Diarrhoea: Lessons from Bangladesh

Diarrhoea in children is caused by viral illnesses, notably rotavirus which accounts for 45% of diarrhoea cases.

In their 2019 Annual letter, Bill and Melinda Gates wrote that they got their impetus for starting their foundation from a news story about hundreds of thousands of kids in poor countries dying from diarrhoea. Diarrhoea, you say?

Sure, it is uncomfortable and draining but is it really such a big problem? Unfortunately, it is. In fact, it accounts for 9% of deaths of children under-five, in India. Diarrhoea in children is caused by viral illnesses, notably rotavirus which accounts for 45% of diarrhoea cases. It causes children to lose fluids, causing dehydration rapidly and putting their lives at risk.

The good news is that in this century, the world has made steady progress in reducing its diarrhoea burden. From 2000 to 2016, global diarrhoea deaths of children under-5 reduced by 61% from 1.237 million to 477,000.

The same figure for India has reduced by 70% from 340,000 to 102,000. Bangladesh has performed significantly better than most countries, including India, in fighting diarrhoea. From 2000 to 2016, Bangladesh has reduced under-five diarrhoeal deaths from 38,877 to 7,062 (81.8%). This is particularly commendable when you consider that its per capita income is significantly lower than India as shown in the chart.

So, what did Bangladesh do to control diarrhoea? Few elements stand out:

  • Granular health system: Bangladesh has built a well-structured decentralised health system with three tiers of primary health care facilities - Community Clinics (CC) at the village level. Union Health and Family Welfare Centres (UHFWC) at the Union (cluster of villages) level and Upazila Health Complexes (UHCs) at the sub-district level. These feed into district hospitals and other tertiary facilities. In 1997, the Government introduced the Control of Diarrhoeal Disease (CDD) program establishing an Oral Rehydration Therapy (ORT) corner in each UHC, district hospital and tertiary care centre. This made treatment easily accessible. India has a similar tiered, well-conceived structure of health facilities. However, there are gaps in implementation. Basic equipment and supplies are often missing, and vacancies go unfilled.
  • Community led-action and behaviour change: Oral rehydration has become a part of household life in Bangladeshi society. Starting 1980, BRAC and International Centre for Diarrhoeal Disease Research, Bangladesh (ICCDR, b) have trained 12 million mothers, in mission mode, to make Oral Rehydration Solution (ORS) at home itself.¬† When a child falls ill, the mother simply mixes water, sugar and molasses together to create an ORS that prevents dehydration. Rice water is also used as an alternative. Community Health Workers (CHWs) serve as the link between the health system and the community. They routinely visit houses, offer basic counselling and refer cases to local facilities. They also play a key role in community mobilisation and are comparable to ASHA workers in India. The Government has augmented its CHW network by partnering with development organisations such as BRAC. Close to 75% (163,000 / 219,000) CHWs in Bangladesh are supported by NGOs. The ratio of CHWs for a given population has more than doubled between 2005 and 2015. The close link between CHWs managed by NGOs and the health system is a good example of public-private partnerships in rural healthcare. CHWs per 1000 people continues to be lower in Bangladesh (0.36) than India (0.58). However, their ability to drive behaviour change and work effectively with NGOs and the Government is impressive.
  • Limiting open-defecation: It is essential to eliminate open defecation as faeces contain pathogens which cause diarrhoea. Bangladesh has reduced open defecation from 42% in 2003 to 1% in 2015[6]. While the Government did promote rapid construction of indoor toilets, a big part of the success was due to the community-led approach. Campaigns worked with local representatives to trigger people's inherent emotions of shame and disgust. Associations were drawn between faeces and consumption. Reports suggest that toilets are now seen as a symbol of status and dignity in the society, even becoming a consideration during matrimonial alliances. These efforts have had knock-on benefits. Earlier, women held back food intake for fear of going out in the open to defecate. Now, they feel more secure and are better nourished. In this regard, it is worthwhile to mention the Swachh Bharat Mission (SBM). 9 crore toilets have been built under the scheme as of January 2019. Utilisation of toilets in rural areas remains a concern. The Government is now taking up behaviour change campaigns across the country.
  • Treatment facility and research centre: Bangladesh is home to 'ICDDR, b', the only diarrhoeal hospital in the world. The centre treats over 100,000 diarrhoea patients a year. It has also gone beyond treatment to perform path breaking research. Its accomplishments include developing oral rehydration solutions in the 1960s (then known as East Pakistan), proving the case for zinc-based treatment in the 1990s, developing guidelines for managing severe acute malnourishment now adopted by the WHO and many more. The centre has also emerged as a centre of excellence, training practitioners from around the world. Diarrhoea has important ramifications for a society's health and development. Studies have drawn clear links between diarrhoea, malnutrition and death. Bangladesh is a case study in achieving success in controlling diarrhoea despite having slower economic development than us. In recent years, the Government of India has undertaken some commendable measures such as the adoption of the Integration Action Plan for Prevention and Control of Pneumonia and Diarrhoea (IAPPD). In 2017, the Intensified Diarrhoea Control Fortnight (IDCF) was launched. Following the monsoons (when diarrhoea is most prevalent), a fortnight is dedicated to intensive care and counselling for diarrhoea. There are other positives - introduction of rotavirus vaccine in the Universal Immunisation Program in various states (11 as in September 2018) will help limit the largest cause of diarrhoea. Bangladesh has also announced plans to induct the vaccine in its program. If there are three things, I would emphasise from the Bangladesh experience, they are a) driving community ownership, b) empowering community health workers and driving closer engagement with NGOs, and c) investing in research. Bangladesh's success goes to show that supply and demand forces need to work seamlessly together to impact public health outcomes. The Government can initiate large programs, build facilities and capacity but ultimately community ownership is necessary for far-reaching impact.

The writer is the CEO, Antara Foundation. He has worked in management consulting with Arthur D Little and KPMG.