health
education. Some issues under consideration are the inclusion of a health
education component in the new national health policy and strengthening of
coordination among the HEB,
ongoing government health programmes and NGOs.
Related Links Director General of Health Service Health
Promotion, NCD – WHO/SEARO Health Education – WHO/HQ Health Promotion – WHO/HQ
6.2 Maternal and
child health/family planning/adolescent health
During 2004, the proportion of women attended by trained
personnel during pregnancy was 27.2 percent; that of deliveries attended by
trained personnel was 13.4 percent; and the ratio of women of childbearing
age currently using family planning was 58.1 percent (Bangladesh Demographic
and Health Survey 2004). In maternal health, there is slow progress as MMR reported for 1991 was 4.7 per 1000 live
births, which has declined to only 3.8 per 1000 live births in 2002. The TFR declined from 3.67 in 1991 to 3 in 2004, but
is still high.
Based on the causes of maternal deaths, several project
activities have been initiated to reduce maternal mortality (Sample and Vital
Registration System, 2002). These
include providing comprehensive reproductive health, family planning and
essential obstetric care (EOC)
supported by UNFPA. UNICEF assistance to EOC
is implemented through the Obstetric and Gynecology Society of Bangladesh. The WHO-assisted programme on
maternal and neonatal care including EOC
is managed by the government and the ICDDRB. Training and logistic supply
management for MCH/FP is also
being strengthened. Some of the main constraints are lack of skilled
manpower, weak management capabilities and limited resources. In the future,
priority will be given to more training and utilization of midwives at the
peripheral level.
Related Links Director General of Health Service Family Program in Bangladesh Adolescent
Health – WHO/SEARO Child
Health - WHO/SEARO Child Health – WHO/HQ Gender,
Women and Health – WHO/SEARO Maternal
Health – WHO/HQ Reproductive
Health – WHO/SEARO Reproductive Health – WHO/HQ Making Pregnancy safer
- WHO/SEARO Making Pregnancy safer – WHO/HQ WHO/Bangladesh
6.3 Immunization
The proportion of infants (0-11 months) who have been
fully immunized according to the national EPI schedule in 1999 was 52.8
percent. By individual vaccines, the proportions in 2005 were: DPT3 - 83
percent, OPV3 - 90 percent, measles vaccine - 77 percent, and BCG - 99
percent. The percentage of pregnant women immunized with tetanus toxoid (at least one) was 85 percent (BDHS 2004).
Immunization services have been extended up to village
level, and community support is readily available. Three NIDs
for polio have also been successfully implemented during the last three
years. The morbidity and mortality rates of EPI-target diseases have been
considerably reduced. A good opportunity is now available to utilize the
already established and well known EPI outreach centers for delivery of other
components of PHC as well.
Related Links Director General of Health Service IVD – WHO/SEARO Immunization WHO/HQ
6.4 Prevention and
control of locally endemic diseases
Dengue
Dengue was an unfamiliar disease in Bangladesh till the outbreak in
2000. It occurs in epidemic form in
most countries of Asia, East and West Africa and some Pacific Islands. Epidemic outbreaks of Dengue have become
frequent in recent years in the neighboring countries including India, Myanmar
and Thailand. Almost all ages and both sexes are
susceptible to Dengue. The infection
can lead to fatal Dengue Shock Syndrome (DSS). It is a vector borne disease transmitted by
certain species of Aedes mosquito. Aedes aegypti (and Aedes albopictus) is a peri-domestic
mosquito, which lay eggs in small collections of clean water such as flower
vases and pots, which act as breeding places.
Usually Dengue transmission occurs during the rainy season of the
year. In Bangladesh, Dengue was never
looked for seriously, except scattered studies which indicated sporadic cases
over the last few years though not confirmed by definitive laboratory
investigations.
Since July 2000, there had been an outbreak of Dengue and
Dengue Haemorrhagic Fever (DHF) in the Dhaka City and cases had also been reported
from other big cities of different parts of the country. As on 10/8/04, a total of 16,388 Dengue
cases were reported of which 210 were deaths.
The Case Fatality Rate (CFR)
found was 1.28 percent.
The Directorate General of Health Services has taken
initiatives to develop national guidelines by adapting the WHO guidelines
according to the local needs. The
objective of the guideline is to control transmission of Dengue Fever and DHF
and reduce morbidity and prevent deaths.
This will help to establish Early Diagnosis and Prompt Treatment
(EDPT) of Dengue Fever and DHF.
Related Links Director General of Health Service Dengue
- WHO/SEARO
Tuberculosis
Tuberculosis (TB) is major public health problem, which
ranks Bangladesh
fifth among the high-TB burden countries in the world. The national tuberculosis control and
prevention programme was started in 1965. The services were mainly curative and were
provided through 44 TB clinics (presently Chest clinics), eight segregation
hospitals and four TB hospitals. TB
services expanded to 124 Upazila Health Complexes
(UHC) during 1980-86 through the project, “Strengthening TB and Leprosy
Control Services,” and became integrated with leprosy during 1986-91 under
the “Mycobacterial Disease Control Programme.”
However, it was reported that treatment completion was less than 50
percent and case detection less than 20 percent of the estimated cases.
The present revised NTP was launched under the project
“Further Development of TB and Leprosy Control Services” and adopts the DOTS
strategy. Its field implementation
started in November 1993 in four thanas, expanding
progressively to the 460 upazilas by June
1998. NTP will also be implemented in
the metropolitan cities.
The present estimates of TB are based on two surveys
performed in 1964-66 and 1987-88.
Annual report of Tuberculosis of 2005 shows tuberculosis incidence is
221/100,000 population. Tuberculosis death is 7% of total death in the
country.
The present revised NTP, adopting the DOTS strategy, dates
from end of 1993. It was expanded to
all rural upzilas in less than five years under the
Fourth Population and Health Project (FPHP), with the technical assistance of
the WHO and partnership of NGOs. Since
July 1998, NTP is administered under the HPSP, and integrated into the CDC
area of the ESP. At the end of 2000, NTP reached 95 percent
geographical coverage of the country including the main cities of Chittagong, Khulna and Rajshahi.
NTP reported 654,068 TB cases till December 2003, of them
44,447 were new pulmonary cases, smear-positive. Of the reported cases, 55.5 percent of the
total pulmonary cases are smear-positive and 44.5 percent are smear-negative. The ratio of pulmonary new smear-positive
cases to pulmonary smear-negative and extra-pulmonary is 1:1.
In 2000, the NTP notification rate was 28.6/100,000 new
sputum-positive cases (corresponding to 29 percent detection rate). The male-female ratio among the NTP new
smear-positive patients was 1:0.4.
This ratio increased to 1:0.8 in the metropolitan areas.
The NTP overall treatment success in the new
smear-positive patients is excellent, with steady annual improvement till the
81.3 percent treatment success in the last patient cohort of 1999.
Related Links Director General of Health Service TB
– WHO/SEARO TB –
WHO/HQ
Leprosy
Leprosy has been a major health problem in Bangladesh
for a long time. Bangladesh was considered a high
endemic country and was listed among ten countries with high case load one
(1992). Leprosy situation dramatically
changed globally after 1981 after the introduction of MDT
by WHO. After
the success of MDT in many
counties, WHO visualize the possibility of eliminating leprosy globally as a
public health problem and fixed an achievable goal by 2000. Elimination was defined as low level of
prevalence, determined a <1 case/10,000 population. Bangladesh is signatory to the
1991 WHO resolution calling for elimination of leprosy by the year 2000,
i.e., to achieve prevalence to <1/10,000 population. The government followed up this resolution
by making substantial allocations to the national leprosy elimination programme under the Fourth Population Health Project:
1991-98 and continuing it in the HPSP since July 1998.
The national leprosy programme
was first launched in 1965 with the introduction of Dapsone
through Government and NGO hospitals.
The Multi Drug Therapy (MDT)
introduced by WHO is recognized as a major technological tool for leprosy
control. The MDT
programme was introduced in Bangladesh in 1985 and extended
phase-wise to about 120 upazilas either by the
government or through NGO collaboration.
Intensive MDT
implementation started in late 1993 with the following objectives:To introduce MDT
services with upazila (country wide) as the
peripheral unit.
 To
introduce MDT services with upazila (country wide) as the peripheral unit.
To
detect >85 percent of the estimated cases within 5 years of programme implementation.
To
provide fixed duration MDT free
of cost to all registered cases.
To
achieve >85 percent treatment completion cure rate.
To
reduce deformity grade-2 among newly detected cases to <5 percent within 5
years of programme implementation.
Since 1996, 625 MDT
units were established in the country.
In 1993, Bangladesh
was estimated to have a leprosy prevalence rate of 13 per 10,000 populations,
i.e., 136,000 cases, which made Bangladesh the country with the
third highest leprosy case-load in the world.
The estimated number of leprosy cases was revised to 80,000 in 1996
and by the end of 1997; the estimated prevalence of leprosy was 3.5 per
10,000 populations with a registered prevalence of 1.17 per 10,000
populations. Since 1994, all registered cases are provided with MDT. Thus,
the MDT coverage of registered
cases is 100 percent in Bangladesh.
Bangladesh
has made considerable progress in achieving the goal of elimination of
leprosy at national level. The WHO
goal of elimination of leprosy as a public health problem by the year 2000 is
defined as to achieve leprosy prevalence (registered) to less than 1/10,000,
population. Bangladesh achieved elimination
of leprosy at national level at the end of 1998 with prevalence of
0.86/10,000, before two years ahead of target date. The present leprosy work is going on for
sub-national elimination by the year 2005.
Related Links Director General of Health Service Leprosy
– WHO/SEARO
Malaria
The control strategy for malaria was revised and approved
in 1995. The new strategy is being gradually implemented, and it emphasizes
disease control aspects and endorses four technical elements (early
diagnosis, prompt treatment, recognition of treatment failures and management
of severe and complicated cases in hospitals). Emphasis is also placed on
malaria surveillance, preparedness for control of malaria
outbreaks/epidemics, and the introduction of insecticide impregnated bed
nets. The main constraint is the reduced capacity of the core technical unit
for control of vector-borne diseases to take on activities countrywide.
Related Links Director General of Health Service Malaria
– WHO/SEARO WHO/Bangladesh
Other diseases
In Bangladesh,
kala-azar is a re-emerging disease since the
cessation of DDT spraying operations. At least 20 million people in more than
27 districts are at risk. The estimated cumulative disease specific burden is
35,000 cases. Under the project for integrated control of vector-borne
diseases, an emergency plan for the control of kala-azar
was initiated in 1994-95 in 22 thanas of 11
districts (population five million). This has been successful and further
expansion is now planned. At least 8,000 kala-azar
patients have been successfully treated to date. The major constraint is
similar to that faced in the control of malaria.
Eighteen (18) million people in 12 districts are
considered to be at risk of filariasis. A revised
strategy for the elimination of filariasis is being
pilot tested in one district. This strategy involves administering a single
dose of ivermectin with albendazole
yearly for a period of three years to the total population in the district.
Dengue has yet to become a public health problem; but in
view of the high potential that exists, surveillance and preparedness
capability have been strengthened.
To date 17 AIDS cases have been reported, but 13,000 cases
of HIV infection are estimated. Current data available categorizes Bangladesh
as a low prevalence country at present.
Related Links CDS – WHO/SEARO CDS – WHO/HQ HIV
- WHO/SEARO LF
- WHO/SEARO Kalazar - WHO/SEARO AI
- WHO/SEARO Cholera
- WHO/SEARO JE
- WHO/SEARO WHO/Bangladesh
6.5 Prevention,
control and management of common diseases and injuries
Acute respiratory infection accounts for about 145,000
deaths annually among children under five years. The
under-five mortality rate due to ARI
was reported to be 33 percent (ICDDRB 1994). Forty to sixty percent of
outdoor visits and 30-40 percent of indoor admissions are attributed to ARI. The programme for
the control of ARI continues to
be implemented on a phased basis according to the recommended WHO strategies.
Diarrhoeal diseases continue to
be responsible for much morbidity and mortality, but current strategies have
considerably reduced mortality. Multi-sectoral
partners were involved in mobilizing the community regarding correct
home-based care and timely referral. The availability of ORS has increased
through the formation of ORS depot holders in the community. Constraints
include inappropriate use of anthelmintics and
anti-diarrhoeals, especially in the private sector,
and the underutilization of health facilities including ORT corners.
The incidence of measles has dramatically declined since
the introduction of measles vaccine into the immunization programme.
Malnutrition still remains a problem both in urban and rural areas, with the
latter being more affected. Of the non-communicable diseases, cancer and
cardiovascular diseases are the leading causes of morbidity and mortality.
The incidence of cancer is estimated at 200,000 per year.
Related Links Director General of Health Service NCD – WHO/SEARO NCD
– WHO/SEARO Mental
Health – WHO/SEARO Mental Health – WHO/HQ Cancer
– WHO/HQ WHO/Bangladesh
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