By Abdullah Muhammad Rafi, ARK Foundation

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ARK’s SIMPLE Solution to the Urban Data Dearth On December of 2022, the Government of Bangladesh declared its next major initiative – the Smart Bangladesh Initiative – with a view to building a Smart Nation by 2041. Government’s Aspire to Innovate (a2i) program defines a ‘smart nation’ as “harnessing emerging technologies, networks, and data to create tech-enabled solutions that contribute to nation-building.” The initiative is structured around four pillars: Smart Citizen, Smart Government, Smart Society, and Smart Economy. According to the plan, all government agencies and institutions will undergo reforms to achieve the vision of Smart Bangladesh. Public health will receive top priority, with the government developing a new health system aimed at addressing non-communicable diseases (NCDs), digitalizing patient records, ensuring secure health information management, establishing sustainable health financing, strengthening primary healthcare services, and promoting health literacy, among other initiatives. In addition to that, the upcoming Fifth Health Population, and Nutrition Sector Program (HPNSP) also has been designed to contribute to the Smart Bangladesh initiative. The progress towards Smart Bangladesh provides much needed opportunity to address the challenges of coordinating primary care services across multiple public, private and NGO providers to improve the health of the expanding urban population. ARK Foundation Bangladesh, is supporting Bangladesh government in multiple capacities to modernize and digitize the health sector. Among its efforts, a significant initiative includes introducing the Simple App — a tool previously used for collecting health-related data in rural areas — into urban settings. Simple APP: A Solution to the Data Scarcity in Urban Areas Innovation in the health sector is a crucial element to deliver a holistic health service to the citizens. With rapid urbanization in Bangladesh, the demand for primary healthcare providers, both in the government and private sectors, has increased significantly. However, due to the diverse data systems used by multiple private, public and NGO providers, there is no unified data dashboard to assess and monitor health indicators in urban areas. World Health Organization (WHO) defines health innovation as “a new or improved solution with the transformative ability to accelerate positive health impact.” More broadly, innovation, as addressed in the WHO’s Policy Brief on Urban Health, is the process by which new ideas, methods, or technologies are generated, evaluated, and applied to existing and emerging problems in urban health. [i] To underscore the importance of translating data into policy recommendations to address urban health issues, the WHO brief titled “Generation and Working with Evidence for Urban Health” states: “To take effective action on urban health, decision-makers need a comprehensive understanding of the health and well-being of their urban populations. This includes knowledge of health outcomes and risks, as well as the social, environmental, economic, and commercial determinants of health. Additionally, they must be aware of the stakeholders influencing urban health, their needs, motivations, priorities, resources, and capabilities, and their likely actions in various situations. Achieving this requires high-quality data that, when processed, analysed for insights, and applied to specific questions, can serve as evidence supporting or opposing specific actions or approaches. Furthermore, when addressing health challenges, decision-makers often rely on structured information products and evidence-based recommendations from diverse sources.”[ii] Earlier, the health systems of Bangladesh have been applauded globally for its remarkable performance achieving in the Millennium Development Goals (MDG) especially Goals 4 and 5 with significant declines in child and maternal mortality. These remarkable achievements have provided immense confidence to set Universal Health Coverage as one of the post-MDG targets under the Sustainable Development Goals 3 (SDGs) - Goal 3.[iii] According to the recently published document titled Bangladesh Digital Health Strategy 2023-2027 by the Ministry of Health and Family Welfare (MoHFW), the government has been following a “whole of society” approach in carrying out the task of implementing the Sustainable Development Goals (SDGs). While SDG 3 is the main SDG with an explicit focus on health, at least 10 other goals are also concerned with health issues. In total, more than 50 health-related SDG indicators have been agreed upon internationally, to measure health outcomes and proximal determinants of health or health-service provision. A recent cross-study in the context of urban health shows how 48 SDG indicators are relevant to understand the links between social determinants of health, environmental exposures, behaviour, health outcomes and urban policies.[iv] Challenges of Urban Health Data in Bangladesh Despite the government’s vehement efforts to find solutions to the public health problems of Bangladesh, the lack of infrastructure and systematic management – was creating hurdles on delivering health services to the urban masses.  Health data is often collected by various institutions, including government hospitals, private clinics, NGOs, and community health workers. This fragmentation leads to inconsistencies and gaps in the data, making it difficult to obtain a comprehensive picture of urban health. On the other hand, many urban health facilities lack the necessary infrastructure to collect, store, and manage health data efficiently. This can lead to data loss, errors, and inefficiencies in data handling. In addition to that, Urban health systems in Bangladesh often face resource limitations, including insufficient funding, staff shortages, and lack of training. These constraints affect the ability to collect, analyse, and utilize health data effectively. Other than this, the Ministry of Health and Family Welfare (MoHFW) and the Ministry of Local Government, Rural Development and Cooperatives (MoLGRDC) are pivotal in Bangladesh’s urban primary healthcare (PHC) system, overseeing the major PHC facilities. For an efficient urban PHC system that includes NCD care, these ministries must communicate and collaborate. However, despite multiple national strategies and action plans, there remains a persistent lack of synergy between them. Although their roles and responsibilities are defined on paper, practical clarity and coordination are missing, leading to frequent lapses in communication during urban PHC planning. This issue is highlighted in the national urban health strategies developed in 2014 and 2020 by MoLGRDC and MoHFW, respectively. The 2014 strategy recognizes MoHFW as the leading health services provider responsible for national healthcare policy and notes its success in establishing a robust PHC network in rural areas. However, it fails to mention Urban Dispensaries (UDs) operating in urban areas and emphasizes the need for better coordination among different organizations. The 2020 strategy by MoHFW admits to the lack of effective coordination between MoHFW, LGD/MoLGRDC, and urban local bodies in delivering urban health services. Despite these acknowledgments, there has been little progress in improving inter-ministerial coordination. Rise of Non-communicable Diseases (NCDs) In the current world, NCDs have risen to become one of the major challenges for governments across the globe. According to the WHO’s factsheet, NCDs, including heart disease, stroke, cancer, diabetes and chronic lung disease, are collectively responsible for 74% of all deaths worldwide. More than three-quarters of all NCD deaths, and 86% of the 17 million people who died prematurely, or before reaching 70 years of age, occur in low- and middle-income countries. With rapid urbanisation and a growing urban poor population, Bangladesh is experiencing an enhanced risk of NCDs. The country is undergoing an epidemiological transition, shifting from communicable to non-communicable diseases.  This trend is reflected in three consecutive surveys conducted in 2010, 2018, and 2022 in Bangladesh. In 2010, the prevalence of hypertension was found to be 12.5%, which increased to 21% in 2018 and 23.5% in 2022. Similarly, the prevalence of diabetes has risen over the years, with self-reported cases at 3.9% in 2010, 8.3% in 2018, and 9.7% in 2022. Why data on NCDs is urgently needed The Bangladesh government has also taken steps to address this major health issue. However, since addressing NCDs requires extensive patient data to provide tailored long-term care, effective data management, dissemination and presentation to inform decision-making are crucial components in tackling NCDs. Effective management of NCDs necessitates continuous follow-up by health professionals to ensure that patients receive appropriate medication and tailored lifestyle advice. This ongoing monitoring allows for adjustments to be made based on the patient’s progress and response to treatment. However, a significant challenge in the current healthcare system is the lack of accessible individual patient data. Without this data, health professionals are unable to effectively track a patient's history, making it difficult to provide personalized care. The availability of comprehensive patient data is crucial for optimizing treatment plans, improving patient outcomes, and ensuring that each patient receives the best possible care tailored to their specific needs. Existing Data Systems in Primary Care Examining the data management aspect of the health system, ARK Foundation had found that the Management Information System (MIS) under the Directorate General of Health Services (DGHS) of the MoHFW operates the District Health Information Software-2 (DHIS2), which aimed to provide comprehensive real-time health data but primarily focused on maternal and child health indicators. The dashboard included some data on non-communicable diseases (NCDs) from various health facilities but lacked data from urban primary healthcare (PHC) facilities and did not update NCD data regularly. Additionally, the data this dashboard provided did not include information from urban dispensaries or NGO clinics. DHIS2 was linked to another dashboard known as the Urban Primary Health Care Service Delivery Project dashboard under the Ministry of Local Government, Rural Development and Cooperatives (MoLGRD&C), which primarily reported on maternal and child health from NGO clinics. While this dashboard featured data on NCDs like hypertension and diabetes, it provided only an overview from 188 NGO clinics, lacking detailed center-wise or area-wise NCD data. ARK’s studies revealed that the existing health information system (HIS) lacked coordination in several aspects: (i) it did not include urban PHC facilities (Government Outdoor Dispensaries or Urban Dispensaries (UDs) under the Ministry of Health and Family Welfare (MoHFW)); (ii) it did not include the NGO clinics operating under the MoLGRD&C; (iii) the NCD-related data provided was outdated; (iv) development partners and INGOs prioritized rural over urban areas for NCD focus; and (v) the dashboards used by different non-governmental organizations were not integrated with DHIS2. To address these gaps, ARK Foundation’s Community-led Responsive and Effective Urban Health Systems (CHORUS) research team coordinated and engaged with various national and international stakeholders through multiple events. Initially, the CHORUS team partnered with the Non-communicable Disease Control (NCDC) program of the Ministry of Health and Family Welfare (MoHFW) to address NCD-related issues in urban areas. Subsequently, to enhance NCD-related data integration from government outdoor dispensaries and NGO clinics, ARK collaborated with the Dhaka Civil Surgeon Office (DCSO), Upazilla Health Care (UHC) facilities, and Dhaka North City Corporation (DNCC). This initiative explored possibilities to integrate NCD recording and reporting into the DHIS2 dashboard. ARK’s engagement with government agencies proved effective, leading to the formation of a steering committee comprising members from NCDC, DCSO, UHC, and DNCC. This committee facilitated co-creation workshops involving development partners such as UNICEF, WHO, BRAC, icddr,b, and the National Heart Foundation (NHF). Following these extensive workshops, it was decided to introduce Simple App, an existing health data software already operational in public health systems in rural areas, into urban settings. This Simple App would be linked with the DHIS2 dashboard to streamline health data management across urban domains. First introduced by the Heart Foundation, Simple App was developed by Resolve to Save Lives (RTSL) at the rural NCD corners of Bangladesh Subsequently, ARK Foundation was given access to the Simple App to record and publish urban NCD data. Medical Assistants (Sub Assistant Community Medical Officers – SACMOs at Government Outdoor Dispensaries and Paramedics at NGO Clinics) from 10 urban NCD centers were trained to collect comprehensive patient data. This dataset includes 14 different variables related to NCDs. Notably, the enhanced Simple App now receives follow-up data on patients, including information about their medications, marking a crucial advancement in NCD management. Currently, NCDC and ARK are collaborating to analyse this data and formulate policies aimed at addressing NCDs in urban areas of the country. As of March 31, 2024, 16 urban primary healthcare centers are utilizing the Simple App. Reported cases include 398 cases of hypertension, 205 cases of diabetes mellitus, and 137 cases of both hypertension and diabetes. The Road Ahead According to the Digital Health Strategy, the state of digital health in Bangladesh is evaluated through the Global Digital Health Index (GDHI), serving as a national ‘digital health scorecard’ to assess maturity across various aspects. Scores range from one to five, aligning with different phases. Bangladesh scores four out of five overall in the GDHI assessment (Phase I–Experimentation, Phase II–Early Adoption, Phase III–Developing and Building Up, Phase IV–Scale Up, and Phase V– Mainstreaming), placing it in the ‘Scaling Up’ phase [v]. GDHI is based on the seven building blocks that the WHO/ITU toolkit references – leadership and governance; strategy and investment; legislation, policy and compliance; workforce; standards and interoperability; infrastructure; and services and applications.[vi] Building on ARK’s progress, the NCDC has pledged to establish additional NCD corners in collaboration with the ARK Foundation at UDs and NGO clinics in Dhaka, equipped with necessary amenities to ensure flawless NCD service delivery. To enhance Simple App utilization, new Urban Dispensaries (UDs) and NGO clinics will be included to the list. Furthermore, with ARK Foundation’s support, the use of Simple App will expand to UDs in one of Bangladesh’s secondary cities, Khulna. Since its establishment in 2013, ARK Foundation has dedicated itself to impacting people’s lives through operations research, evidence-based solutions, training, advocacy, and communication across health, nutrition, population, education, gender, environment, and human resources development. In pursuit of these goals, ARK supports the government and aligns with the objectives outlined in the Digital Health Strategy which aims to advance integrated digital health, nutrition, and family planning services, enhance citizens’ access to services according to their needs, ensure data availability for informed decision-making and governance, and empower service providers and health professionals with digital tools to deliver quality health services to the people of Bangladesh.[vii] The forthcoming Fifth Health Population, and Nutrition Sector Program (HPNSP) will be a crucial tool to advance the Smart Bangladesh initiative. According to a report published in the daily Business Standard, 5^th HPNSP aims to expand coverage, improve access to, and increase utilization of quality primary healthcare services in both rural and urban areas within five years from July. The honourable Health Minister Dr. Samanta Lal Sen said, “primary healthcare and universal health coverage will be our top priorities. Besides, we will emphasize prevention of maternal and child mortality. We will work from the first day of the 5th HPNSP so that we can spend the allocated money in the program properly.” According to the report, the budget for the 5th HPNSP is 53% higher than that of the fourth program, which ends this June. In the 5th HPNSP, officials from the Directorate General of Health Services and the Economic Relations Division (ERD) state that there will be a strong focus on expanding primary health coverage, disease prevention, and promoting healthy lifestyles. These efforts are expected to reduce out-of-pocket healthcare expenses for the public. In the End … Rapid and unplanned urbanization in Bangladesh has led to a significant increase in non-communicable diseases among the urban population, requiring immediate attention and action. To effectively manage NCDs, it is essential to collect comprehensive data and regularly update information from urban primary healthcare (PHC) facilities, including Urban Dispensaries and NGO clinics. However, in Bangladesh, the absence of comprehensive NCD data creates a significant gap, impeding the development of effective strategies and progress measurement. Addressing this gap requires robust coordination and collaboration between ministries and development partners. Furthermore, investing in urban PHC infrastructure is essential to manage the growing burden of NCDs and provide equitable health services to urban populations. Since the independence in 1971, Bangladesh’s healthcare system has received acclaim from various international organizations for its consistent success. The renowned British medical journal, The Lancet, has even described this success as ‘one of the great mysteries of global health.’ The Bangladesh government’s ongoing support and commitment to reforming the healthcare system are key factors behind these achievements. With continued monitoring and support from the authorities, we believe that public-private partnerships in the health sector will be crucial in overcoming internal challenges and progressing towards the implementation of the Fifth HPNSP, ultimately helping to achieve Bangladesh’s Smart Nation vision by 2041.   [i] WHO, Innovation for Urban Health Policy Brief [ii] Generation and Working with Urban Health, Policy Brief [iii] Bangladesh Health Workforce Strategy, 2023 (https://dgnm.gov.bd/sites/default/files/files/dgnm.portal.gov.bd/go_ultimate/ddeae4a2_47b3_48ae_b812_e9ce8539854f/2023-08-13-14-06-3fd85cf63ab05484abdd4faa20afb023.pdf) [iv]Bangladesh Digital Health Strategy 2023-2027, MoHFW (https://dghs.portal.gov.bd/sites/default/files/files/dghs.portal.gov.bd/page/4124d18a_ab99_40e2_8fef_ff4052948739/2024-04-23-07-09-48541d4dd55108137e50961ebcba0477.pdf) [v] Bangladesh Digital Health Strategy 2023-2027, MoHFW [vi] Bangladesh Digital Health Strategy 2023-2027, MoHFW [vii] Bangladesh Digital Health Strategy 2023-2027, MoHFW   Photo Credits: ARK Foundation