'Bangladesh's urban health system needs to focus on prevention, primary care'

With a growing number of people living with noncommunicable diseases (NCDs) such as diabetes, heart disease, cancer and mental illnesses — accounting for about 70% of all deaths in Bangladesh — the country's urban healthcare system must prioritise prevention and strengthen primary care through better coordination between public and private providers, said Professor Helen Elsey from the University of York, UK, in an interview with The Business Standard's Md Jahidul Islam.

Helen Elsey, a fellow of the UK's Faculty of Public Health and holding a PhD from the University of Southampton, works with ARK Foundation, a non-profit implementing health projects under CHORUS Bangladesh – a research programme consortium which unites experts from South Asia, West Africa and the UK to strengthen urban health systems for the poor.

Bangladesh's urban NCD care faces challenges due to limited public facilities, uncoordinated private and NGO providers and weak record-keeping. CHORUS Bangladesh seeks evidence-based solutions to improve urban primary healthcare.

How can Bangladesh's interim govt improve urban health?

I think urban health issues really need to be addressed. Improving the urban environment, so it becomes healthy for people to live in, has to be a top priority. The number of people coming to the city is only going to increase and we have to start planning our cities better to keep people healthy. 

We also need a robust urban healthcare system, but by focusing on disease prevention, people can stay well, reducing reliance on the system and enabling them to live healthy, happy and productive lives.

Which areas need addressing?

We must address broader issues like air pollution, access to healthier environments for diet and exercise, and clean water and sanitation, which help protect against both communicable and non-communicable diseases. 

Tobacco use is a prime example: despite Bangladesh's commitment to the Framework Convention on Tobacco Control and its strong policies, smoking in public places persists. Exposure to second-hand smoke puts everyone, including women and children, at risk of cancer, heart disease and respiratory issues. These challenges require action from city governments, businesses and citizens.

What roles should local govt and city corporations play?

City corporations can play a crucial role in leading and coordinating action across various sectors. They are well-positioned to ensure health is integrated into urban planning, housing, and transport. Through this multi-sectoral approach, they can drive change to make cities healthier for everyone. 

A key priority is understanding urban populations. Currently, the urban poor, especially those in informal or illegal settlements, are often excluded from health data, which skews the city's overall health picture. Including these groups in surveys is essential for accurate data, allowing decision-makers at both city and national levels to better address community needs.

How has ARK Foundation helped our urban healthcare system?

I began working on this particular project in 2020, though I've been working with ARK Foundation for many years. One of our first collaborations focused on NCD corners when they were first introduced in rural health facilities. Our study highlighted the challenges of setting up these corners, given the limited drug supply, staff, and early-stage training. 

This was in the early days of Bangladesh's NCD response, shedding light on the difficulties in caring for people with non-communicable diseases, especially diabetes and hypertension. 

While there have been significant improvements in NCD care in rural Bangladesh, urban areas still face many challenges. These issues are common across various countries, which is why CHORUS is working with partners in Nepal, Nigeria, and Ghana, where similar challenges exist despite different contexts.

What is your perception of Bangladesh's urban health system?

Urban primary healthcare in Bangladesh is really limited. When you think about the massive growth in urban populations and appreciate the limited structures in place for public primary care the challenge is clear to see.  

Here in Bangladesh, this is complicated by the fact that primary care sits under city corporations as well as the Ministry of Health and Family Welfare, so there is a great need for coordination.

 Why is the system so overwhelmed?

Due to climate change and economic shifts, many people are leaving rural areas and moving to cities, often settling in informal areas and working long hours. 

Our research shows that when urban residents fall ill, they typically first visit private pharmacies or informal providers, or they delay seeking care until their condition worsens, at which point they go to hospitals. This results in hospitals being overwhelmed, even though many of these patients could be treated and managed at the primary care level.

Any suggestions for improvement?

The system is under significant pressure, and with the urban population expected to rise, this issue will only worsen if we don't act now. Key actions include working across sectors, implementing regulations and plans to protect public health, and engaging communities to improve urban planning to keep all residents healthy. 

This will help prevent the rise of NCDs. It's essential to recognise that all providers — whether public, private, NGO, or informal — must collaborate. Setting up systems for coordinated care to ensure all patients have access to primary care is crucial.

What is the future plan of ARK Foundation?

Our findings will assess how effective these interventions have been in strengthening the primary care system to provide quality care for diabetes and hypertension, and whether this approach has reached urban poor populations. 

We expect to have the results in the next six to 12 months and plan to share them with the government, health providers, city corporations and the media. This will ensure that decision-makers can leverage the findings to improve health systems in cities across Bangladesh.