Short Communication http://www.alliedacademies.

org/journal-pulmonology-clinical-research/

A critical analysis of Bangladesh national tuberculosis control program.

Forid Warid Ahmed*
Dhaka Medical College Hospital, Dhaka, Bangladesh

Accepted on July 15, 2018

Background and Rationale Strengths of the Program

Tuberculosis (TB) is a major global public health problem, First of all, the Directly Observed Treatment, Short course
about 9.6 million cases were reported as newly diagnosed TB (DOTS) strategy, which is an integral part of NTP, is supported
and about 13 million cases were reported as active TB patients in by evidence. Several studies have demonstrated the success
2015. Most of the cases occur in lower middle-income countries of the DOTS strategy [5,6]. The goal is achievable if the
[1]. This is an infectious disease caused by an organism called components are fulfilled. Cure rate could be doubled if it
Mycobacterium tuberculosis. Locally known as ‘Jakkha’ or is successfully implemented. The main benefits of DOTS:
‘Khoy Rog’, it is also one of the most important health threats of (i) High cure rates (up to 95%) (ii) Prevention of MDR--TB
Bangladesh, and this country ranks sixth among the top twenty- emergence (III) Improvement of longevity of AIDS patients by
two high burden countries (HBC) of tuberculosis by World TB control, (iv) It is "one of the most cost-effective of all health
Health Organization (WHO) [2]. Moreover, Multidrug-Resistant interventions", according to World Bank [5].
TB(MDR-TB) is increasing, the majority of the childhood TB
The program was adopted after successful piloting, steps
is not reported [1]. Combating TB was part of one of the goals
were adopted gradually. The coverage level of the program is
of Millennium Development Goals (MDGs), in Sustainable
exemplary, covering almost 100% of the population across the
Development Goals (SDGs) it has been placed under health
country regardless of age, gender, socioeconomic status, and
related targets to reduce its epidemics [3]. The target has been
place of residence [2]. The services are decentralized; recipients
set to reduce TB incidence and TB-related deaths by 90% and
become beneficial in a successful decentralized system [7]. As
95% respectively in the year 2035 in comparison to 2015 [4].
a result of increased coverage, more TB patients are now being
The National Tuberculosis Control Program (NTP) is providing
registered and treated [2].
services throughout Bangladesh to combat tuberculosis [2].
All of the staffs are trained on tuberculosis. A major strength
The National Tuberculosis Control Program (NTP) was first
of the program is that it put a significant focus on field level
launched by the then Pakistan government (now Bangladesh) in
staffs by providing training to them; one of the best examples
1965 in the country. Bangladesh emerged as a new country after
of the programs where the concept of task shifting is being used
being independent of Pakistan in 1971. Now, the Government
effectively, similar to the program directed to AIDS [8]. Not
of Bangladesh in partnership with 44 national and international
so highly qualified technicians are trained to diagnose the TB
Non-governmental Organizations (NGOs) is implementing NTP.
organism by microscopy; tasks of a professional high skilled
World Health Organization (WHO), United States Assistance
microbiologist are shifted to a midlevel staff. Easy, reliable
in Development(USAID), Bangladesh Rural Advancement
& fast diagnosis by the microscopy made the treatment more
Committee (BRAC), International Center for Diarrheal Disease
accessible to the patients, and adequate quality assurance is
Research, Bangladesh (ICDDR, B), and Damian Foundation
done through checking a definite number of slides from all of
Bangladesh are the main partners2. Every organization plays
the health centers in each month by the central laboratory [2].
some roles in the whole process. For instance, World health
Organization provides technical support to epidemiological To make a program successful, not only past evidence of the
analysis, impact analysis, revision of the strategic plan, survey, strategy/plan but also successful collaboration is important. The
development of guidelines, and capacity building [2]. partnership between the public and private sector is significant
for maintaining quality services; this partnership with reputed
The overall goal of the NTP is to reduce morbidity, mortality,
national and international NGOs in revised NTP is unique [2].
and transmission of TB [2]. The vision of NTP is to eliminate
tuberculosis from Bangladesh. Elimination of tuberculosis This program has a strategy to provide socioeconomic support
implies that incidence of TB would be less than one in per million to the patients of multidrug-resistant tuberculosis (MDR-TB)
population. The history, vision, strategy, delivery approaches, by providing foods, transportations for the patients and their
and other components have been described elsewhere [2]. families [2]. This will help the patients to adhere to the treatment
regimen.
The aim of this paper is to investigate the strengths, weaknesses,
opportunities and threats (SWOT analysis) of National The framework is strong where targets are clearly stated, the
Tuberculosis Control Program of Bangladesh. The SWOT ways to achieve them are clearly addressed, the obstacles of
analysis was performed to identify existing competencies and the target are also identified, and the possible solutions to these
gaps as well as drawing lessons to further scale up. problems are also recommended.

16 J Pulmonol Clin Res 2018 Volume 2 Issue 1

Citation: Ahmed FW. A critical analysis of Bangladesh national tuberculosis control program. J Pulmonol Clin Res. 2018;2(1):16-19.

To prevent a disease like tuberculosis, public awareness against existing health system are also reducing by this programme [5].
the disease is important; raising public awareness about TB was As people are getting both treatment and diagnosis from the
also included in the plan. This is done by activities including same facility, this helps to build trusts of patients on the health
orientation on TB among the folk team, involving women system. People are coming to the facilities, they are getting
group, behavioral change communication. These activities the opportunity to know about family planning, antenatal care
also develop skills of community health workers, leaders, and (ANC), safe delivery practices, breast feeding, immunization,
volunteers [2]. integrated management of childhood illness (IMCI), and other
services of health facilities. Bangladesh is suffering from high
Since its implementation, treatment success is increasing
maternal, neonate and childhood mortality in addition to the
gradually. It has consistently achieved the WHO-recommended
high burden of tuberculosis [14]. The concept of ‘diffusion
targets of case findings. The guideline was also updated based
of information’ could be successfully integrated here [15].
on international recommendations. It has also given a significant
Treatment providers are getting additional training as a part the
focus on smear negative, extra-pulmonary, and childhood
program, this is increasing skills of the service providers.
tuberculosis [2].
Several diseases can resemble TB [16], as patients are getting
Weaknesses of the Program the diagnosis through laboratory investigations this is also
In this program, strengths outweigh the weaknesses. The least helping to reduce over-diagnosis and over-treatment of some
number of weaknesses include reaching all of the patients, one other diseases including lung infections, Chronic Obstructive
important weakness of the program is that it is not able to ‘catch’ Pulmonary Disease (COPD), lung carcinoma. The large
a significant portion of all TB cases. Though this program aimed inequality among several regions could be a huge challenge
and tried to cover 100% of the population of Bangladesh, this is [17].
challenged by geographic locations of the patients, where it is The patients are receiving the treatment without any cost, so this
difficult for the services to reach [9]. is benefitting them as they can spend the treatment-related costs
Adherence to treatment is difficult as the period of treatment for other purposes, for instance, nutritional purposes [5].
is longer and laborious. Discontinuation of Anti-TB drugs is
common, as symptoms disappear within a couple of weeks
Threats (Challenges) of NTP
after starting treatment; a major cause of multi-drug resistant Maintaining this evidence-based program is important in the
TB9. Though raising awareness was a critical component of this country context as this country has a high burden of TB and the
program, some studies in Bangladesh revealed that perceived people are at increased risk of tuberculosis due to the prevailing
risk of TB was low and inequalities in treatment seeking risk factors. Moreover, the disease can spread from person
behavior was high [10,11]. to person if it is not cured; the epidemic could return if this
program ends.
Another weakness is increasing HIV-TB co-infection. Though
it is not a problem inherent in NTP, but this weakens success Though patients get diagnosis and treatment from the same
of national tuberculosis control program. The directly observed health facility, this may increase the number of patients in the
treatment may hamper privacy of the patients. Ensuring health facilities where some of the health facilities are already
continuous logistical supply is another major predicament [9]. under-staffed and over-tasked [18,19].
Efficacy of anti-tubercular drugs is also a constraint of The NTP was implemented with sustainability in mind, it
the program. Studies have reported that efficacy of certain is in existence since 1965 in different phases, and however,
categories of anti-TB drugs is lower than expected. Due to maintaining funding is a major future challenge. Most of the
the small number of drugs when there is resistance to drugs, funds come from external donors, the Government should take
treatment becomes difficult [12]. steps to support the program even after expiration of external
funds. Unfortunately, the proportion of health budget in
Treatment providers of the private sectors do not have access
national budget of Bangladesh is very small and most of the
to the services of the program. A significant proportion of TB
public health programs including NTP, immunization programs
patients is treated by treatment providers of private sectors
depend on external donors [20,21]. Political commitment is an
[11]. This includes patients mostly from low-income, rural
integral component of the DOTS strategy to make the program
households who are treated outside the NTP and are charged
sustainable.
for it. One possible explanation for this is a lack of awareness of
the program and its benefits among the local population. Similar One excellent part is that infrastructure in the health facilities
problems or limitations were faced by India where the same has been built by this period. As human resource development is
program is in implementation [13]. a critical component of the revised NTP, all the staffs have been
trained. These two would obviate the need for spending a huge
Opportunities of NTP amount of money if the external funds expire. This could also
The National Tuberculosis Control Program has significant help the infrastructure for other purposes [22,23].
impacts on existing health system of Bangladesh. In addition to A large number of people in Bangladesh live in rural areas
reducing primary tuberculosis cases, this program is reducing [24], rural people are deprived of most health facilities than
tuberculosis-related complications. Costs of patients, costs of their urban counterparts [14]. Covering this huge proportion of

J Pulmonol Clin Res 2018 Volume 2 Issue 1 17

 Ahmed

patients is a major challenge for any program in Bangladesh 3. United Nations. Suatainnable Development Goals; 17 Goals
[17]. to Transform the World. 2016.
Recommendations to Overcome the Impediments 4. WHO. Tuberculosis Fact Sheet. 2016.
To raise public awareness against tuberculosis, more 5. Murali MS, Sajjan BS. DOTS strategy for control of
advertisement in mass media could be a good solution. The tuberculosis epidemic. Indian J Med Sci. 2002;56(1):16-18.
government could make a law which would make it mandatory 6. Frieden TR, Munsiff SS. The DOTS strategy for controlling
to broadcast awareness program about tuberculosis for a couple the global tuberculosis epidemic. Clin Chest Med.
of minutes every day. These programs could incorporate 2005;26(2):197-205.
awareness programs about AIDS, cancer, non-communicable
diseases, immunization, breast feeding, family planning, 7. Khaleghian P. Decentralization and public services: the case
hygiene practices, and other public health problems in addition of immunization. World Bank Policy Research Working
to tuberculosis [17,22,23]. The disease could be included in Paper. 2003(2989).
text-books of schools. 8. World Health Organization. Taking stock: task-shifting to
A review of BRAC-ICDDR, B Joint Research Project Working tackle health worker shortages. 2016.
Paper Series in Bangladesh concluded that microcredit 9. Queiroz EM, De-La-Torre-Ugarte-Guanilo MC, Ferreira
programs improve maternal and child health, the Government KR, et al. Tuberculosis: limitations and strengths of
of Bangladesh could also explore this to improve the condition Directly Observed Treatment Short-Course. Rev Lat Am
of tuberculosis patients, as tuberculosis is closely related to Enfermagem. 2012;20(2):369-377.
poverty and lower socio-economic condition [25].
10. Ahsan G, Ahmed J, Singhasivanon P, et al. Gender difference
More investment in research is required to invent new drugs, in treatment seeking behaviors of tuberculosis cases in rural
diagnostics, and vaccines. The Government of Bangladesh communities of Bangladesh. Southeast Asian J Trop Med
could work through the South Asian Association of Regional Public Health. 2004;35(1):126-135.
Cooperation (SAARC) with other countries as most of the
neighboring countries share this common problem of the high 11. Hossain S, Zaman K, Quaiyum A, et al. Care seeking in
burden of tuberculosis. A common platform could be made with tuberculosis: results from a countrywide cluster randomised
scientists and researchers from these countries. Sharing of the survey in Bangladesh. BMJ Open. 2014;4(5):e004766.
total costs of research would also reduce costs of an individual 12. Jain NK, Bajpai A, Jain S. Outcomes of category III and I in
country. immunocompetent patients of tuberculous lymphadenopathy
The Government of Bangladesh could integrate the program treated in revised national tuberculosis control programme.
with other programs of the country to make the program Lung India. 2010;27(3):115-117.
sustainable even after the external funds expire. A comparison 13. Verma R, Khanna P, Mehta B. Revised National Tuberculosis
between government sector’s strategy and an NGO found that Control Program in India: The Need to Strengthen. Int J Prev
strategy of the NGO to use community health workers was more Med. 2013;4(1):1-5.
cost-effective, government could utilize this finding [11]. This
program could also be incorporated with AIDS programs. 14. National Institute of Population Research and Training
(NIPORT), Mitra and Associates, ICF International.
Conclusion Bangladesh Demographic and Health Survey 2014. 2016.
We have described several weaknesses and major challenges of 15. Folland S, Goodman AC, Stano M. The economics of health
the NTP, however, we believe the program is overall successful and health care. Pearson Prentice Hall, New Jersey. 2007.
given its numerous strengths with possible opportunities. Though
this program has made remarkable progress to provide diagnosis, 16. Bhatt M, Kant S, Bhaskar R. Pulmonary tuberculosis as
treatment, and other supports to TB patients, controlling of the differential diagnosis of lung cancer. South Asian J Cancer.
disease is still a major impediment. New drugs, diagnostics, 2012;1(1):36-42.
and vaccine are required to combat the disease and achieve the 17. Kibria GMA, Burrowes V, Choudhury A, et al. A
targets of Sustainable Development Goals (SDGs). Funding comparison of practices, distributions and determinants of
is a significant issue for the sustainability of the program. The birth attendance in two divisions with highest and lowest
Government of Bangladesh along with other donors should take skilled delivery attendance in Bangladesh. BMC Pregnancy
steps to boost funding in order to further increase and maintain Childbirth. 2018;18(1):122-018-1770-9.
the impact, and the effectiveness of the program.
18. Beaglehole R, Dal Poz MR. Public health workforce:
References challenges and policy issues. Human resources for health.
2003;1(1):1.
1. World Health Organization. Global tuberculosis report
2015. 19. Dussault G, Franceschini MC. Not enough there, too
many here: understanding geographical imbalances in the
2. NTP B. Revised Strategic Plan for National Tuberculosis
distribution of the health workforce. Human Resources for
Control Program 2012-2016. 2013.
Health. 2006;4(1):1.

18 J Pulmonol Clin Res 2018 Volume 2 Issue 1

Citation: Ahmed FW. A critical analysis of Bangladesh national tuberculosis control program. J Pulmonol Clin Res. 2018;2(1):16-19.

20. United States Agency in Development. Global Health. 2017. involvement with mother's awareness and knowledge of
newborn danger signs in facility-based childbirth settings:
21. World Bank. Projects and Operations. Bangladesh - Health
a cross-sectional study from rural Bangladesh. BMC Res
Nutrition and Population Sector Program.
Notes. 2018;11(1):286-018-3386-6.
22. Al Kibria GM, Hossen S, Barsha RAA, et al. Factors
24. World Bank. Rural population (% of total population).
affecting contraceptive use among married women of
reproductive age in Bangladesh. J Mol Studies and Medicine 25. Sarkar M, Haider M. The Case for Microcredit: Does It
Res. 2016;2(01):70-79. Improve Maternal and Child Health and Wellbeing? Intern J
Public Health Sci. 2014;3(2):107-116.
23. Zaman SB, Gupta RD, Al Kibria GM, et al. Husband's

*Correspondence to:
Forid Warid Ahmed
Dhaka Medical College Hospital
Dhaka
Bangladesh
E-mail: [email protected]

J Pulmonol Clin Res 2018 Volume 2 Issue 1 19