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.


Background
Non-communicable diseases (NCDs) are the most prominent cause of morbidity and mortality worldwide [1]. According to the Global Burden of Disease study, NCDs were responsible for the deaths of 38 million people in 2013 [2]. Forty-two percent of NCD deaths occurred among people under 70 years of age and of those deaths, 82% were in the low-and middle-income countries (LMICs). The burden of NCDs are projected to exceed the combined burden posed by communicable, maternal, perinatal, and nutritional diseases by 2030 and would emerge as the most common cause of death taking more lives than all other causes combined if appropriate measures are not taken without delay [3,4].
In order to tackle the burden of NCDs, there is a need for comprehensive, coherent and multi-sectoral policies and strategies at international, national and local levels [5,6]. This has already been recognized by the World Health Organization (WHO) in its 2013-2020 Action Plan for the Global Strategy for the Prevention and Control of NCDs (hereafter referred to as the Action Plan) [7]. This action plan has set six objectives for the prevention and control of NCDs. While this has increased awareness regarding the growing burden posed by NCDs and the need for effective policy response, it remains unclear how far it has led to the development and implementation of appropriate policies, particularly in developing countries [8].
The developed countries, in most cases, have already undertaken broad policy and programmatic analysis to address the challenges posed by the NCDs. However, effective application of such policy analysis seems to remain limited [8,9]. It may be noted that while more than 70 % (72%) of research on the burden of NCDs are conducted in high income countries, Low and Middle-income countries (LMICs) are home to only 57% of such research is conducted in low and middle income countries [10]. Nevertheless, seldom such research translates into concrete policy actions in LMCs. Moreover, there is an acknowledged lack of theoretical and conceptual framework that could be used to design appropriate healthy public policy in LMICs [11].
Like many other developing countries, in Bangladesh also non-communicable diseases (NCDs) are emerging as major cause of morbidity and mortality, accounting for 61% of deaths [12]. The most common NCDs include cardiovascular diseases, diabetes mellitus, cancer, and chronic respiratory diseases. As the prevalence of these diseases increase, they will impose an even greater burden in the near future [13]. In response to these emerging trends, the Government of Bangladesh has designed and introduced some innovative initiatives. A substantial number of policy documents have been published to address the critical issues related to the prevention and control of NCDs; however, little effort has been made to conduct a comprehensive analysis of the past and current policy instruments with a view to learn from the experience. The study uses the WHO Action Plan framework and six objectives for the prevention and control of NCDs. Since Global Action Plans provide a guide to developing national policy framework and also guide health care systems on how to manage NCDS and in comparing it by region. This analysis of national NCD policies in lowincome Bangladesh allows for an assessment of the extent to which the objectives of the WHO Action Plan have been met at a policy level. It could also be useful in better understanding the operational dynamics of the Ministry of Health's planning cycle.
Although the study is aimed at comprehensively review and analyze the NCD policies and plans of Bangladesh following the framework of the WHO Action Plan, due to the paucity of available data, it could not cover all the NCDs.

Design
A pre-structured case methodology was adopted, using an existing conceptual NCD framework to define the structure for data collection and analysis [14]. The framework used is the six points of the WHO Action Plan listed below: 1. "To raise the priority accorded to the prevention and control of non-communicable diseases in global, regional and national agendas and that of internationally agreed development goals, through strengthened international cooperation and advocacy". 2. "To strengthen national capacity, leadership, governance, multi-sectoral action and partnerships to accelerate country response for the prevention and control of non-communicable diseases". 3. "To reduce modifiable risk factors for noncommunicable diseases and underlying social determinants through creation of health-promoting environment". 4. "To strengthen and orient health systems to address the prevention and control of non-communicable diseases and the underlying social determinants through people-centered primary health care and universal health coverage". 5. "To promote and support national capacity for highquality research and development for the prevention and control of non-communicable diseases". 6. "To monitor the trends and determinants of noncommunicable diseases and evaluate progress in their prevention and control".
The paper covered policy initiatives introduced by the government of Bangladesh through 2016.

Data source and search strategy
Health policy is defined as the decisions, plans, and actions undertaken to achieve specific health care goals within a society [15]. Documents published between 1971 and 2016 were identified through searches of websites of the Government of Bangladesh, organizations/institutions operating in the country, donor agencies, government and non-government organizations and health-related professional associations. Different search engines such as PubMed and Google Scholar were also used to identify relevant documents. The key terms used in the website searches were 'cardiovascular diseases, ' 'hypertension, ' 'diabetes, ' 'cancer, ' 'chronic respiratory disease, ' 'asthma, ' 'overweight, ' 'obesity, ' 'nutrition, ' and 'physical activity' combined with 'policy, ' 'action plan, ' 'strategy, ' and 'guideline.'

Data extraction
For the first stage of the study, a detailed and extensive review of existing policies and laws was performed to identify relevant laws and policies that potentially have direct or indirect impact on addressing NCD risk factors. At this stage, a data display matrix was developed using the selected policy-and law-related documents. Two separate matrices were developed-one for policies and one for different acts introduced by the government of Bangladesh. For policies, the columns comprised six key data points: The source of the information; The year in which the policy was introduced; The title or name of the policy; Important points with potential direct or indirect implication in addressing the ND risk factors; Limitations in addressing NCDs; and Remarks The source of information included information regarding the title of the documents and web links that can be used to access them at any time. The second column consisted of the years in which the policies and acts were passed in the parliament and were implemented in Bangladesh. The third row simply contains the title/name of the policy or act. The fourth column includes important points regarding the acts and policies with potentially positive impact on reducing the risks of NCDs. The column of limitation includes information on how these acts and policies could have been made more specific to address NCD risk factors and how they lack the focus on addressing NCD related issues. The remarks column is designed to provide any essential background information, if needed, and summarize policies and acts focusing on NCDs. Information from all the policies and acts were collected to fill all the columns of the data display matrices.

Data analysis
For data analysis, the data display matrices used is described above. After literature and document review, the relevant documents were separated and key information from each relevant document was identified using the matrix. The authors themselves conducted the document review and analysis, as many of the documents were in Bengali as the authors were fluent in both Bengali and English. Once the key points regarding the NCDs from the policies and acts were identified, the authors went for further analysis by synthesizing the key findings to identify the limitations and weaknesses of the analyzed acts and policies related to NCD risk factors. The final data display tables were checked and rechecked by all the authors and cross checked with existing literatures and other documents to confirm the accuracy of the analysis which resulted in further additions and adjustments of the data display matrixes to ensure that all the information provided were accurate and reliable. The first author very closely supervised and monitored all the steps of the analysis to ensure quality.

Results
Of the 51 documents analyzed, seven (13.7%) were research/survey, nine were on policies (17.7%), while seventeen (33.3%) were on acts. On the other hand, five (9.8%) and thirteen (25.5%) were related to guidelines and/or strategic plans/documents respectively from government institutes and non-government institutes ( Table 1). Table 2 presents the summary of policy documents against objectives of the action plan. In addition it may be noted that Bangladesh all guideline are usually developed by non-government organization organizations and adopted by the government.

Objective 1:
This objective was addressed by eight documents (Table  3). Seven were strategic plans/others and one is a national policy. The National Strategic Plan for Surveillance and Prevention of Non-Communicable Diseases in Bangladesh 2007-2010 was the first strategic plan issued by the Directorate General of Health Services, Ministry of Health and Family Welfare, Bangladesh in 2007 [16]. As such, this strategy highlighted several action plans such as for hospital based surveillance, inpatient NCD surveillance in specialized institutes, and monthly reporting of morbidity and mortality attributable to NCDs, as well as inpatient surveillance in medical college, district, and upazila hospitals, review meetings, publication of newsletters, reports, capacity building of the human resources and strengthening of information technology (IT) for the improvement of recording and reporting.
In addition, one of the key driving forces is the new Health, Nutrition and Population Sector Intervention Program (HNPSIP, 2016-2021) that highlighted tackling the rising burden of NCDs through cross-sectoral work to promote healthy lifestyles and healthy environments. Under the HNPSIP, four key action plans mentioned below were implemented: Development and implementation of effective, integrated, sustainable, and evidence-based public policies for non-communicable diseases. Strengthening the capacity and competencies of the health system for integrated early detection and management of non-communicable diseases and their risk factors. Development and further strengthening the capacity for surveillance of non-communicable diseases. Provision of services for conventional and nonconventional NCDs, particularly, mental health, gender based violence, suicide, injuries, and poisoning.

Objective-2:
This objective was addressed by twenty-six documents (Table 4). There was some evidence of building

Objective 3:
This was addressed by twenty-three documents ( Table  5). The first is the " The Environment Conservation Act, 1995 saw the establishment of a Department of Environment with the supervision of a Director General to ensure safe and controlled processing, storage, transportation, supply, import, export, disposal and dumping of hazardous waste materials so that the environment, surroundings and public health is safe from any danger [17].

Objective 4:
This was addressed by sixteen documents (Table 6). In response to the findings of the National NCD Risk Factor Survey 2011, the health care system of Bangladesh took some initiatives to combat chronic non-communicable diseases. The National NCD plan has been developed, and a dedicated unit titled Non-Communicable Diseases Centre (NCDC) with dedicated line director has been established within the ministry of Health and Family Welfare. With a view to bring NCD services to the doorstep of the National cancer control strategy and plan of action [68] 2009-15 Hospital cancer registry report [69] 2008-2010 Hospital cancer registry report [69] 2011-2013 population, one of the key initiatives was the introduction of NCD corner in Upazila Health Complexes. The concept of NCD corner was first piloted in 2012,with the introduction of three NCD corners in three UHCs in the southwestern districts of Khulna Division [12]. Since then, the Government of Bangladesh has taken encouraging steps to expand the NCD corners to 300 UHCs throughout the country.

Objective 5:
This was addressed by ten documents (    financial/ technical support from numerous international agencies such as the World Health Organization (WHO) and the Japanese International Cooperation Agency (JICA).

Objective 6:
This was addressed by thirteen documents (Table 8).

Discussion
The government of Bangladesh introduced numerous of initiatives to combat chronic NCDs. A total of 51 relevant documents were identified. Seven (14%) were research and/or surveys, nine (18%)were on formulated policies, while seventeen (33%) were on action programmes. Five (10%) were related to guidelines and thirteen (25%) were strategic planning documents from various government organizations or institutions. One of the most effective initiatives was the establishment of NCD corners at the Upazila Health Complexes. The 2013 ban on tobacco product advertisements and the more recent introduction of plain packaging for tobacco product materials by the government also make evident to be effective initiative in combating NCDs [18]. The National Safe Food Act of 2013 was aimed at   safeguarding the health of the general population by ensuring food safety. The Act empowered regulatory bodies in conducting research on food, standardizing the quality of food, and controlling the production, import and sale of food products. However, effective enforcement of these policies and acts remains problematic. Close monitoring and supervision of the system is lacking making it difficult to ensure proper implementation of these policies at the ground level. A multi-sectoral approach is also lacking that could maximize the positive output of these policies and acts. Bangladesh has introduced a National Drug Policy (NDP), however the health system is not fully prepared to understand and effectively address the epidemiological and demographic transitions that affect the efficacy of the National Drug Policy. There is a critical need to reform the NDP with a view to accommodate medicines and supporting resources for handling NCDs. Similarly, while the National Women Development Policy recognizes that during every stage of a woman's life she has the right to receive the highest level of nutrition, physical, and mental health care, it remains silent on pregnancy related health issues including hypertension, diabetes, and epilepsy. Bangladesh adopted the National Children's Policy and educational policy to promote good physical and mental health for children by ensuring proper nutrition, healthy psychological development and the opportunity for physical exercise. However, there is little serious effort in properly implementing the said policy. With a view to promote health and prevent NCDs through physical exercise, WHO outlined various guidelines for creating opportunities for games and physical activities in educational institutions [19]. Unfortunately, educational institutions in Bangladesh, especially in urban areas, lack adequate space or playground for physical activity. The National Sports Policy also emphasized establishing and maintaining open space or fields in all educational institutions. Again, the policy may be remains poorly implemented. There are also directions to establish sports facilities, swimming pools and gymnasium in educational institutions -from village to the city level. However, little attention is being paid to operationalize these directives. The national agricultural policy clearly emphasized the need to diversify the agriculture sector and produce agricultural products with higher quality of nutrition to satisfy the nutritional needs of the general population. However, in this case too there are no clear directions in ensuring the availability of fresh vegetables and fruits for the city dwellers. The National Integrated Multimodal Transport Policy emphasized on walking and cycling as mode of primary commute. The policy also emphasized the need to prevent air pollution and that of using good quality fuel in vehicles. The policy, therefore, put a ban on two-stroke engines. Nevertheless, there is little effort in enforcing these policy guidelines.
A recent study in Bangladesh entitled "A scorecard for tracking actions to reduce the burden of noncommunicable diseases" reported that among the four domains of governance, risk factor surveillance, research, and health system response, the country's performance score was low in three domains, except for the governance domain (moderate performance) [20]. It means that although the government initiated many policies or programs, there was a clear lack of forceful implementation and monitoring of these policies and programs. On the other hand, the country lacks any integrated community public health program focused on monitoring NCDs on a regular basis. Bangladesh also lacks any national surveillance program focused on NCDs. Unfortunately, only a few tertiary hospitals maintain such NCD surveillance systems [21]. Another study identified a total of 11 NCD programs in Bangladesh focusing on tobaccorelated illnesses, diabetes or cardiovascular diseases [22].
In short, Bangladesh designed and introduced numerous policies and programs aimed at addressing challenges posed by surging chronic non-communicable diseases. However, serious efforts may be improperly implementing these policies and programs were critically lacking.
Similar to the resent one, a study in Mongolia using WHO 2008-2013 NCD Action Plan came out with similar findings the Mongolian government had a welldeveloped action plan on NCDs that lacked forceful implementation [23]. Sadly, many other developing countries also suffer from similar failures in forcefully implementing NCD policies and programs.

Limitations
The scope of this document review was limited to publicly available central government policies introduced since the liberation of Bangladesh in 1971 in relation to the key objectives in the WHO Action Plan. This analysis was not meant to elaborately assess the development, implementation or outcomes of the government's relevant policies, but instead considered the existence of policies as indicators of high-level government commitment and response to NCDs. The study, therefore, cannot comment on the effectiveness of the overall NCD policies or the extent to which these policies are implemented. Another limitation is that the review process we included only publically available documents. It is likely that some relevant documents are yet to become publicly available.

Conclusions
Although the analysis is limited to electronically available policy document, government of Bangladesh successfully demonstrated a positive response toward global action plan through institutional recognition of NCDs, high level coordination mechanism like designated line director, management and information system for NCDs and treatment corner in the primary health care facilities, integrated NCD programs in the community level, inclusion of NCDs in the sector health program. Beside the maternal and child health issues, the government increased the readiness of health workforce in NCDs due to high and dual burden. Largely, a number of policy documents on NCDs are available, but significant effort is required for implementation and evaluation how these policies or acts can be effectively implemented in the health system further strengthened to effectively address the NCDs. Needless to say, this policy analysis could also guide monitoring, opportunities and challenges for assessing the success of the health system in tackling NCDs and will aid for corrective measures at an early stage within the resource poor context.