IPCRG visit Bangladesh and Launch Asthma Right Care
Our President Ee Ming Khoo and CEO Siân Williams are just back from a week in Bangladesh at the invitation of the Bangladesh Lung Foundation and Bangladesh Primary Care Respiratory Society (BPCRS). As well as launching Asthma Right Care at the Pulmocon conference in Dhaka, they had the opportunity to visit primary care centres in Kurigram and experience the activities of BPCRS in the northern part of Bangladesh.
Delivering the right asthma care in primary care is challenging. There is no structured postgraduate family medicine course/equivalence qualification equivalent to other clinical disciplines; primary respiratory care is mainly delivered by doctors with an undergraduate MBBS degree and by pulmonologists at OPD and in a hospital setting rather than the chronic care model in community, all working in private chambers which also offer dispensing.
There are also public services at three levels: at the frontline, community clinics with a community health worker. Sometimes these are organised with the support of the local community, eg providing some land for the clinic building. They typically offer health education on nutrition, family planning, maternal and child health, acute care and some chronic disease treatment with access to a subset of the national essential medicines list e.g. salbutamol syrup and tablets with no availability of inhaled medicines. The one we visited also had a new delivery suite and ten babies have been safely delivered there.
Then there are child and maternal health clinics offering education and monitoring for pregnant mothers and a family planning service. At the level above are upozilas, which are bigger community health centres providing general health service with community-based 50-bedded hospitals including medicine, surgery, gynae- and obs wards and focusing mainly on infectious disease and urgent care. They launched recently an “NCD corner” offering some inhaled medicine, which is not always available.
There are only a few, if any, trained pharmacists working in hospitals or the community. In rural areas pharmacies are set up as small local shops selling over the counter. Montelukast and doxoyphyllin are more visible than inhaled medicines.
Pharmaceutical science graduates work for the pharmaceutical industry that takes responsibility for teaching clinicians with their limited clinical knowledge about the guidelines and, importantly, inhaler technique.
So, where does Asthma Right Care start? We think the biggest opportunities may lie with starting in one region where there is already good collaboration between the private and public sectors at a personal clinical level and also at the management levels including the Civil Surgeon.
The goal needs to be to move closer to guideline care including a shift from short-acting relief to anti-inflammatory treatment. However, the lack of a consistent supply of inhalers in public services and a fiercely competitive market of generic companies working in the private chamber sector means that prescribing and adherence to inhaled medicines will be extremely challenging. Our main metric, an improvement in the ratio of ICS:SABA remains a good measure - if sales data can be analysed.
Ee Ming Khoo