Addressing the burden of Noncommunicable diseases (NCDs) among refugees and migrants remains a major challenge globally. While communicable diseases continue to be an overriding concern among displaced populations in humanitarian settings, the increasing burden of NCDs –which include cardiovascular diseases, chronic respiratory diseases, diabetes and cancer– is leading to a shift of focus in emergency preparedness and response interventions.
In the Rohingya refugee camps in Cox’s Bazar, the most densely populated in the world, WHO is supporting Government health authorities and humanitarian partners to better integrate NCD services into primary health care, and thus improve health and wellbeing and prevent premature deaths among the refugee population and adjacent host communities.
The successful outcomes reached within the NCD delivery programme in Cox’s Bazar have been acknowledged by external actors and partners, leading to the identification of standardized practices that can be replicated in other humanitarian settings.
Over 260 healthcare workers are currently applying the NCD national protocol in 60 Primary Health Care centers across the refugee camps thanks to WHO PEN training. WHO Bangladesh/Irene Gavieiro Agud
International webinar on NCD prevention and management in humanitarian settings
On 14 September 2021, WHO Bangladesh in coordination with the WHO Regional Office for South-East Asia (SEARO) and WHO Headquarters, held a webinar on “Strengthening Noncommunicable Disease Prevention & Management in Humanitarian Settings - Reviewing the Cox's Bazar approach”. Organized in close coordination with the Government of Bangladesh, the webinar provided a comprehensive review of NCD care delivery in the world’s largest refugee camp from community-based interventions up to primary health care facilities, while helping identify key common aspects that could be extrapolated to similar settlements around the world.
Experts on Noncommunicable Diseases (NCDs) from UN agencies, international and national non-governmental organizations – including WHO, UNHCR, Save the Children and RTM International – participated in the event which aimed to discuss NCD control and management in emergencies, highlighting collaborative efforts with partners to deliver care and reflecting on practical lessons from its implementation in Cox’s Bazar.
Additionally, panel discussions enabled a deeper comprehension on how the recent COVID-19 pandemic has affected the NCD programme in the humanitarian setting. “The COVID-19 pandemic has deeply affected all of us, everywhere. But it has had an even more significant impact on comorbidities among the vulnerable populations due to the restricted access to health care services and facilities. Leading and coordinating the Health Sector, WHO has been tirelessly working closely with national and international partners to ensure the delivery of essential health services, with special focus on NCDs prevention and management”, says Dr Bardan Jung Rana, WHO Representative to Bangladesh.
High-level representatives for WHO and the Government of Bangladesh launching the webinar acknowledging the achievements and addressing the challenges for NCD delivery in Cox’s Bazar. WHO Bangladesh
Under the leadership of the Ministry of Health and Family Welfare (MoHFW), WHO is supporting the Government in the roll out of national protocols for integrated management of hypertension and diabetes using a total cardiovascular risk approach in Primary Health Care (PHC) facilities in Cox’s Bazar. Based on the WHO Package of Essential NCD interventions in low-resource settings – known as WHO PEN – an integral system has been established in primary healthcare facilities for the prevention and control of NCDs in the refugee camps, where an extensive network of 175 Government and partner-led healthcare facilities cater the health needs of over 884 000 Rohingya refugees along with 472 000 Bangladeshi host population living in the adjacent area.
“Increasingly emergency responses have to cater to the needs of diverse populations in terms of health profiles, entitlements and location. In many humanitarian settings like in Bangladesh, forcibly displaced populations are in camps but increasingly also living in urban and rural settings outside camps often in places where marginalized and poor host population resides as well. In order to leave no one behind and progressively realize the vision of universal health coverage, governments and humanitarian partners have a moral responsibility to design and provide NCD services to both affected populations as well as host communities”, explained Dr Slim Slama, Unit Head of Noncommunicable Diseases Management-Screening, Diagnosis and Treatment (MNC) of the NCD Department at WHO Headquarters during his opening remarks.
To this end, over 80 partners coordinated under the WHO-led Health Sector provide NCD related services in the refugee camps, such as screening, diagnosis, treatment, counselling, referral or healthy lifestyle promotion.
In total, 93 health posts, 41 primary health care centers and 4 field hospital are providing NCD services focusing on priority NCDs among the Rohingya people. WHO Bangladesh/Irene Gavieiro Agud
NCD care delivery at emergencies: from community level up to primary health care center
NCDs are a major public health problem nationwide, representing the cause of 67% of all deaths in Bangladesh. Through a holistic and multi-level approach, various efforts to support the NCD response have taken place throughout the Rohingya humanitarian crisis response, including NCD coordination, capacity building, health education, provision of emergency medicines and supplies, and monitoring supervision, which have continued despite the constraints imposed by the COVID-19 pandemic.
“Management of NCDs in emergency settings requires treatment of acute exacerbations and complications, continuation of ongoing treatment, addressing stress and mental health issues, and coordination of care provision and follow-up against the disruption and displacement”, expressed Dr Razia Narayan Pendse, Director of HPN at WHO South-East Asia Regional Office (SEARO).
Health promotion materials have been distributed among Primary Health Care facilities to raise awareness on healthy lifestyle among Rohingya patients. WHO Bangladesh/Irene Gavieiro Agud
Essential disease components of NCDs have been incorporated in the District Health Information System (DHIS-2) that monitors disease burden and trends in Cox’s Bazar. The systematic collection of real time data for NCDs surveillance provides a comprehensive overview of the health status of the refugee population and becomes crucial in developing a more targeted and coordinated public health response to NCDs.
Additionally, NCD screening has also been incorporated in some healthcare facilities across the refugee camps becoming instrumental for the early detection, diagnosis and appropriate treatment of Rohingya patients.
“Strengthening the evidence base through expanding our NCD surveillance mechanisms and monitoring results is particularly meaningful in the complex context here in Cox’s Bazar, with a population that has a history of limited health care seeking behavior and undiagnosed NCDs”, explains Dr Kai von Harbou, Head of WHO Emergency Sub-Office in Cox’s Bazar by adding that: “By strengthening NCD screening and improving counseling at primary healthcare facilities as well as detection, health promotion and prevention at community level, we can truly make the difference in the Rohingya population well-being”.
The progress achieved in the prevention and control of non-communicable diseases is evident in the world’s largest refugee camp. According DHIS-2, the number of patients seeking medical care for NCDs has considerable increased over the past years. To date, over 720 000 NCD consultations from the Rohingya refugee camps and adjacent host communities in Ukhiya and Teknaf Upazilas have been registered.
NCD screening has been incorporated in primary health care facilities across the refugee camps to capture data and progression of NCD prevalence among the Rohingya population above 40 years of age. WHO Bangladesh/Irene Gavieiro Agud
Ensuring a quality and skilled workforce has been another of the keystones in the successful implementation of the NCD programme in Cox’s Bazar. Since 2019, a total of 283 primary healthcare workers from 64 primary healthcare (17 Government facilities and 47 partners-led centers) along with 8 Upazila Health Complexes have participated in the WHO PEN training in the district. These training sessions, implemented in close collaboration with the Directorate General of Health Services (DGHS) and the BRAC James P Grant School of Public Health, aimed to help healthcare professionals better respond to an increasing prevalence of NCDs in the camp setting following the total cardiovascular risk assessment approach.
These healthcare professionals work along with Rohingya volunteers to help the communities identify NCDs’ risk factors through health promotion strategies. A skilled team of over 1,400 trained volunteers – of which 60% are Rohingya – established under the Community Health Workers (CHWs) working group led by UNHCR and World Concern/Medair share related NCD information to targeted community members through door-to-door visits. “A few years ago, we noticed a critical gap in knowledge of NCDs at community level. Similarly, the CHWs were not well capacitated to provide this service, so we worked with the NCD team at WHO, the James P Grant School Of Public Health, BRAC University and the Ministry of Health in developing a training facilitation guide and flipcharts, and then we capacitated them through several trainings”, says Dr Allen Maina, Senior Public Health Officer at UNHCR in Cox’s Bazar.
“During the pandemic, our community outreach team raised awareness regarding the possible impacts of COVID-19 in patients with NCD or other comorbidities. So, patients were sensitized and encouraged for a periodical follow up to be in control state of their associated NCDs”, adds Dr Abdullah-Al-Noman, Senior Programme Manager (Health) at Save the Children International.
However, the shortage in the stock of essential medicines due to the logistic challenges imposed by the pandemic also affected the Rohingya refugee camp, having an impact on patient’s health seeking behavior. “The availability of insulin, especially for type-1 diabetic patients, was a great challenge. Sometimes, we lost regular follow-up for patients as a result”, points out Dr Riad Hossain, Quality Assurance Officer at RTM International in Cox’s Bazar. In order to cope with this situation, WHO offered continuous gap filling support to partner-led and Government health care facilities throughout the COVID-19 pandemic, with the supply of NCD medications and basic diagnostic equipment.
Emergency logistic and operations support for NCD care continued throughout the COVID-19 pandemic in the Rohingya refugee camps. WHO Bangladesh/Tatiana Almeida
Although there is still a long way to go in NCD prevention and control among refugees and migrants , the integration of the national policies and protocols led by the Government of Bangladesh in the Rohingya refugee camps, along with the dedication and hard work of the numerous health humanitarian partners providing NCD services in the camps is transforming Cox’s Bazar into a blueprint for other humanitarian settings.
“We have a vision of making Cox’s Bazar a model NCD district, and we believe that the NCD standard of care for Forced Displaced Myanmar Nationals (FDMNs) will greatly benefit from this vision and related activity”, states Professor Dr Mohammad Robed Amin, Line Director of Noncommunicable Diseases Control (NCDC) at the Directorate General of Health Services (DGHS) in Bangladesh.