The best solutions to the most serious health issues that remain in Bangladesh

Bjorn Lomborg | Sunday, 8 May 2016

Over recent decades Bangladesh has seen amazing improvement across many health indicators. Maternal mortality has decreased 75 per cent, infant mortality has halved, and life expectancy has surpassed that of both India and Pakistan. The progress has been so impressive that in 2013 The Lancet, one of the oldest and most prestigious medical journals in the world, devoted a six-part series to Bangladesh, calling it "a remarkable success story for health."
However The Lancet also noted that great challenges remain as Bangladesh strives to improve health even more. Bangladesh Priorities can offer solutions to these serious health issues, as well as the country's many other development challenges. The project, a partnership between the Copenhagen Consensus Center and BRAC, has commissioned dozens of top economists from Bangladesh and around the world to estimate the cost and benefit of the best solutions for the country. The goal is to discover how it can do the most good for every taka spent toward its development efforts.
Research by expert economists on a variety of health topics examines the most cost-effective solutions for Bangladesh, including for chronic diseases as well as tuberculosis, arsenic-contaminated drinking water, and child and maternal mortality. And for several of these strategies, the pre-existing network of 14,000 community clinics across the country makes investments very cost-effective.
For a long time, infectious diseases were the biggest killers of most people around the world. But as we find better treatments for infections and people live longer and more people now die from what doctors call chronic or non-communicable diseases (NCDs), which include things like heart disease, cancer, and diabetes.
The same pattern has emerged over recent decades in Bangladesh, as NCDs are now the biggest killer nationwide, responsible for 59 per cent of all deaths. Recent research focuses on several strategies to fight NCDs in Bangladesh, and the most cost-effective solutions aim to reduce hypertension and tobacco use.
It's extremely likely that you or someone you know suffers from hypertension, or abnormally high blood pressure-one in three women and one in five men over age 35 in Bangladesh have the disease. It's not only very prevalent, it's also a primary risk factor for more serious conditions like heart disease or stroke. Treatment is straightforward, however, and fairly cheap through community clinics. The cost to treat one person is about Tk 7,000 each year, to pay for screenings and medicines.
Seventy-five per cent of all patients treated would live three years longer on average. So because so many people suffer from high blood pressure, this solution would benefit a lot of people. Overall, each taka spent would provide 37 takas of benefits.
Tobacco is another big killer that is also related to heart disease - 70,000 Bangladeshis die from tobacco-related causes annually. While men commonly smoke or chew tobacco, and women mostly use smokeless products, an estimated 41.3 million people over age 15 use tobacco of some sort.
The analysis proposes a tax on all tobacco products, similar to cigarette taxes that have significantly reduced smoking in other countries. A strictly enforced tax that rises to 50 per cent of retail price by 2021 would reduce demand of tobacco products by 7.0 per cent, and the reduction in tobacco use would avert more than 5,000 deaths each year. Each of these people would live at least 10 years longer. In all, raising the tobacco tax would do 8.0 takas of good for every taka spent.
The analysis also studies cervical cancer, one of the most deadly cancers for women in Bangladesh. It causes about 10,000 deaths each year, and although we know how to help, it turns out to be rather costly. The experts find that investment to vaccinate, screen, and treat cervical cancer would provide less than half a taka in benefits for each taka spent.
As awful as this disease is, we have to take into account whether there are better strategies that can help more women and men survive, for instance, in tackling infectious diseases like tuberculosis (TB) that remain. And as we

see, the health improvements that can come through very low-cost TB treatment are quite large when compared to investing in more costly and less beneficial health options.
TB kills nine Bangladeshis every hour-80,000 people each year. Research shows how you can avoid almost all of these TB deaths via community health clinics. Each TB patient could be treated with standard drugs and follow-up at a cost of Tk 7,850. By treating one person for the disease, you also prevent that person from infecting others, which makes TB treatment an even better investment. In total, each taka spent will do 19 takas of good.
Some tuberculosis strains, however, do not respond to traditional medicines. These are called "multi-drug resistant" TB, and there are about 4,700 cases in Bangladesh each year. The World Health Organisation (WHO) is piloting a "Bangladesh regimen" trial in the country that shortens treatment time for these strains from 24 months to just nine months. But because multi-drug resistant TB is up to 45 times more expensive to treat, each taka spent will do just 3.0 takas of good. The cutting-edge treatment may hold promise for the future, but the evidence shows how the most-talked-about solutions are sometimes not necessarily the most effective ones. In the case of TB, it can be much more effective to target the much larger group of people who can be helped with standard treatments.
Arsenic is not quite as deadly as TB in Bangladesh-but it is close. Sixty-three thousand people die each year from arsenic-related causes. The problem is contaminated water sources-25 per cent of household water sources contain arsenic levels that exceed the WHO guideline, despite the fact that 98 per cent of Bangladeshis have access to either piped water or a well.
Research investigates three water supply technologies to limit arsenic exposure: deep tube wells, rainwater harvesting, and pond sand filters. These options would cost between Tk 1,250-1,850 each year for each affected household and could avert virtually all deaths related to arsenic, doing 7.0 takas of good for each taka spent. Focusing investment on the 20 per cent worst affected households, however, would be even more cost-effective-this would do up to 17 takas in benefits for each taka spent.
Investments in sanitation and hygiene programmes, on the other hand, turn out to be much less effective. Bangladesh has already had great progress in these areas, so the extra benefits will be fairly small, while the costs are rather large. In total, these investments would do just 1-2 takas of good per taka of spending.
One area where Bangladesh has greatly reduced deaths is in child and maternal health, but the progress has been uneven. The mortality rates for infants and young children in the poorest 20 per cent of the population are practically double those in the richest 20 per cent, according to World Bank data.
Our new research examines ways to save lives by making births safer. Moving more women into medical facilities for deliveries, which only half do now, would help.  The strategy is not practical for everyone, particularly in remote areas. But many pregnant women could be helped, at an estimated cost of Tk 6,000 per delivery. The experts estimate that total spending of Tk 8.94 billion (Tk 894 crore) could move 80 per cent of currently unattended births or 1.5 million deliveries, into medical facilities. This would avert more than 37,500 deaths in all. In all, each taka spent would do 8.0 takas of good.
Another option is for community health workers to visit mothers at home, both before and after births. This strategy is very cheap-just 850 takas over the course of a pregnancy. At the same time, it would do great good: homecare visits could help about 750,000 pregnant women and would save lives of more than 8,900 infants. A policy that costs so little but does great good is clearly advantageous: each taka spent would do an impressive 27 takas in benefits.
Finally, the experts have assessed child vaccinations. Eighty-five per cent of children ages 12-23 months in Bangladesh are fully immunised. But when it comes to children in remote rural areas, the rate is only 51 per cent, and in urban slums, it's even lower-just 43 per cent. It costs at most Tk 1,900 to vaccinate each child, and immunising children in these underserved areas could save more than 4,100 lives each year. Each taka spent would do 10 takas of good.
These studies suggest some of the smartest solutions for the health challenges that still plague the country. Would these health strategies be some of your top priorities for Bangladesh? Learn about more of the solutions to many other challenges at bangladesh-priorities.com.

Dr. Bjorn Lomborg is president of the Copenhagen Consensus Center, ranking the smartest solutions to the world's biggest problems by cost-benefit. He was named one of the world's 100 most influential people by Time Magazine.

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