By Dr. Asad Khan 16 January 2019
In recent years Bangladesh has done well to achieve multiple health targets – has reduced under-5 infant mortality, eradicated most communicable diseases, increased longevity etc. etc. However, with the change of time and circumstances it now faces new challenges in health for which country’s health education and the health system is both least aware and also least prepared. This is worrying.
Rise of Non-Communicable Diseases (NCDs): Bangladesh’s New and Least Prioritised Health Risks
In Bangladesh, deaths caused by non-communicable diseases (NCDs) that include mainly heart disease, stroke, diabetes and breast and colon cancer are on the rise and this is due to several reasons but most important among these, is lack of regular physical activity. Over the past eight years, total deaths attributable to NCDs have increased by 15% in Bangladesh, 52% in 2008 to 67% in 2016, where lack of physical activity has been recorded as the 3rd leading risk factor for NCDs. Two in five (39%) adults in Bangladesh do not engage in the recommended levels of physical activity and among these, women and urban people are less active (1). Furthermore, three in five (59%) children aged 13-17 years do not meet the WHO recommended physical activity guidelines (2). Sedentary behaviour that constitutes non-physical idle/relaxed behaviour such as sitting, reclining or lying (e.g. watching TV, or playing on the computer) has also increased considerably in recent past years and this is mainly due to rapid urbanisation and modernisation where people are more technology-centred with an increased access to labour-saving technologies and motorised vehicles, and prolonged engagements with screen-based entertainments.
Indeed, recent increase in NCDs poses a threat to the country’s overwhelmed health care systems, which lack resources and capacity to respond to the growing burden – financial, logistics and emotional – the NCDs cause.
Good news is that there is remedy. World Health Organization’s (WHO’s) 2013-2020 Action Plan for the Global Strategy for the Prevention and Control of Non-Communicable Diseases has called for increasing physical activity at all levels. The action plan sets a global target to a 10% reduction in physical inactivity by 2025 and offered pragmatic policy options for member countries to promote physical activity at the community level. In its most recent Global Action Plan for Physical Activity 2018-2030, WHO has stressed “…Failure to act to increase levels of physical activity will see related costs continue to rise, with negative impacts on health systems, the environment, economic development, community well-being and quality of life.” This action plan has set a new global goal to reduce physical inactivity by 15% by 2030 with a framework of effective and feasible policy actions to promote physical activity and reduce sedentary behaviours. WHO has emphasised “…Effective implementation will require bold leadership combined with cross-government and multi-sectoral partnerships at all levels to achieve a coordinated, whole-of-system response”. It has argued that working in partnership with various actors and investing in policy actions to promote physical activity can enhance community wellbeing and quality of life for all, in addition to various environmental benefits including cleaner air, reduced traffic, and less congestion. The policy actions on physical activity are interconnected and are linked to 13 of 17 goals of United Nations 2015-2030 Sustainable Development Goals (SDGs). To complement the SDGs with physical activity dimension of health a similar framework has also been endorsed in the 2016 Bangkok Declaration on Physical Activity for Global Health and Sustainable Development. The Bangkok declaration has identified physical activity as important component of healthy lifestyle that has the potential to promote development more sustainably and equitably thus warranting urgent prioritisation and action on it.
Reducing NCD Risks in Bangladesh: Challenges and Options
Given the context, Bangladesh should create every opportunity to make its people become more physically active and work in partnership with other stakeholders to promote walking, cycling, sports, active recreation and play and other forms of physical exercises.
The government of Bangladesh has indeed initiated a number of policies related to NCDs but these are somewhat ad hoc and fragmented and thus lack the capacity to improve things in a more integrated manner. For example, the most recent 2016-2021 Health, Nutrition and Population Strategic Investment Plan that has suggested ‘lifestyle approach’ to reduce future costs of treating rapidly increasing chronic NCDs is not complemented by relevant and specific details as to how to go about it and the other concern is that despite its established health and psychosocial benefits active lifestyle is yet to be recognised as a priority agenda of health in any of the country’s existing policy documents. Furthermore, despite its deleterious effects on health and wellbeing of people none of the policies have recognised sedentary behaviour as a risk factor. This is unhelpful.
The 1998 National Sports Policy suggested establishing and maintaining open space for playgrounds in all educational institutions, but this policy has not been implemented fully. Most of the educational institutions in Bangladesh, especially in urban areas, lack adequate facilities for sports and physical activities.
Similarly, even though the 2013 National Integrated Multimodal Transport Policy encouraged active commuting and advocated walking and bicycling as a primary mode of transportation, the existing cycling and walking infrastructure, especially in urban areas are anything but ideal. Furthermore, in the current conditions of chaotic and poorly managed traffic control in most urban areas it is also not only not possible to encourage people to engage in active travelling but such activities without enabling traffic and other relevant infrastructural facilities are also likely to be hazardous.
Another issue is lack of data for planning. While the policy document, 2011-2015 Strategic Plan for Surveillance and Prevention of NCDs in Bangladesh had duly underscored the need for surveillance of NCD risk factors, the country is yet to set a comprehensive and integrated national surveillance system to produce national-level data that are key to determining remedial options. Similarly, while Bangladesh Demographic and Health Survey (BDHS), a nationally representative sample survey, periodically collects data on different aspects of health, population and nutrition to monitor health trends in the country, activity behaviours are not included in this national surveillance activity. As a result, lack of nationally representative data limits understanding empirically, the risk profiles of the population and hence compromises capacity to make informed decisions relevant to designing appropriate intervention strategies.
Prevention is another important aspect of combating NCDs but so far none of the governments in Bangladesh have come up with a comprehensive prevention strategy as a priority. Even though some of the policies or programs recognise the importance of exercise, sports or physical activity to promote a healthy lifestyle, lack of required budgetary allocations and adequate appreciation of the gravity of the issue have continued to impede progress in promoting an active lifestyle program in the country.
In sum, given the rapid increase of NCDs in recent times and its cost to the people and the country, it is crucial that the government of Bangladesh and other stakeholders recognise ‘active lifestyle’ as a health priority for the nation and undertake integrated innovative initiatives to get the people engage in more physical activity. While recreational sports, dance or play is important, creating sustainable opportunities for active travel such as walking, bicycling and more importantly, creating enabling environment – both infrastructural as well as organizational – to undertake these activities are key to promoting active lifestyle in the country. In addition, appropriate educational campaign to foster awareness among the people in healthy lifestyle especially in promoting physical activity and reducing sedentariness should also be given due consideration. Furthermore, to promote suitable healthy lifestyle policies due attention should also be given to the issue of periodic comprehensive and integrated surveillance for integrated healthy life-style planning. (see – http://www.ahkbd.org, an international collaborative initiative that monitors and gathers data on physical activities of children at schools in Bangladesh).
Given the limited share of GDP invested in health (<1% by public sector) in Bangladesh, adapting and investing in active and healthy lifestyle that have the potential to prevent NCDs and thus minimise costs of NCD treatments can in fact be more of a cost-saving strategy than a costly initiative. The alternative is the spectre of rapidly rising NCDs, rising unhealthy population and rising medical costs of treatment of NCDs. Choice is clear – take the issue of healthy lifestyle seriously, develop a comprehensive and inter-sectoral plan and investment in it.
1. Zaman MM, Bhuiyan MR, Karim MN, Rahman MM, Akanda AW, Fernando T. Clustering of non-communicable diseases risk factors in Bangladeshi adults: An analysis of STEPS survey 2013. BMC Public Health. 2015;15:659.
2. Khan A, Kadir MA, Choudhury SR, Ashraf F, Rahman M, Ahmed KR, et al. Results from Bangladesh’s 2018 report card on physical activity for children and youth. Journal of Physical Activity Health. 2018;15:S318-S9.