Improving access to noncommunicable disease services for Rohingya refugees and immediate host communities in Cox's Bazar, Bangladesh

Noncommunicable diseases (NCDs) account for 67% of all deaths in Bangladesh, with nearly one in five at risk of dying due to NCDs between 30 and 70 years of age. NCDs disproportionately affect the poor, leading to a vicious cycle of disease, poverty, and non-productivity. In August 2017, at the time of mass influx into Bangladesh, Rohingya refugees living with NCDs were vulnerable to deterioration of health due to difficult living conditions and interrupted access to health care services. The WHO Country Office in Bangladesh established a coordination mechanism, supplied medicine kits for NCDs, and supported the establishment of basic services for care and management of NCDs as part of essential health services for Rohingya refugees and immediate host communities (approximately 1.44 million people). As of February 2022, more than 95% of health facilities provide care for people living with NCDs with the support from 908 primary health care workers trained by WHO.

How did Bangladesh do it, and how did the WHO Secretariat support Bangladesh?

The WHO Country Office supported the Government of Bangladesh with technical expertise to adapt the WHO Package of Essential Noncommunicable (PEN) Disease Interventions for Primary Health Care to the specific context of primary health care facilities in Bangladesh and to develop guidelines, protocols, and tools to support implementation and integration with other essential health services delivered in health facilities. Early detection of NCDs through a primary health care approach is a high impact intervention, preventing premature death and disability.

To support PEN package implementation in Bangladesh, the WHO Country Office rolled out training for health care providers in 65 primary care facilities that delivered care to Rohingya refugees and immediate host communities. A total of 321 medical doctors, nurses and medical assistants were trained on risk-based management of NCDs, motivational counselling and tobacco cessation. WHO, in collaboration with Cox’s Bazar Civil Surgeon Office, continued providing supportive supervision to trained health personnel. WHO extended support to include on-site, hands-on technical support at facility level to accelerate field level implementation of PEN. The managerial staff in-charge of the health facilities were also oriented on the WHO PEN.

Photo Credit: © WHO Bangladesh/Tatiana Almeida

Photo Caption: Among WHO PEN training participants in September 2020, Sarmin Nahar, a midwife, is concerned about the impact of NCDs on the health of pregnant women.

In addition, WHO trained 427 community health workers on identification of NCD risk factors and promotion of healthy lifestyle among Rohingya refugees to strengthen preventive interventions, especially at community level. This trained workforce offers behavioral interventions and motivational counselling to community members for modification of behavioral risk factors, including tobacco cessation, adoption of healthy diet and regular physical activity. WHO developed risk communication flipcharts for healthy lifestyle promotion which were distributed to 1400 community health care workers to equip them to engage with communities and individuals. With the aid of flipcharts, group counselling sessions and courtyard meetings were arranged in refugee camps on a regular basis to allow for reinforcement of NCD related messages. Innovative risk communication activities, such as theatres for drama and audio messages on use of tobacco and betel nut, were implemented based on WHO guidance.

WHO filled the gap in the supply of essential commodities for diagnosis and management of NCDs. Various modules of NCD kits with diagnostic equipment, including stethoscopes, blood pressure machines, glucometers with strips, anthropometric equipment, essential medicines, insulin, X-ray films and ECG machines, were donated to health sector partners which facilitated more than 95% of primary care centers providing standard NCD services in the camps.

To promote streamlining of NCD services in accordance with national guidance, eliminate coverage gaps, and avoid duplication, WHO established a coordination mechanism involving the Ministry of Health and Family Welfare, United Nations agencies, international and national nongovernmental organizations, and philanthropic institutions to collaborate through the WHO-led NCD Core Group. The core group provides technical guidance and develops recommendations for health sector partners both at policy and implementation level. It also carries out advocacy work with the government and relevant stakeholders to promote risk-based management of NCDs and develop local capacity of health facilities to ensure uninterrupted care for people living with NCDs.

As a result of these efforts, the number of Rohingya refugees and people from the adjacent host community (total population: 1.4 million (45% adults) accessing NCD services increased from 3.7% of the population in 2018 to 27.3% in 2021 [1]. WHO supported five key integrated public health interventions for Rohingya refugees, namely capacity building of health care providers to deliver NCD services using WHO PEN, gap-filling support for essential NCD medicines and equipment, health promotion, risk communication, and stakeholder coordination which resulted in a significant increase in uptake of NCD services among beneficiaries. Interest and support of key stakeholders, including donors, played a vital role in improving access to NCD care for Rohingya refugees. Although the COVID-19 pandemic and associated restrictions compromised essential NCD service delivery in the early days of the pandemic, the integration of infection prevention and control measures in NCD service delivery design enabled maintenance of NCD care as a part of the delivery of essential health services. With the Rohingya refugee crisis becoming a protracted situation with intermittent acute exacerbations, it is timely to shift the focus of NCD related interventions from short-term to a more sustainable approach which can also be translated to routine care to strengthen NCD services.

[1] DHIS2, Directorate General of Health Services, Ministry of Health and Family Welfare, Bangladesh