Control Diabetes, Don’t Let Diabetes Control You!

My mother wakes up at 5am every morning, says her prayers, and heads off to the kitchen to make breakfast for the family. Now, don’t misconstrue this to think that we don’t have household help, but like most mothers in Bangladesh, my mother would rather do the cooking herself. After breakfast, she leaves the house by 8am to go to work at her own school where she is the Principal. She returns by 3pm, spends time with her grandchildren, and by 7pm is back in the kitchen to make dinner. Her day finally ends at 12am, when she eventually goes to bed.

For someone in her 60s, my mother has incredible energy, not to mention that she has been diabetic for the last two decades. However, she wasn’t always quite as fit. Before she was diagnosed with diabetes, she used to be fatigued all the time and would frequently be hungry or thirsty. Once she began to follow the doctor’s instructions on managing her diabetes – including modifying her diet and exercising – she started to feel better and is now in control of her condition.

Diabetes is a chronic disease in which the body cannot produce insulin or cannot properly use the insulin that it produces. Insulin is a hormone that controls the amount of glucose in the body. As a doctor, I understand diabetes better than most people and, with the firsthand experience I gathered of how to tackle this disease, I realized how crucial it is to be aware of this disease that may lead to death if poorly managed.

Given the state of healthcare in Bangladesh, where there is a palpable void in terms of providing trusted and quality healthcare, I have contemplated for a long time how I could make a difference. When I first heard about Praava Health and met with the CEO Ms. Sylvana Sinha, I instantly knew that this is the kind of healthcare company that I had always imagined to be working for, a healthcare company that cares about people, provides empathy, and most importantly, provides accurate diagnosis and test results. Praava Health will assist people to understand their conditions and be better equipped to deal with their diseases.

I take diabetes so personally and spend a considerable amount of time researching and learning about it because I believe such a widespread disease that affects so many people needs to be taken care of – and Praava will help to do that.

Globally, diabetes is a leading cause of blindness, kidney failure, heart attacks, and stroke. According to the World Health Organization (WHO), in 2014, the prevalence of diabetes in adults over the age of 18 rose to 8.4%. There were a reported 7.1 million cases of diabetes in Bangladesh alone in 2015 and that number is 1.71% of the total number of people with diabetes in the world. A nationwide survey done in 2014 found that 9.7% of adults in Bangladesh were suffering from diabetes – nearly doubling from 5% in 2001. Even more surprisingly, an additional 22.4% of Bangladeshi adults was pre-diabetic.

Despite the increasing prevalence of diabetes, the International Diabetes Federation reported recently that over 52.1% of people with diabetes in south Asia were unaware of their condition.  A recent study in Bangladesh actually found that 56% of diabetics did not even know they had the disease and only 40% were regularly receiving treatment. 

It is imperative for Bangladeshis to educate themselves on prevention and management of diabetes. Properly managed, many diabetics live long, healthy, fulfilling lives.

Prediabetes

Ask your doctor if you should take a blood glucose screening test if you have any of the below risk factors for prediabetes:

  • You are overweight, with a body mass index above 25
  • You are inactive
  • You are over the age of 45
  • You have a family history of type 2 diabetes
  • You developed gestational diabetes while pregnant or gave birth to a baby that weighed more than 4 kilograms
  • You have polycystic ovary syndrome
  • You have high blood pressure
  • Your high-density lipoprotein (HDL) cholesterol is below 0.9 millimoles per liter, or your triglyceride level is above 2.83 millimoles per liter

There are three types of diabetes: Type 1, Type 2, and Gestational. I will broadly explain what the types are, including the symptoms, causes, risk factors, and treatment for each.

Type 1 Diabetes

This is also known as juvenile diabetes and mostly develops at a young age. Older people may also develop it, but the chances of that are low. In this type of diabetes, the immune system destroys cells in the pancreas called beta cells that produce insulin, so, the body is no longer able to make insulin.

Causes:

The reason this type of diabetes develops is still unclear, but scientists have found that type 1 diabetes can develop in people who have a particular HLA complex, human leukocyte antigen, which triggers an immune response in the body.

Symptoms:

  • Thirst
  • Hunger (especially after eating)
  • Fatigue
  • Rapid breathing
  • Belly pain
  • Frequent skin and urine infection
  • Frequent urination

Risk Factors:

  • Family History
  • Genetics
  • Age

Treatment:

  • Insulin
  • Carbohydrate counting
  • Blood sugar monitoring
  • Eating healthy food and managing sugar intake
  • Exercising regularly and keeping weight in check

Type 2 Diabetes

This is the most common form of diabetes. Someone could suffer from Type 2 diabetes for years without even knowing that. In this type of diabetes, the body creates insulin but the cells do not know how to use it properly, which doctors call “insulin resistance.”

Causes:

The exact reason this type of diabetes develops is also unknown but factors such as genetics, environment, excess weight, and inactivity play a key role.  

Symptoms:

  • Increased hunger (Polyphagia)
  • Increased thirst (Polydipsia)
  • Frequent urination (Polyuria)
  • Weight loss
  • Fatigue
  • Areas of darkened skin
  • Frequent infections
  • Blurred vision

Risk Factors:

  • Age
  • Prediabetes
  • Weight
  • Family history
  • Fat distribution
  • Physical inactivity

Treatment:

  • Healthy eating
  • Physical activity
  • Monitoring blood sugar regularly
  • Diabetes medication and insulin

Gestational Diabetes

Gestational diabetes develops in about 4–5% women during pregnancy. Steps must be taken to control gestational diabetes during pregnancy, otherwise it can lead to the development of type 2 diabetes.

Causes:

During pregnancy, the placenta that make hormones in the body can lead to a buildup of blood sugar. Generally, enough insulin can be produced by the body to handle this but if not, then gestational diabetes develops.

Symptoms:

Typically, there are no noticeable symptoms for this kind of diabetes, but doctors recommend screening tests between weeks 24 and 28 of pregnancy.

Risk factors:

  • Overweight before pregnancy
  • Higher blood sugar level
  • Family history of diabetes
  • Previous history of gestational diabetes

Treatment:

  • Regular monitoring of blood sugar level
  • Regular urine test for ketones
  • Healthy diet
  • Exercise

As terrifying as the thought of living with diabetes might be, especially since even in 2016 there is no cure, it is not all bad news. An individual with diabetes can lead a completely normal life if they alter their lifestyle somewhat and take proper medication.

And as I always say to anyone with diabetes – “Control diabetes, don’t let diabetes control you!”

By Dr. Faisal Rahman, MBBS, PGT, MPH, FCGP, FRSH

Healthcare in Bangladesh: We Can Be The Change We Want

A few years ago, an acquaintance fell very ill and was admitted to a hospital in Dhaka. The patient’s health condition was so unstable that doctors had to perform surgery right away. Specialist doctors performed the surgery, after which the patient was moved to the ICU. However, his condition began to worsen rapidly. Family members decided to move the patient to a more reputed and upscale hospital hoping for better treatment After an investigation, it was found that the breathing tube that went inside the patient’s throat in the first hospital, had deadly germs in it which led to post-operative infections, and hence the suffering of both the patient and the family.. After a few months, he finally recovered, but the family had spent all of its savings.

We all have stories of such incidents where a family member or a friend has suffered, at great personal or financial expense, due to our irresponsible health system. As responsible citizens, there are many things for us to do.

In my 21 years of professional experience in healthcare organizations, I have seen firsthand just how helpless this country’s patients are. I believe it is high time we start taking effective steps within our capacity by raising awareness and directly working towards improving our health care services. We all should think of patients as our own family members – only then can we bring about a real change.

Those directly involved with healthcare services, such as doctors, nurses, and technicians, should be more accountable and connect to the vulnerability of their patients. They should also remain updated with the latest developments and innovations in medical care.  

Today, patients still prefer to travel to India, Thailand, Singapore, and beyond for medical care. This needs to change. Fortunately, there are people who are taking innovative steps to effectively change the poor condition of our healthcare system and have the potential to successfully take it a step ahead in the right direction.

The team at Praava Health is working hard every day to build an organization where patients will be treated with proper care and empathy. The aim is for our countrymen to regain confidence in our healthcare system and not face the atrocious outcomes many have fallen victim to in the past. We are dedicated to achieving and maintaining international standards of healthcare services in Bangladesh and to providing the kind of treatment everyone rightfully deserves.

I used to dream of working with an organization where I could contribute to the betterment of the society – and not just earn a living. Praava Health provided me that opportunity, and I am proud to be a part of it. I wake up every morning knowing that I am doing my part to serve the people of my country in my own small way.

The Dire Need and Means of Achieving Accurate and Reliable Test Results in Bangladesh

Since our independence over 4 decades ago, Bangladesh has rapidly emerged as a middle-income country and consequently the purchasing power of consumers has increased. It’s time now to ensure the basic human rights of people – and one of them is healthcare. Pathology test results play a vital role in healthcare. There are numerous diagnostic centers that have been established in the country which use the latest lab equipment and doctors depend on these results to treat patients.

A few years ago, a close relative of mine fell severely ill. After consultation with several doctors, he had his blood work and other pathology tests done at a reputed facility. Although the results could not reach any proper conclusion, his health deteriorated further. After a week, he got the same tests done at another facility, and this time the results were different – he was diagnosed with stage 1 cancer. He eventually went on to get proper treatment and is now a cancer survivor. But not all such stories in the healthcare system in Bangladesh lead to a happy ending like my relative’s. There is an overwhelming quantity of misdiagnoses in the country, a majority of which lead to horrific endings. 

Given this predicament, the biggest questions facing us are – with such sophisticated lab equipment, why are test results still not dependable? Why are there discrepancies in the results of the same lab tests at different diagnostic centers? The one palpable answer is that there is a huge lack of standard quality lab practice in these facilities, and hence they are not being able to ensure reliable reports.      

I have been working in medical diagnostic laboratories for the last 17 years, including establishments such as icddr,b and Thyrocare. I am lucky to have been able to work in accredited labs which helped me to gather in depth knowledge and experience. I met Ms. Sylvana Sinha, the Founder and CEO of Praava Health, about 15 months ago and learned about the new standard of healthcare that she was striving to bring to Bangladesh. She mentioned to me that Praava’s lab would be internationally accredited and that further intrigued me. What I was most taken by was her commitment to provide quality and accurate test results to ensure patients do not have to suffer through emotional turmoil. Eventually in May 2016, I embarked on a new journey with Praava Health, serving as the Lab Director. It is my aim to establish an exemplary lab in Praava Health that will bring about a change in people’s mindset regarding lab results in Bangladesh. The only way to do that is to ensure proper quality.

Quality assurance is a broad spectrum of plans, policies and procedures that together provide an administrative structure for a laboratory′s effort to achieve quality goals. The term quality control (QC) is often used to represent those techniques and procedures that monitor performance characteristics.

A quality assurance program involves virtually everything and everybody in the clinical laboratory. An error in any step during the acquisition, processing, analysis and the reporting of a laboratory test result can invalidate the quality of the analysis and cause the laboratory to fall short of its quality goals. There are several essential elements of a quality assurance program which include the following:

Dedication: Dedication to lab quality service is an absolute must. Quality needs to be a major consideration in all management decisions because a single decision could jeopardize other plans and practices for attaining quality goals.

Facilities and resources:  Laboratories must have adequate space, equipment, materials, supplies, staff and supervisory personnel and budgetary resources. These are the basic skeleton upon which quality services can be developed and maintained.

Technical competence: High competence of personnel is essential to obtain high quality services. The educational background and experience of all personnel are important, as is the capability for providing in service training to develop and maintain skills and knowledge.

Quality assurance procedure: Control of preanalytical variables such as test request, patient preparation, identification, specimen acquisition and transport, specimen processing and distribution, preparation of work lists and logs, and maintenance of records need to be ensured, while analytical variables such as analytical methodology, standardization and calibration procedures, documentation of analytical protocols and procedures, and the monitoring of critical equipment and materials, must also be maintained. Monitoring with the use of statistical methods and control charts plays a very important role as well.

So how is Praava going to incorporate quality assurance? Praava’s core vision is to provide commitment to the patients that their lab test results will be accurate and reliable. This can be achieved through internal and external quality assessment schemes and by following international accreditation lab protocols.  We are also recruiting lab personnel with extensive experience and sound technical knowledge in their line of work. They will go through local and international training to further hone their skills. Competent workforce, coupled with a state-of-the-art accredited lab, will help us achieve the highest quality test results.

For the overall development of improving the healthcare sector certain steps need to be taken – government initiative to strictly regulate quality and proper planning and awareness of the professionals. Praava aims to be the trusted brand in healthcare in Bangladesh and we take steps toward achieving that every day. It is my belief that Praava Health will be able to bring about that change for the people of our country, and I am thrilled to be a part of this journey!

Global Healthcare Technology: Trending Now

I’ve always wanted to be part of something revolutionary that has the potential to change people’s lives in a meaningful way. Born in Dhaka, and having spent most of my life outside Bangladesh – mainly Nigeria, UK, and USA – I’ve incessantly found myself drawn to Bangladesh and its people. After years of working in the technology industry and in one of the top fortune 500 companies in the US, when I moved back to Bangladesh a couple years ago, I felt the two major development areas where technology could be used to bring significant difference in people’s lives are health and education. Over the last few years, myriad perturbing stories from friends and family regarding their experience with the healthcare industry in Bangladesh prompted me to be involved in the health care sector. What brought me to Praava was this impulse to revamp the healthcare service in Bangladesh through technology, in terms of both quality and service.

2016 is already shaping up to be one of the biggest years for healthcare technology ever, with innovations in medical devices, software, and changes in how healthcare is administered. 

Here are some of the most promising healthcare technologies of 2016 and beyond:

The Tricorder – Star Trek Style

Millions of people are inspired by Star Trek, especially when it comes to the thought of achieving the impossible. Futuristic medical devices are no exception.

tricorder, in the make-believe Star Trek universe, is a versatile hand-held gadget used for sensor scanning, data analysis, and recording. The medical tricorder is a wireless mobile device that monitors and diagnoses the user’s health condition and is held in the palm of a user’s hand. It can be used by doctors to help diagnose diseases and collect bodily information about a patient. The end result is radical innovation in healthcare that will give individuals far greater choices in when, where, and how they receive care.

Qualcomm has a contest called XPrize that was just extended till 2017 for 7 final teams attempting to develop the almighty Tricorder.

Interoperability between Health Systems

An interoperability solution for exchanging patient information across care settings is one specific technological development that will frame the future of healthcare organizations.

By including post-acute care in interoperability strategies, such as long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs) and home health agencies, healthcare organizations can ensure that critical patient information across all care settings will be connected. Hence, interoperability between health systems can provide a more detailed patient picture for more specific treatment plans and improved patient care.

In the US, hospitals lose $75+ million per year per 100 affiliated physicians due to referral leakage, a burden that can be reduced by proper referral network management. Without an electronic way to exchange information, the process of maintaining different workflow requirement breaks down, information is not accurate, and time is wasted.

The scenario in Bangladesh is very different, and unfortunately much worse. Here, other than a few clinics and hospitals, most healthcare services are fully paper based, and the ones that do have some sort of electronic medical record do not provide patients electronic access to their medical history. As a result, patients in Bangladesh have to maintain their medical files physically and carry them every time there’s a need to go to the doctor. Interoperability between health systems in Bangladesh can only be achieved once it’s ensured that all health providers use some sort of hospital information system (HIS). The integration would be most efficient if they use the same HIS. The good news is, although the health system of Bangladesh is fragmented, in 2008 GIZ agreed to assist Ministry of Health and Family Welfare (MoHFW) in developing a well-functioning HIS, which incorporates data across all the different levels of the health system. The initiative that started in 2009 and is still ongoing aims to bridge the gap between the disintegrated systems by bringing together the data from various databases into a single software platform.

At Praava, we are going to have a cohesive HIS system that will include patients’ medical history, appointment management, lab and radiology, and pharmacy – all maintained through a central database so that Praava’s network will be internally integrated at the least. Additionally, we will introduce Bangladesh’s first patient portal through which patients can access their medical history, lab and radiology reports, prescriptions and billing history, as well as appointment management system.

Remote Patient Monitoring

Remote patient monitoring allows patient diagnostic data, for example from electrocardiograms, to be transmitted to health professionals in facilities such as monitoring centers in primary care settings, hospitals and intensive care units, skilled nursing facilities, and centralized off-site case management programs.  Health professionals monitor these patients remotely and act on the information received as part of the treatment plan.

In Bangladesh, a similar concept known as telemedicine, where doctors can treat patients located some distance away and isolated from specialized care, was first introduced in 1999 by a charitable trust named Swinfen charitable. It was an email-based connection between Centre for the Rehabilitation of the Paralyzed (CRP) in Dhaka (Bangladesh’s capital city) and Royal Navy Hospital, Haslar. As the telecommunication sector got a huge boom in the last few years, several private and public telecommunication operators have established their networks all over the country, subsequently paving the way for improved telemedicine services. A number of private entities and NGOs have already implemented successful telemedicine projects and continue to fine-tune them, most of these linking rural patients with specialized urban doctors.  

At Praava, we plan to incorporate telemedicine, especially for patients who live far away from the Praava centers, as part of our membership plans for follow up consultations. We also have plans for in-home blood and urine sample collections for the disabled and elderly.

Anti-Aging Drugs

A lot of us dream of living forever, or at least in the foreseeable future to 120+ years old. 2016 will be the year of a new anti-aging drug test that will enter trials and that could see diseases like Alzheimer’s and Parkinson’s consigned to distant memory. Researchers have already proven that the diabetes drug metformin extends the life of animals, and the Food and Drug Administration in the US has now given the go ahead for a trial to see if the same effects can be replicated in humans. If successful, this would mean that a person in their 70s would be as biologically healthy as a 50-year-old. It could usher in a new era of “geroscience” where doctors would no longer fight individual conditions like cancer, diabetes and dementia, but instead treat the underlying mechanism – ageing.

All these technological advances deeply inspire me to introduce and incorporate cutting edge health care technology to Praava. I’m immensely thrilled about all the possibilities. Hope you are too!

Immunotherapy: Paving the Way for Cancer Treatment

Years ago, when the time came to decide, I opted to become a scientist and not a medical doctor. The decision was based on the naïve dream of the boundless challenges that science provided, the desire to break boundaries and solve the mysteries of nature.  Cancer research provided for me the ultimate challenge. My first few years as a post-doc brought me to Dana-Farber Cancer institute where we were embarking on identifying genetic mutations in cancer and signaling pathways that cancers opted for with the possibilities of targeting these from a therapeutic perspective. But simply coming in to work, I faced a bigger challenge: facing little children who came in for their chemotherapy every day. It was a feeling of helplessness- bordering on guilt. Where is the cure? How can I help these innocent little children who are fighting this deadly battle?

At some point, it became obvious to all of us in the cancer community that there was no “magic bullet”. No single cure was in sight. But what also emerged was that early detection offered the patient the most hope. Detecting cancer early was more beneficial as an outcome predictor than surgery, radiation or chemotherapy.  So, many years later, I feel the same excitement in trying to use our expertise in detecting cancer-causing changes in the body and use methods that have only now been developed to follow progression of the disease.

As dreadful a disease as cancer is at an individual level, it also puts an enormous burden on society. According to a GLOBOCAN estimate, in 2012 alone, there were 14.1 million new cancer cases and 8.2 million deaths worldwide. The direct medical costs (total of all health care costs) for cancer in the US in 2011 were $88.7 billion. Moreover, due to a multitude of reasons, the burden has been shifting to less developed countries, which account for about 57% of cases and 65% of cancer deaths worldwide.

Surgery, radiotherapy, and chemotherapy have been the main approaches for treating cancer in previous decades. Great excitement arose with the completion of human genome sequencing in 2003 and the possibility of targeting DNA mutations that were possible “cancer drivers”. Treatment options started to changefrom harsh non-specific chemotherapy to single-agent therapy or “smart bombs” that selected cancer’s ability to survive or propagate based on driver genes. Worldwide spending on cancer drugs has expanded rapidly and is expected to reach over $100 billion this year.

However, in spite of the advent of all the targeted therapies over the last 3 decades, many patients are not being helped at all. As an example, up to a third of patients with breast cancer experience recurrence, which is lethal in the majority of cases.

In this bleak landscape of existing cancer therapies, a new player has emerged in the form of immunotherapy. Immunotherapy has turned out to be an exciting area of discovery research for many different kinds of cancer. However, the concept of immunotherapy is not new and pioneering work by Emil von Behring and Erich Wernicke over 100 years ago showed that animals infected with diphtheria could be cured by injection of sera produced by other animals that had been immunized with an attenuated form of diphtheria. So, for the first time it was demonstrated that immunity could be transferred. Subsequently, pioneering work by William B. Coley, a surgeon in New York known as the father of immunotherapy who injected bacteria into a patient with cancer, demonstrated the possible efficacy of immunotherapy in oncology.

Immunotherapy was cited as the “Breakthrough of the year’’ in 2013 by the prestigious Science magazine and has received wide publicity in national newspapers (e.g., in The New York Times, 2016) and by the news of the remarkable response to immunotherapy by former President Jimmy Carter (who was suffering from a form of skin cancer) to specific antibody treatments. While researchers have known for many years that our immune systems can recognize and attack cancer cells, actual progress made today is the result of new understanding about the complex interaction between the immune system and cancer.

So what Is Immunotherapy?

Immunotherapy is a type of cancer treatment that is designed to stimulate or enhance the body’s natural immune responses. Unlike conventional therapy, it does not target the tumor but is directed towards the tumor-responding immune cells of the host.

The immune system (our body’s defense system against infections) is made up of a network of cells, tissues, and organs that recognize and destroy foreign invaders such as bacteria and viruses or abnormal cells in the body. This process is mediated by the ability of the immune system to recognize the difference between “self” and “non-self”. Self means your own body tissues. Non-self means any abnormal cell or foreign invader, such as bacteria, viruses, etc. The immune system is generated in a person in such a way that it will not target anything that it recognizes as a healthy part of self. Herein lies the problem. Cancers arise from our own healthy cells. As part of their malignant growth, cancer cells undergo a number of changes that transform them and they lose resemblance to normal cells. Sometimes our immune system can detect and respond to these differences. But at other times, the cancer cells escape immune cell attack by multiple strategies including by suppression of the immune system.

What are the advantages of immunotherapy?

Immunotherapy agents have four positive attributes:

They are powerful, have exquisite specificity, remain in the patient over time (memory) and they have universal applicability across multiple types of cancer.

So far 15 cancer immunotherapies have been approved for use in various solid and liquid tumors, and several more are in clinical trials awaiting approval by the Food and Drug Administration (FDA).

Immunotherapies can be classified as active (agents that induce a response in non-responsive patients) and passive (agents that stimulate intrinsic immune response in the patients). Active immunotherapies include cancer vaccines (e.g., Sipuleucel-T in prostate cancer), monoclonal antibodies (bind to specific proteins or antigens) (e.g., nivolumab, ipilimumab in melanoma and lung cancer), cytokines (e.g., interleukin-2, interferon-α in RCC, melanoma, NHL). Passive immunotherapies include cell-based therapies that includeactive T cell therapy (e.g., TIL, CAR-T that are not approved by FDA yet), oncolytic viruses (e.g., T-vec in melanoma), bi- and multispecific antibodies (e.g.,Blinatumomab in ALL) and tumor targeting antibodies (e.g., Rituximab in NHL, CLL). In Bangladesh, some of these novel therapeutic modalities are still be unavailable. However, the excitement that the clinical trial data is generating will very quickly reach us, and some of these drugs will become widely available and accepted.

I have joined Praava with the hope that we can help make available the promise of immunotherapy to the cancer patients in Bangladesh. Our goal at Praava will be to provide the tools of molecular diagnostics that are essential in determining patient selection and help the clinician better treat patients with the advanced therapies that are only now becoming available.

While great strides are being made daily with newer targets being identified for selection against which monoclonal antibodies are being generated, variability in patient response pose challenges. However, combinations involving multiple immunotherapies or other cancer therapies such aschemotherapy, radiation, and targeted therapies are providing better outcomes. Thus, the current clinical trial data suggest that combination immunotherapy is the future of cancer treatment.

Now, more than ever, understanding how the immune system works is opening the doors to developing new treatments that are changing the way we think about and treat cancer.

Pediatrics And The Need For Proper Children’s Healthcare

I am a retired Professor of pediatric surgery and started my medical training at Chittagong Medical School in Bangladesh in 1963. Soon afterwards, I went to the United Kingdom to pursue higher post-graduate training. It was there that I developed an interest in pediatric surgery. I spent time at the Great Ormond Street Hospital learning pediatric surgery and also trained in general surgery in the UK. After completion of my training, I was a locum consultant at the George Elliot Hospital in Nuneaton. I returned to Bangladesh in 1982 and joined government service. I eventually became a Professor of pediatric surgery at Bangabandhu Sheikh Mujib Medical University followed by Dhaka Medical College Hospital.

Pediatrics is a branch of medicine that deals with the care of children, from being a new born to the ages of 16-18. Pediatricians look at specific health issues and diseases related to different stages of growth and development. It is a diverse and stimulating specialty and is hugely rewarding for doctors.

Globally, child mortality rate – the rate of death among infants and children between the ages of 1 month and 5 years, has been a concerning issue, particularly in Africa and South Asia. A 2015 UNICEF analysis shows that child mortality rate has dropped by 53% from 1990. Under-five deaths have reduced globally from 12.7 million in 1990 to 5.9 million in 2015. However, 16,000 children under 5 still die every day. 45% of these deaths occur in the neonatal period i.e. the first 28 days of life.

In 1990, Bangladesh had an under-five mortality rate of 144 per 1,000 children. That number dropped to 38 per 1,000 children in 2015, exemplifying the huge strides the country has taken to achieve this feat.

The main causes of death in Bangladeshi children include prematurity, pneumonia, complications during labor and delivery, diarrhea, sepsis, and malaria. Nearly half of all under-five deaths are associated with undernutrition. Most of these deaths are preventable with simple interventions.

Broadly, pediatricians work in the following areas:

  1. General pediatric units
  2. Community based settings
  3. Specialized units such as neonatology

Treating a child is different from treating an adult. There are differences in anatomy, physiology, and pathology. As a child grows, anatomical and physiological parameters change. Congenital defects, genetic variance, and developmental issues are of great concern to pediatricians. Another major difference between adults and children is the issue of consent. Children are generally not able to make decisions for themselves and parents or guardians are responsible for these decision. A pediatrician often has to treat the parents as well, rather than just treating the child.

In the developing world, malnutrition and infectious diseases are the predominant problems that pediatricians are faced with.  There are also several social issues that need to be overcome including poverty, chronic illness in the family, child labor and others. Malnutrition leads to poor growth and development, making the child susceptible to a range of other consequential secondary diseases. Infectious and diarrheal diseases are extremely common, while HIV and hepatitis are endemic. A lack of accessible medical care makes these diseases potentially fatal.

Overall, pediatrics is an incredibly important specialty. Children are our future and we need to ensure that we are taking the best possible care of them. With the financial constraints faced by the healthcare system in a developing country such as Bangladesh, it becomes more of a challenge to provide this service. Currently, this service is provided by a combination of government funding, non-government organizations, and the private sector. With the continued development and growth of the country there will be an increased expenditure on pediatric healthcare, which should help in improving the health and wellbeing of children in Bangladesh.

At Praava Health, we will prioritize healthcare for children. We will provide a comprehensive immunization program with monitoring of growth and development as per international guidelines. We will ensure children get the most up to date, evidence-based treatment.

The Nakshikantha Approach to Healthcare

Health is wealth. That’s something we were taught when we were kids. But as we grow up and are confronted with harsh realities of life around us, we learn an uncomfortable truth. Wealth is health. If you do not have wealth, you cannot afford to have access to good healthcare. While this is true in many developing countries around the world, the situation is particularly acute for Bangladesh.

The health sector in Bangladesh is plagued with layers of problems. On the one hand, we have serious quality of care issues. In many cases we cannot rely on seeing a doctor with the hope of being correctly diagnosed the first time around. We seek second opinions and third opinions. On the other hand, we have a dysfunctional resource allocation system. It is next to impossible to find a reasonably good healthcare facility beyond Dhaka. We have more doctors than nurses. But the most unfortunate part is that for most of us healthcare is just not affordable. 

A predominant flaw in our healthcare system is inadequate budget allocation. The government spends only 3.6 percent of its GDP on health. Our total health expenditure as a percentage of GDP is in fact less than the average total expenditure on health of countries in similar economic conditions. It is also less than the percentage that WHO recommends. Furthermore, the health sector budget is about 6 percent of our total budget, which too is lower than our peers. Consequently, our out-of-pocket expenditure is exceptionally high: 64 percent of the total expenditure on health. Because out-of-pocket spending can be regressive, the system we have does not allow for adequate financial risk or cost sharing mechanisms, and therefore, could lead to extreme financial burdens for many in cases of catastrophic illness and health expenses.

Health costs are a heavy burden for the poor. Most of our reasonably good health facilities are concentrated in Dhaka. An overwhelming majority of the poor live outside Dhaka. They do not have access to good health facilities where they live. It is, moreover, difficult for them to arrange funds for treatment in Dhaka. Even when they manage the funds somehow (often by selling assets or borrowing under unfavourable terms), they face a higher time-cost-visits factor than their wealthier counterparts. In effect, they pay a poverty penalty.

Bangladesh is not, however, sitting idle. Vision 2021 promises a future where all citizens enjoy a quality of life that includes basic health care and adequate nutrition. The National Health Financing Strategy (NHFS) 2012-2032 has been put in place to move the country toward Universal Health Coverage (UHC), setting some aggressive targets, such as halving the out-of-pocket expenditure to 32 percent by 2032.

Shasthyo Suroksha Karmashuchi (SSK) is a government designed health insurance scheme targeting people below the poverty line. However, SSK had a delayed start a year ago and only covers 7,500 households in the first pilot sub-district. Furthermore, early experience indicates difficulties in adoption and utilisation. Since health insurance requires a sufficiently large population base and risk pooling mechanisms, it is unclear if, how or when SSK might succeed.

There are some existing health financing mechanisms that target organisations with large employee bases using a business-to-business (B2B) model. These collectively cover less than 1 percent of the population today. A few new similar schemes are currently in development, but these too rely on the B2B model, some targeting the large RMG sector. However, the incentive for a RMG factory to cover its workers with health insurance is untested at scale. Given the global pressure to continually reduce costs to remain competitive, as well as incurring additional costs for safety compliance measures in the wake of Rana Plaza, it is not clear whether RMG factory owners will be able to justify yet another cost component.

The Nakshikantha Approach

pi STRATEGY has conducted studies in the health financing domain over the last few years. The firm believes that a multi-faceted approach could potentially lead to a sustainable model for innovative health financing – the firm calls this the Nakshikantha approach. This approach weaves several distinct facets into a single product offering – much like the various palettes of a classic Nakshikantha. Two of the most important facets are described below:

The first facet is the introduction of a business-to-consumer (B2C) model. While there is a risk of adverse selection in a B2C model, that risk can be judiciously mitigated if this is implemented at scale using the household as the unit of analysis. There may be some people in a household that require more health care services than others, but it is unlikely that this will be the case for everyone in a household. The poor and the wealthy alike will have the option to choose from the same menu of packages, priced the same, and offering them the same core services (e.g. access to same health facilities, same doctors). The key difference offered for premium packages will be the ‘hoteling’ components of health services. The wealthy would pay for their packages themselves, while the poor would receive subsidies to cover a large part of the cost of their packages.

The second facet of the Nakshikantha approach will take advantage of increased government funding (expected to meet NHFS 2032 goals) using an innovative strategic purchasing mechanism. This would allow paying for a service based on outputs (connected directly to treatment outcome factors and patient satisfaction factors) rather than inputs, as is currently done today. The price for a medical interaction/intervention will be determined in advance for partner health facilities. A patient will choose which facility they visit. Strategic purchasing mechanisms can thus better align the incentives for improved quality of care.

Furthermore, the Nakshikantha approach will incorporate many other facets. An intricately woven IT platform could incorporate electronic health records, digital payments and other technologies.

As Bangladesh continues its journey toward a middle-income country status, diminishing donor support will need to be offset by increasing government and private spending. There are few sectors better placed to provide a higher dividend than investments in health.Within the health sector, solving the health financing conundrum is a critical pre-requisite. The Nakshikantha approach represents a path forward. Perhaps one day we too will be able to tell our grandchildren’health is wealth’ with the same conviction that our grandparents had when they taught us that mantra.

Note: This article was also published in The Daily Star on April 8, 2017.

My experience with healthcare in Bangladesh and the long road ahead

In 1995, my father was diagnosed with a cancerous brain tumor by top neurologists in the country. He experienced a persistent burning sensation in his head and horribly bloodshot eyes. When doctors claimed he didn’t have much longer to live, my father, then in his late 30s, was broken. He couldn’t fathom leaving behind his family at such a young age. Since MRI machines were not available in Bangladesh at that time, my father was advised to go to India to confirm the diagnosis. We traveled to Kolkata, where after an initial physical examination, the neurologist declared with 99% certainty that my father did not have a brain tumor. Believing the symptoms were indicative of an eye infection instead, the doctor referred my father to an ophthalmologist. The doctor still insisted on an MRI scan to rule out a tumor and give us much needed peace of mind. As it turns out, the doctor’s diagnosis was correct; my father did indeed have an eye infection, and the MRI scans showed no trace of any tumor. My father took the prescribed eye drops for the next couple of months, and 22 years later has not suffered any of his earlier symptoms.

My father’s ordeal is one of many that our family alone has experienced. Earlier in 2009, I was hospitalized for an extended period of time with excruciating abdominal pain at some of the best hospitals in Dhaka. Numerous lab and imaging tests were performed on me. A medical board comprised of a group of doctors was set up, and I was given 22 injections a day – all without any concrete diagnosis. Eventually, after visiting a hospital in Delhi, I was diagnosed with IBS (Irritable Bowel Syndrome).

Needless to say, healthcare and I have a long and often tempestuous relationship. While we have some exceptionally talented doctors and surgeons in this country, they are mostly overshadowed by their not-so-great counterparts.

Still, one must acknowledge the advances Bangladesh has made in healthcare. Despite being plagued by poverty and political turmoil, since 1980, the country’s maternal mortality rate has dropped by 75%. The infant mortality rate has dropped by 50% since 1990, and life expectancy rose to 68.3 years, which is higher than that of neighbors India and Pakistan. Currently, there are 64,434 registered doctors, 6,034 dentists, 30,516 nurses, and 27,000 nurse midwives inBangladesh. As of 2013,64% of these registered doctors are working in the private sector.  Numerous health facilities have opened in recent years to cater to this increased demand for care. As of 2015, the total number of hospitals in the country was 1683, of which 678 were government hospitals.

Despite growth in certain areas, much work remains to be done within the healthcare sector. The troubling reality is that the public health facilities are marred with low quality treatment, inefficiency, and poor management. While the private health facilities are better equipped with the latest medical machinery, they are expensive and often provide substandard service. Given the lack of quality and affordable health services, people from all social backgrounds have no choice but to seek treatment from private health facilities, which often creates a huge financial burden. The more affluent opt to fly to neighboring countries for care. In fact, data from the Indian government revealed that in 2015 alone, 1,34,344 medical visas were issued from Bangladesh, while 97,000 were issued in just the first six months of 2016. These staggering numbers do not account for patients who visit India for medical purposes with tourist visas.

One of the things that always catches my attention upon entering a health facility in Bangladesh is the disregard for a patient’s feelings. It saddens me to say that I seldom witness hospital staff exhibiting any form of empathy, or even a genuine smile. It’s an established fact thatempathy allows patients to build trust with their providers and experience better rates of recovery. At Praava, we take empathy and hospitality very seriously. All of our staff, including our family doctors and top management, are going through rigorous hospitality training. We will require doctors to spend more time with their patients to comprehend their reality. I am proud to take the lead in service excellence to ensure that patients coming into our clinics are treated with kindness, empathy, and respect. Overall, we want our patients to have a seamless experience at our facility from the minute they enter till the time they leave. Healthcare is not just about getting treated for an illness–it’s a very personal affair that needs to be dealt with delicately, which is exactly how we envision treating our patients.

Prior to joining Praava, I worked for two national newspapers, local and international magazines, and the BBC Media Action. A trained electronics and telecommunication engineer, I was drawn to writing and journalism because it allowed me to voice opinions, raise awareness, and create impact. When I met Ms. Sylvana (CEO of Praava Health) in early 2016, I was intrigued and inspired by her mission to revolutionize healthcare in Bangladesh, which resonated with my own desire to see significant change in the current system. It wasn’t an easy decision to quit an eight-year writing career to jump into a new role, but as I was striving to create impact with my written words, I knew I could create impact in healthcare with Praava. For the last year, I have worked towards delivering a better healthcare experience for the people of this country, and believe our work will speak for itself once we open our doors.