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Abstract
Objective To estimate the costs of scaling up the HEARTS pilot project for hypertension management and risk-based cardiovascular disease (CVD) prevention at the full population level in the four subdistricts (upazilas) in Bangladesh.
Settings Two intervention scenarios in subdistrict health complexes: hypertension management only, and risk-based integrated hypertension, diabetes, and cholesterol management.
Design Data obtained during July–August 2020 from subdistrict health complexes on the cost of medications, diagnostic materials, staff salaries and other programme components.
Methods Programme costs were assessed using the HEARTS costing tool, an Excel-based instrument to collect, track and evaluate the incremental annual costs of implementing the HEARTS programme from the health system perspective.
Primary and secondary outcome measures Programme cost, provider time.
Results The total annual cost for the hypertension control programme was estimated at US$3.2 million, equivalent to US$2.8 per capita or US$8.9 per eligible patient. The largest cost share (US$1.35 million; 43%) was attributed to the cost of medications, followed by the cost of provider time to administer treatment (38%). The total annual cost of the risk-based integrated management programme was projected at US$14.4 million, entailing US$12.9 per capita or US$40.2 per eligible patient. The estimated annual costs per patient treated with medications for hypertension, diabetes and cholesterol were US$18, US$29 and US$37, respectively.
Conclusion Expanding the HEARTS hypertension management and CVD prevention programme to provide services to the entire eligible population in the catchment area may face constraints in physician capacity. A task-sharing model involving shifting of select tasks from doctors to nurses and local community health workers would be essential for the eventual scale-up of primary care services to prevent CVD in Bangladesh.
- program cost
- hearts hypertension management and cvd prevention program
- scale-up of primary care services
- bangladesh
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- program cost
- hearts hypertension management and cvd prevention program
- scale-up of primary care services
- bangladesh
Strengths and limitations of this study
This study uses the HEARTS costing tool to assess the expected cost of scaling up the programme to all eligible adults in the participating subdistricts (upazila).
The study assesses two programme scenarios: a hypertension management programme and an integrated risk-based hypertension, diabetes and cholesterol management programme.
The study disaggregates costs by function, identifying areas for efficiency improvements, such as task-sharing and bridging programme delivery from the upazila level to more localised community facilities.
Due to lack of data at a local level, the cost projections rely on assumptions regarding population coverage, risk factor prevalence, primary care attendance rate, distribution of cardiovascular disease (CVD) risk among the population, distribution of patients by treatment protocols and frequency of patient visits by CVD risk.
The study uses average medicine prices, unit costs of supplies, wages and provider time, which may vary across subdistricts depending on the procurement arrangements and operational efficiency.
Background
Hypertension is a major and preventable risk factor for cardiovascular disease (CVD). An estimated 1.13 billion people (1 in 4 men and 1 in 5 women) worldwide have hypertension.1 Among people with hypertension worldwide, fewer than one in five have it under control.1 High blood pressure (BP) is a leading global risk factor for premature death and disability, accounting for about 10 million (or 1 in 6) deaths worldwide each year.2 3 Uncontrolled hypertension significantly increases the risk of stroke, myocardial infarction, heart failure, dementia, renal failure, retinopathy and other diseases.4–7 Almost half of all CVD events are attributable to uncontrolled hypertension.2 3
Reducing the prevalence of hypertension is a standing global health objective.8–11 This objective complements the 2030 Sustainable Development Goal of reducing premature deaths from non-communicable diseases (NCDs) by 25%.12 Low-income and middle-income countries (LMICs), where two-thirds of all hypertension cases reside, are increasingly cognizant of the long-term benefits of addressing hypertension in their populations. However, implementing population-level measures targeting hypertension may present challenges for many LMICs where health systems have traditionally focused on infectious diseases and where the capacity for NCD care may be limited.
Bangladesh is among lower-middle-income countries with a high burden of hypertension. In 2018, the prevalence of elevated BP (SBP and/or DBP ≥ 140/90 mm Hg) among adults in Bangladesh was 21%.13–15 According to the 2011 Bangladesh National Demographic and Health Survey, of 14.4 million hypertensive people (adults aged 35 and above), only 7.3 million (51%) were aware of their condition, 41% were treated and 18% had their BP levels under control.16 The burden of hypertension in Bangladesh is expected to grow alongside increased population ageing, rapid urbanisation with commensurate increases in sedentary lifestyle and processed food consumption, and other socioeconomic and lifestyle changes. However, only less than 5% of the health sector programme budget is allocated for NCDs control.16 This demonstrates the need for an effective, low-cost and efficient population-level approach in addressing hypertension.
In 2016, WHO introduced the HEARTS technical package as a framework for CVD prevention at the primary care level.17 The HEARTS technical package consists of guidelines for implementing a primary care approach to CVD management, focusing on screening and management of CVD risk factors, including lifestyle modification and pharmacological treatment of metabolic risk factors such as hypertension, diabetes and hyperlipidaemia. In this paper, we describe the local budgetary impact of implementing the HEARTS programme at the population level for four subdistricts in Bangladesh, based on programme cost data obtained from a representative healthcare facility in each subdistrict. Although the initial focus of the programme in the four subdistricts is presently limited to hypertension control, scaling-up of the initiative may include screening, diagnosis and treatment of diabetes and high cholesterol. Understanding the cost drivers of CVD prevention approaches in the Bangladesh primary care system can support budgeting, procurement, evaluation and planning for scale-up.
Methods
Setting
In 2018, the Directorate General of Health Services and the National Heart Foundation of Bangladesh collaborated with Resolve to Save Lives (an initiative of Vital Strategies, a non-profit global public health organisation) to implement a pilot programme to strengthen the detection, treatment and follow-up management of hypertension in primary care. The programme was introduced in four health complexes in four subdistricts (upazilas) in the Sylhet district: Golapganj, Fenchuganj, Beanibazar and Bishwanath. In Bangladesh, hospitals and health facilities that are in the subdistrict (upazila) level or below are termed as primary health complexes. A typical upazila health complex is a 50-bed hospital with service coverage in the range of 100 000–400 000 population and plays a pivotal role in the provision of primary healthcare through a three-tier system consisting of the ward level, union level and upazila level. The upazila health complex performs a wide range of functions that includes prevention, promotion, treatment (inpatient, outpatient, limited diagnostic services), management, technical support, training, coordination and patient referral services. The outpatient service is usually staffed with five outpatient general practitioners including one resident medical officer, two medical officers and two medical assistants. An ‘NCD corner’ was set up in the outpatient with necessary logistics and personnel for screening and treatment. We project programme costs under two intervention scenarios: a hypertension-focused programme, and a risk-based integrated hypertension, diabetes and cholesterol management programme.
Patient and public involvement
Patients or the public were not involved in the design, conduct, reporting or dissemination plans of this research.
Hypertension management program
The HEARTS Technical Package for CVD prevention in primary care is organised around six modules: H–Healthy-lifestyle counselling, E—Evidence-based treatment protocols, A—Access to essential medicines and technology, R—Risk-based CVD management, T—Team-based Care and S—Systems for monitoring.18 Components of these modules are described in figure 1. In the four upazila primary care complexes in Bangladesh, programmed activities included: training of staff in following a standard treatment protocol, record keeping and reporting; ensuring adequate supply of necessary drugs; community outreach to increase awareness of the need for hypertension screening; introduction of patient monitoring tools and a monthly reporting system; and establishing a mechanism for patient referral from primary care to secondary care and tertiary care at MAG Osmani Medical College. The clinical management protocol for adults with hypertension (defined as systolic blood pressure (SBP)/diastolic blood pressure (DBP)≥140/90 mm Hg, or SBP/DBP≥130/80 mm Hg with comorbidity or high CVD-risk) entailed a first line of treatment with amlodipine 5 mg daily; a second line of treatment using amlodipine 5 mg plus losartan 50 mg daily; and a third line of treatment using amlodipine 5 mg plus losartan 50 mg plus hydrochlorothiazide 12.5 mg daily. Online supplemental appendix 1 depicts the hypertension treatment protocol. The prescribed medicines are typically obtained by public health facilities, generic, domestically manufactured and provided free of charge to patients. The national drug policy recommends that 70% of the public sector medicines be purchased from the state-owned Essential Drug Company Limited (EDCL), 25% from the Central Medical Stores Depot (CMSD) and 5% from local sources.19 20 In order to provide continuous care more sustainably and to reduce burden on physicians, a team-based care strategy was implemented. The healthcare providers were trained to acquire the necessary skills to provide brief interventions to record patients’ medical history, measuring BP, point-of-care testing to assess fasting blood glucose and cholesterol levels and urine dipstick for proteinuria, encourage behaviour change, assess CVD risk or initiate treatment protocol. The training sessions were conducted in one setup with a pool of selected doctors, nurses and community health workers (CHWs) trained with relevant modules. In this approach, CHWs were trained to provide counselling and some screening services along with the doctors and nurses. For the costing estimate, equal burden sharing in terms of provider time was assumed.
Supplemental material
Cost components of the HEARTS programme in Bangladesh.
Risk-based integrated hypertension, diabetes and hyperlipidaemia management programme
To further strengthen CVD prevention, the HEARTS programme in Bangladesh also planned to integrate diabetes and hyperlipidaemia management in addition to hypertension management in primary care patients. The programme entails assessment of target population by total CVD risk estimation to categorise their risk for CVD. The risk stratification is based on WHO and International Society of Hypertension cardiovascular risk prediction charts and expressed as the probability of developing CVD over 10 years: low CVD risk (0 to <10%); medium CVD risk (10% to 20%) and high CVD risk (≥20%).21 The treatment protocol for patients with uncomplicated type two diabetes (defined as fasting plasma glucose ≥ 7.0 mmol/L or routine plasma glucose ≥ 11.1 mmol/L or HbA1C ≥ 6.5%) managed at the primary care level included metformin (500 mg), metformin (1000 mg), then metformin (1000 mg) and gliclazide (80 mg) as the first, second and third lines of treatments, respectively. The protocol is based on the WHO guidance on diagnosis, classification and management of diabetes (HEARTS - D), which is aligned with the WHO Package of Essential Noncommunicable Disease Interventions in Primary Healthcare.22 For managing plasma lipid levels (ie, high cholesterol), the use of statins as the primary therapy is widely recommended, however, the WHO is yet to offer any specific guidance.23 For costing, the local consultants and experts proposed a statin-based treatment protocol for hyperlipidaemia including simvastatin (10 mg) as first, atorvastatin (20 mg) as second and atorvastatin (40 mg) as the third line of treatment. Costs associated with implementing integrated hypertension, diabetes and hyperlipidaemia treatment protocols include provider time spent on estimating CVD risk using risk charts during an annual primary care visit; training in CVD risk estimation, in addition to time spent collecting patient history; medication costs and diagnostic test costs including provider (technician) time, complete blood count panel, fasting blood glucose and blood lipid panel tests.
HEARTS costing tool
Programme costs were assessed using the HEARTS costing tool, an Excel-based instrument to collect, track and evaluate the incremental annual cost of implementing the HEARTS programme from the health system perspective. The tool is organised by HEARTS modules.24 In July–August 2020, we obtained unit costs from four upazila complexes and used these to project annual resource needs for implementing the CVD prevention programme at the subdistrict population level. The researchers completed in-person collection of data from the four facilities on human resource and time costs, diagnostic prices, time-motion on laboratory diagnostics, market price of medicines and others.
Figure 1 shows major cost categories within HEARTS modules. Once programme costs and other inputs such as population coverage, risk factor prevalence and planned provider numbers were entered into the costing tool, the cost calculations were allocated across different HEARTS modules.
The cost elements in the Healthy-lifestyle counselling module ‘H’ included costs of training providers in lifestyle counselling and costs of community awareness programmes and training. Counselling is based on the Assess, Advise, Agree, Assist, Arrange model, which is an evidence-based approach for promoting healthy behavioural changes to prevent NCD risk factors.25 26 Total provider time to administer brief counselling was equal to the average time that the health provider spends to counsel a patient to change behaviour multiplied by the total number of patients who would receive counselling. The cost of total provider time was calculated as the total provider time, multiplied by the weighted average salary of the health providers who have been trained to provide counselling.
The cost elements in module ‘E’ included provider time devoted to assessing patient history, conducting physical exams and diagnostic tests, and return visits. The costs of diagnostic tests (complete blood count panel, blood lipid panel, fasting blood glucose), medications (hypertension, diabetes and cholesterol) and on-site diagnostic technologies and supplies were assessed under module ‘A’. Module ‘R’ reports the costs of training providers in conducting risk-based management and the cost of provider time for estimating patient CVD risk using risk charts. Module ‘T’ reports cost savings from task-sharing by comparing the cost that could have been incurred if the tasks were performed solely by the physicians with costs incurred through task-sharing among physicians, nurses and CHW. Therefore, in the baseline scenario (ie, in the absence of task-sharing allocation), the costing tool assumes a physician-led programme. In our cost projections, we assumed that doctors, nurses and CHWs will equally share the tasks (ie, provider time) when applicable. For instance, CHWs would only provide behavioural counselling and screening service, but they would not assess CVD risk (using risk-cart), or prescribe patients with pharmacologic treatments. Accordingly, the provider time allocated for behaviour counselling and screening will be shared equally among doctors, nurses and CHWs. Nurses will be trained to do major tasks (ie, counselling, screening and assessing CVD risk, and treating according to CVD risk), therefore, providers’ time for performing hypertension/CVD risk-assessment, prescribing suitable treatment and return-visits were allocated equally between doctors and nurses. While the ‘T’ module reports the cost savings from team-based care, the accrued cost of provider time (inclusive of doctors, nurses and CHWs) spent on various tasks is included in the corresponding ‘H’, ‘E’ and ‘R’ modules. Module ‘S’ reports costs related to human resources, technology (software and hardware), supplies and training for patient monitoring.
Data
Data on salaries of government healthcare providers and programme staff were collected from in-person interviews and/or records. Total salary was calculated according to the Government of Bangladesh National pay scale. Size of the population in the examined subdistricts was obtained from census and imputed based on Bangladesh Bureau of Statistics estimates. Other population parameters (eg, primary care attendance rate and risk factor prevalence) were obtained from the nationally representative NCD Risk Factor Survey 2018.15 Medicine prices were collected from the medicine outlets in the public hospitals. The unit prices represent the average price of domestically manufactured generic medicines procured by health facilities from EDCL or CMSD. Prices of laboratory diagnostics were collected from diagnostic labs at the district (Sylhet district) and subdistrict (upazila) levels. Data on time needed to conduct laboratory tests were collected from in-person interviews of laboratory personnel. Training data, including number of training and participants, per-diem costs of staff, costs related to rent, transport, refreshments and other logistics, were collected from the respective project records.
Table 1 presents the prevalence of CVD risk factors as well as cost inputs used to populate the HEARTS costing tool. Fifteen per cent of the adult population was estimated to be at medium and high risk for CVD. The leading risk factors were tobacco use (43.7%), hyperlipidaemia (28.4%) and hypertension (21%), followed by physical inactivity (12.3%), diabetes (8.3%) and alcohol consumption (4.4%); The primary care attendance rate was assumed to be 47.9% in each upazila.15 The distributions of patients by CVD risks and for the pharmacological treatment of hypertension, diabetes and cholesterol by different treatment lines were adopted from the literature and/or based on local physician consensus.27–30 Local currency was converted to US dollars using the Bangladesh Bank official conversion rate in June 2020.
Costing inputs and unit costs
Results
Population coverage
The total population in the four subdistricts was 1.12 million, of which 749 000 were adults aged 18 and above (table 2). The total number of people eligible to receive counselling, screening, diagnosis and treatment under the two types of HEARTS intervention packages (ie, hypertension control and risk-based integrated approach) in the four subdistricts was determined by the primary care attendance rate, the prevalence of low-CVD, medium-CVD and high-CVD risk in the population, the prevalence of hypertension, diabetes and high cholesterol. The estimated number of eligible persons in the catchment area of the four subdistricts was 359 000, of which 305 000, 52 000 and 1800 were projected to be low-CVD, medium-CVD and high-CVD risk patients. The estimated number of persons undergoing treatment for hypertension, diabetes and high cholesterol was 75 000, 30 000 and 102 000, respectively (table 2). Unit costs and other cost inputs were applied to these population parameters to project total programme costs.
Population coverage: care cascade for counselling, screening, diagnosis and treatment
Hypertension management programme cost
Table 3 reports the estimated annual costs, in 2020 USD and Bangladesh Taka (BDT), of implementing the HEARTS hypertension management programme in four upazilas at the population level (adults aged 18 and above). Figure 2 presents the distribution of costs by HEARTS components and subcomponents. The total annual cost was estimated at US$3.2 million, equivalent to US$2.8 per capita, US$4.3 per adult and US$8.9 per eligible participant. Module ‘A’ (Access to medicines and technology) constitutes the largest cost share (US$1.36 million; 43%), followed by module ‘E’ (Evidence-based treatment protocols; US$1.22 million; 38%). The projected medication expenditure per patient treated with medications for hypertension was US$18.
Total annual cost of HEARTS hypertension control programme in four subdistricts
Distribution of annual cost by HEARTS components.
Most of the projected annual cost (95%) of implementing module ‘H’ (Healthy-lifestyles counselling) was attributable to the cost of provider time and information materials for counselling patients (US$433 000). The estimated cost for module ‘E’ (Evidence-based treatment protocols) was attributable to provider time across three major activities: asking patient history (US$180 000; 15%), patient assessment via physical exam and diagnostic tests (US$180 000; 15%), and conducting return visits (US$856 000, 70%). The projected cost to implement module ‘S’ (Systems for monitoring) was US$147 000, primarily attributed to administration staff labour costs (95%), with the remaining cost allocated to technology (software/hardware).
Table 4 highlights an important programmatic aspect by describing health providers’ time needed to implement the hypertension control programme. Implementing the programme at the full population level in all four subdistricts was estimated to require the full-time equivalent of 51 doctors, 51 nurses and 6 CHWs. The largest time requirement activities included providing initial screening and diagnosis and conducting return visits.
Hypertension control programme: estimated health provider time for counselling, screening, diagnosis and treatment
Risk-based integrated hypertension, diabetes and high cholesterol management programme cost
Table 5 reports the estimated costs of implementing the risk-based hypertension, diabetes and high cholesterol management programme in four upazilas at the population level (adults aged 18 and above). Figure 2 presents the distribution of costs by HEARTS components. The total annual cost was estimated at US$14.4 million, equivalent to US$12.9 per capita, US$19.3 per adult and US$40.2 per eligible participant. Module ‘A’ (Access to medicines and technology) constitutes the largest cost share (US$11.7 million; 81%), followed by module ‘E’ (Evidence-based treatment protocols, US$1.9 million; 13%). Within module ‘A’, the projected costs of diagnostic tests, hypertension medications, diabetes medications and cholesterol medications were US$5.7 million (49% of module costs), US$1.4 million (12%), US$0.9 million (7%) and US$3.8 million (32%), respectively. The projected medication expenditure per patient treated with medications for hypertension, diabetes and cholesterol was US$18, US$29 and US$37, respectively.
Annual cost of implementing risk-based hypertension, diabetes and high cholesterol management programme in four subdistricts
The adoption of task-sharing approach would save US$865 000, of which US$803 000 comes from using nurses to complete tasks customarily performed by doctors (ie, counselling, screening and assessing CVD risk, and treating according to CVD risk) and US$62 000 comes from using CHWs to provide counselling to change behaviour. Implementing the risk-based hypertension, diabetes and high cholesterol management programme at the full population level in all four subdistricts was estimated to require the full-time equivalent of 58 doctors, 58 nurses, 6 CHWs and 101 lab technicians (table 6). The largest time requirement activities included providing initial screening and diagnosis and conducting return visits.
Integrated risk-based approach: estimated health provider time for counselling, screening, diagnosis and treatment
Discussion
The HEARTS pilot project in four Bangladesh subdistricts launched a framework for hypertension management in primary care, with a potential for expanding into a comprehensive CVD prevention approach that incorporates hypertension, diabetes and cholesterol management. This study projects the expected cost of scaling up the programme to all eligible adults in the participating subdistricts. We assessed two programme scenarios: a hypertension management programme and an integrated risk-based hypertension, diabetes and cholesterol management programme. The total annual cost was estimated at US$3.2 and US$14.4 million for the hypertension and risk-based comprehensive approach, respectively. The overall per capita cost was approximately US$2.8 per capita for the hypertension control programme and US$12.9 per capita for the risk-based comprehensive approach. These estimates correspond to 0.14% and 0.7% of the 2020 gross domestic product per capita in Bangladesh, respectively. The main cost drivers for the hypertension control programme were medication expenditures (43%) and the cost of provider time for providing care during multiple visits (38%). In the risk-based integrated approach, the combined costs of hypertension, diabetes and cholesterol medications and diagnostic tests make up the largest share of the overall programme cost (81%). Although the main driver of projected programme costs for the integrated approach was expenditure on essential medicines and diagnostic tests, hypertension and diabetes medications contributed a relatively small portion (19%) to this expenditure (ie, module A), whereas cholesterol medications contributed nearly 32%. Hypertension treatment remains among the leading cost-effective ways to combat heart disease. In this study, the annual medication expenditure per patient treated with medications for hypertension, diabetes and cholesterol was US$18, US$29 and US$37, respectively.
Though based on observations gathered in one district of Bangladesh, our results are consistent with those reported by past studies. A previous study on Bangladesh by Nugent et al31 estimated that hypertension treatment would cost about US$13 (BDT1070) per patient per year.31 WHO (2011) has estimated the average hypertension screening cost for LMICs at approximately US$4 for LMICs, not including treatment but including the cost of performing CVD risk assessment and BP measurement in primary care settings.32 Haque33 estimated the average cost of diabetes screening in Bangladesh at approximately US$5 (BDT411), including glucose screening in primary care, documentation, setting up referrals and organising screening events but excluding treatment.33 In this study, the cost elements in the Bangladesh HEARTS programme are wide-ranging including screening, diagnosis and treatment for multiple CVD risk conditions (hypertension, diabetes, hyperlipidaemia) and counselling for CVD risk factors (tobacco use, alcohol use and physical inactivity).
The analysis revealed that scaling up the hypertension management programme within the four subdistricts would require an additional full-time equivalent of 51 doctors, 51 nurses and 6 CHWs. Population-level scale-up of the risk-based hypertension, diabetes and high cholesterol management programme in the four subdistricts was estimated to require the full-time equivalent of 58 doctors, 58 nurses, 6 CHWs and 101 lab technicians. To put this in context, a typical 50-bed subdistrict public health complex in Bangladesh employs 20 doctors, 16 nurses and 1 medical assistant. Oftentimes, not all health provider posts are filled. This gap in provider capacity poses a significant barrier to programme expansion. Team-based care using task-sharing among doctors, nurses and CHWs and volunteers can accomplish the activities required by the HEARTS package more affordably, including NCD-related health promotion, prevention, screening and patient navigation through the health system. A systematic review of intervention trials in LMICs by Joshi et al34 found that team-based care, including task sharing was effective in improving process outcomes (eg, hypertension and diabetes screening) and health outcomes (eg, hypertension and diabetes control) and achieving treatment concordance with doctors.16 34 Krishnan et al35 conducted a study on a community-based hypertension management programme of BP monitoring and lifestyle counselling intervention undertaken by female community health volunteers in Nepal, and assessed the intervention to be highly cost-effective.35 However, there are several barriers to team-based care with task sharing, including staff attrition and turnover, retention of training, patient perception and acceptance toward non-physician health workers, lack of delegation of work by physicians, legislation and policy etc.36
In Bangladesh, of the four entities (ie, the government, for-profit private sector, non-profit nongovernmental organisation and donor agencies) involved in the primary healthcare provision, the government plays the leading role, mainly in rural areas. There are six tiers of public healthcare infrastructure: national, divisional, district, upazila (subdistrict), union and ward levels. To tackle NCDs, the government of Bangladesh introduced ‘NCD Corners’ initiative in 2012 dedicated to providing prevention and care services for common NCDs and related conditions. The government has plans to expand ‘NCD corners’ at the upazila level, and the upazila primary care setting is well positioned to bridge the link the healthcare providers down to the union, ward (and community) levels by harnessing community support and delegating suitable activities under task-sharing principles.16 37 38 This will enhance healthcare access among disadvantaged populations and mitigate health disparities. Further, in Bangladesh, according to the 2016 Household Income Expenditure Survey and 2014 Health and Morbidity Status Survey, one in three patients received treatment from a pharmacy or medical shop, while about one in five received treatment from public health providers.39 40 This emphasises the need for partnerships with various types of public–private health providers.
The models of care introduced in the Bangladesh national hypertension guidelines and NCD operational plan are encouraging; however, there are capacity challenges to the scaling-up of NCD care in Bangladesh.41 42 The fiscal year 2021 budget allocation to the health sector stands just above 5%, which is less than 1% of GDP. Further, less than 5% of public sector funding for health covers NCDs, despite NCDs being responsible for almost two-thirds (63% in 2016) of disability-adjusted life-years in Bangladesh.16 The per capita NCD allocation is only US$0.08.16 There is a need for better coordination of non-state stakeholders in NCD control with the public sector with a stronger focus of the public sector on NCD prevention and health promotion.16 The health sector in Bangladesh is financed 93% from domestic sources (74% out-of-pocket, 17% government health expenditure and 3% other private sources) and 7% from external health expenditures. Domestic general government health expenditure per capita is only US$7 (0.4% of GDP per capita).43 Due to insufficient public sector funding, out-of-pocket expenditure for NCD care is large in Bangladesh, contributing to the impoverishment of patients and their families. Moreover, a recent policy review by Biswas et al44 highlights the lack of proper planning, implementation and monitoring of NCD health initiatives.44 However, the Bangladesh Copenhagen Project assessed the benefits of managing hypertension through targeted investment and reported a high level of return on investment (BDT17 benefit for every BDT spent).31
This report has several limitations. Due to lack of data at a local level, the cost projections rely on assumptions regarding population coverage, risk factor prevalence, primary care attendance rate, distribution of CVD risk among the population, distribution of patients by treatment protocols, and frequency of patient visits by CVD risk, which were assumed to be uniform for the four subdistricts and across age or sex groups. Similarly, unit costs of supplies, wages and provider time allocations were assumed to be the same across subdistricts. Since the examined subdistricts are adjacent to each other, these unit costs may not be considerably different. While we used average medicine prices, they may vary in different subdistricts depending on the procurement arrangement and sources. However, in Bangladesh, the price variations are minimal or low in the public health facilities, given the medicines are procured mainly from EDCL and/or CMSD.19 20 The strength of the study lies in its ability to disaggregate costs by function, identifying areas for efficiency improvements, such as task-sharing and bridging programme delivery from the upazila level to more localised community facilities.
In 2018, the Government of Bangladesh introduced a multisectoral action plan for NCD prevention and control, which emphasises NCD risk factors including tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol.42 This study can inform approaches to scaling up this action plan nationally, with the goal of increasing population outreach for CVD prevention at the primary care level. Using the costs reported in this study for future cost-effectiveness analyses can further support evidence-based decision making for CVD prevention programmes in Bangladesh.
Conclusion
Expanding the HEARTS hypertension management and CVD prevention programme to provide services to the entire eligible population in the catchment area may face constraints in physician capacity. A task-sharing model involving shifting of select tasks from doctors to nurses and local CHWs would be essential for the eventual scale-up of primary care services to prevent CVD in Bangladesh.
Data availability statement
All data relevant to the study are included in the article or uploaded as online supplemental information.
Ethics statements
Patient consent for publication
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Contributors MJH and MSH conceptualised the study, led the formal analysis, implemented the methodology and the excel-based costing tool, and wrote the draft manuscript. DK, SRC, MRB and AEM contributed to the study concept, analytical aspects, manuscript write-up and critical review. RT and SJ contributed to data collection and critical review of the manuscript. MJH, MSH, SRC, RT, SJ and MRB contributed to data collection. MJH and MSH are responsible for the overall content as guarantor. All authors provided critical feedback and helped shape the research, analysis and manuscript.
Funding This analysis was conducted on behalf of Resolve to Save Lives, an initiative of Vital Strategies. Resolve to Save Lives is funded by grants from Bloomberg Philanthropies; the Bill & Melinda Gates Foundation; and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation.
Disclaimer The findings and conclusions of this report are those of authors only and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.