SILVER OPPORTUNITY: CASE STUDIES TIME TO FOCUS ON HEALTHY AGING Challenges, Opportunities, and Recommendations for Bangladesh FEBRUARY 2023 © 2023 The World Bank Group 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org and www.ifc.org SOME RIGHTS RESERVED This work is a product of the staff of The World Bank and the International Finance Corporation (the World Bank Group) with external contributions. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of The World Bank’s Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the information included in this work. The boundaries, colors, denominations, and other information shown on any map in this work do not imply any judgment on the part of The World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. RIGHTS AND PERMISSIONS The material in this work is subject to copyright. Because the World Bank encourages dissemination of its knowledge, this work may be reproduced, in whole or in part, for non- commercial purposes as long as full attribution to the work is given. ATTRIBUTION — Please cite the work as follows: “World Bank Group. 2023. Time to Focus on Healthy Aging: Challenges, Opportunities, and Recommendations for Bangladesh. (c) World Bank Group.” All queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. Authors Khaleda Islam Seemi Qaiser Kathryn Andrews Jigyasa Sharma Xiaohui Hou Bushra Binte Alam Atia Hossain 6 SILVER OPPORTUNITY CASE STUDIES Acknowledgements This report was prepared by a team led by Kathryn Andrews (Health Economist) and Jigyasa Sharma (Economist) and consisting of Khaleda Islam (Consultant), Seemi Qaiser (Consultant) and has benefitted from guidance from Xiaohui Hou (Senior Economist), Bushra Binte Alam (Senior Health Specialist), and Atia Hossain (Senior Economist). The authors are grateful to all the individuals, organizations, and institutions who provided their knowledge and expertise to the development of this report. This work was completed under the supervision and guidance of Monique Vledder (Practice Manager, Global Engagement, Health, Nutrition and Population Global Practice and Feng Zhao (Practice Manager, South Asia Region, Health, Nutrition and Population Global Practice). David Wilson (Program Director, Global Engagement, Health, Nutrition and Population Global Practice) and Juan Pablo Uribe (global director, Health, Nutrition and Population Global Practice) also provided overall guidance. Jocelyn Haye and Marize de Fatima Santos provided administrative support; Naoko Ohno (Senior Operations Officer) and Kyoko Tokuda (Operations Officer) provided Trust Fund administration guidance and support. We are grateful with the Japan Policy and Human Resources Development Fund (PHRD) Trust Fund for support with this report. SILVER OPPORTUNITY CASE STUDIES 7 Executive Summary Bangladesh is home to one of the largest populations of older adults in the world. Driven by increasing life expectancy at birth, this population is increasing. By 2040, one in five Bangladeshis will be 60 years old or older. The increase in lifespan is accompanied by a greater burden of noncommunicable diseases (NCDs), which account for 70 percent of all deaths in the country. These chronic conditions tend to affect older adults, leading to an increased demand for health care services by this group. NCDs are also expensive to treat, placing financial hardship on families in low- resource settings. While the Government of Bangladesh has committed to providing many of the basic rights of older adults, the health care needs of older adults remain unmet. A lack of adequate funding and services point to a need for a health care system that caters to the specific needs of older adults, such as long-term care and consolidation of care. Other supportive structures also appear to be missing, such as a health insurance fund that covers common chronic conditions faced by older adults, which would remove barriers to accessing health care. A bill proposing a pension scheme is currently undergoing approval in Bangladesh’s legislative system. The primary health care (PHC) system, too, is geared toward the treatment of acute illnesses rather than providing older Bangladeshis with integrated, long-term, people- centered care. This study aimed to better understand the current capacity of PHC in Bangladesh to provide care oriented towards older persons. The authors carried out a desk review of global and Bangladeshi literature on aging populations, followed by stakeholder consultations and key informant interviews with government officials, health professionals, and developmental organizations. Field visits to PHC facilities were also carried out to assess whether they met the internationally accepted criteria for age-friendly infrastructure. The data were compiled and analyzed according to the FIRE framework (Financing, Innovation, Regulation, Evaluation) for older adult care. Despite the large burden of NCDs, only USD0.82 is spent per capita on NCD control, much lower than the USD1.50 recommended by the World Health Organization (WHO). Increasing spending on NCD management can help alleviate the financial 8 SILVER OPPORTUNITY CASE STUDIES pressure on households to care for older adults. Neither NCD control nor PHC services adequately take needs of older adults into consideration. For instance, there are no protocols for older adults in place, collected data are not disaggregated by age, and the training of health professionals does not cover older adult care. When it comes to regulations, several policies for older adults have been formally adopted but are not observed in practice. While there is motivation to evaluate the outcomes of service delivery for older adults, a shortage of human resources has made it difficult to carry out formal evaluations. Based on these findings, the authors put forth a set of recommendations to improve care for older adults in Bangladesh. Under the theme of financing, the Government should consider investing more in the health of older adults using an output-based budget. Cost-saving measures can be implemented in parallel, such as involving non-health ministries and enforcing clear guidelines on payment mechanisms. Under the theme of innovation, digital health technology can be leveraged to improve accessibility of care and to create a long-term care lens to improve senior health outcomes. For instance, telemedicine can assist older adults with mobility issues to see their physician from the comfort of their home. Meanwhile, training health professionals to employ an age-sensitive approach to senior care can improve the patient experience. Under the theme of regulation, oversight can play a vital role in improving quality and accountability. The frequency of interruptions in the supply chain should be reduced to ensure a continuous supply of essential drugs. In health facilities, financial management policies can prevent waste. Under the theme of evaluation, the position of an evaluation officer could be created to monitor adherence to quality guidelines. Together, these suggestions can build a foundation for a holistic health care system that is adequately prepared to support the aging population and maximize the years Bangladeshis spend in good health. SILVER OPPORTUNITY CASE STUDIES 9 CONTENTS LIST OF FIGURES 10 LIST OF TABLES 10 ACRONYMS 11 1. INTRODUCTION 13 1.1 Case Study Objective 16 2. METHODS 19 Facility visits 21 Stakeholder consultation 22 Key informant interviews (KIIs) 22 Data analysis 23 3. FINDINGS 27 3.1 The landscape of care for older adults in Bangladesh 27 Population age structure 28 Bangladesh has a large proportion of youth ages 15-19 28 Bangladesh’s low mortality and fertility is expected to cause a population boom in 2051 29 By 2100, the population age structure will be transformed 29 In 30 years, one in five Bangladeshis will be 60 or older 31 Burden of disease in Bangladesh 32 Bangladesh is bearing the double burden of NCDs and communicable diseases (CDs) 32 3.2 Financing older adult care 36 3.3 Innovation for older adult care 39 3.4 Regulations for older adult care 45 3.5 Evaluation for older adult care program 49 4. STUDY RECOMMENDATIONS 51 4.1 Financing 51 4.2 Innovation 52 4.2.1 Digital health 52 Improve record keeping for patient follow-up 52 Establish telemedicine care to increase access 52 4.2.2 Long-term care for older adults in PHC 53 Provide HWF training sensitive to older adults 53 Redesign SDS to center on older adult care 53 Check for multimorbidity and special health needs 54 Offer health education and counseling for patients 54 Provide emergency care for older adults at all levels: facility, community, and household 55 Update list of essential drugs and medical equipment 55 4.3 Regulation 56 Establish a training program for managers on financial regulation 56 Strengthen HWF regulations to improve performance and accountability 56 Prevent breaks in supply via supply chain management 56 Ensure quality across services via telemedicine regulations 57 Oversee the private sector in providing care for older adults 57 4.4 Evaluation 57 5. CONCLUSION 59 6. REFERENCES 63 10 SILVER OPPORTUNITY CASE STUDIES ANNEXES 70 Annex 1: List of facilities observed 70 Annex 2: Observation checklist 70 Annex 3: List of Stakeholders 71 Annex 4: List of Key Informants 71 Annex 5: Guideline for stakeholder consultation and KII 72 Annex 6: FIRE Framework 72 Annex 7: Findings from the field 73 Rural PHC facilities visit 73 Community clinic (CC) 73 Union Subcenter (USC) 74 The Upazila Health Complex (UzHC) 75 Urban PHC facilities visit 77 3.3.2.2 Urban PHC facilities 77 3.3.2.3 Private and nonprofit sector provision of care for older adults 77 SILVER OPPORTUNITY CASE STUDIES 11 LIST OF FIGURES Figure 1: The FIRE Framework for Building Integrated Services for Older Adults around Primary Health Care 20 Figure 2: Gradual increase in percentage of population 60 years and above based on census year data 21 Figure 3: Bangladesh Age-Sex Pyramid (millions) in 2011 and 2022. 22 Figure 4: Bangladesh Age-Sex Pyramid (millions) in 2001 and 2051. 23 Figure 5: Bangladesh’s population age structure for males and females in 1990, 2019 (reference scenario), and 2100 (reference scenario) 24 Figure 6: Proportional mortality from NCDs has been gradually increasing in Bangladesh 26 Figure 7: Proportional mortality from different causes in 2018 in Bangladesh 26 Figure 8: Estimated prevalence of disability (millions) for leading disabling conditions among population groups ages 60+ in low- and middle-income countries 27 LIST OF TABLES Table 1: Overview of methods 15 Table 2: Key figures in Bangladesh’s aging population in 2019 and 2050 23 Table 3: Frequency (prevalence per 100 people) of nine individual chronic health conditions used in defining multimorbidity by sex (n=452) 26 Table 4: Overview of recommendations 36 12 SILVER OPPORTUNITY CASE STUDIES ACRONYMS BDT Bangladesh Taka MOH&FW Ministry of Health and Family CBHC Community-Based Heath Care Welfare CHCP Community Health Care MOLGRD&C Ministry of Local Government, Provider Rural Development & CHW Community Health Worker Cooperative CVD Cardiovascular Disease MOSW Ministry of Social Work DGDA Directorate General of Drug MSAP Multisectoral Action Plan Administration MSR Medical and Surgical Requisite DGFP Directorate General of Family NCD Non-Communicable Diseases Planning NCDC Non-Communicable Disease DGHS Directorate General of Health Control Services NGO Non-Governmental DHIS2 District Health Information Organization System (version 2) NMNC National Multisectoral EDCL Essential Drugs Company Coordination Committee Limited PHC Primary Health Care ESP Essential Services Package SACMO Sub-Assistant Community FP Family Planning Medical Officers FPI Family Planning Inspector SDG Sustainable Development FRP Financial risk protection Goal FWA Family Welfare Assistant SDS Service Delivery System GDP Gross Domestic Product SOP Standard Operating Procedure HA Health Assistant SRH Sexual and Reproductive HAEFA Health and Education For All Health HWF Health Workforce UHC Universal Health Coverage ICT Information Communication UH&FPO Upazila Health and Family Technologies Planning Officer ICOPE The Integrated Care for UH&FWC Union Health and Family Older People Welfare Centre IEC Information, education, UzHC Upazila Health Complex communication UH&FPO Upazila Health and Family IPCHS Integrated people-centered Planning Officer health services UH&FWC Union Health and Family IT Information Technology Welfare Center KII Key Informant Interview UFPO Upazila Family Planning MCH Maternal and Child Health Officer MIS Medical Information System UN United Nations MHV Multipurpose health volunteer USC Union Subcenter MIPAA Madrid International Plan of USD United States Dollar Action on Ageing WHO World Health Organization SILVER OPPORTUNITY CASE STUDIES 13 14 SILVER OPPORTUNITY CASE STUDIES 1. INTRODUCTION Globally, the percentage of older adults—defined in this report as ages 60 and older—in the general population is increasing. This demographic shift is being driven by increased longevity around the world. In 2019, the number of Advances in nutrition, older adults was one billion. This population is expected to reach 1.4 billion by sanitation, health 2030 and 2.1 billion in 2050 (WHO 2022a). In 2019, one in 11 people were 65 and care, and education older. A 2019 United Nations (UN) report projected that, by 2050, one in six people will be 65 or older (United Nations 2019). The report underscored the importance are resulting in of planning for this fastest-growing age group in order to achieve the Sustainable extended life spans. Development Goals (SDGs) and move toward Universal Health Coverage (UHC). To shed further light on this critical issue, the UN has declared 2021–2030 as the Decade of Healthy Aging (WHO 2022b). Developing countries will be particularly impacted by the accelerated growth of the older adult population. Between 2010 and 2015, life expectancy was 68 years in developing regions and 78 years in developed regions. By 2045 or 2050, average life expectancy is projected to increase to 74 years in developing regions and 83 years in developed regions – an increase of six and five years, respectively (UNFPA and HelpAge International 2012). Advances in nutrition, sanitation, health care, and education are resulting in extended life spans. Healthy aging is determined by personal behaviors like diet and exercise, by genetics, and by environmental factors, all of which become components of a person’s life long before they reach the age of 60. By addressing socioeconomic challenges faced by the aging population and their families, governments can maximize this group’s health and social contributions. These include myriad factors, from the quality of the environment (for example, air pollution) to accessibility of health care services. A better understanding of these challenges can help create an age-friendly social structure to provide adequate support (WHO 2022a). Ensuring the health of aging populations has been a global UN priority long before the current Decade of Healthy Ageing (2021–2030). Adopted in 2012, the UN’s Madrid International Plan of Action on Ageing (MIPAA) calls for changes in policies and practices to ensure the rights of aging populations (UNFPA and HelpAge International 2012). Ten years on, this call to action is just as relevant. SILVER OPPORTUNITY CASE STUDIES 15 While some countries have embraced policies and programs for older persons, there remains a need for enforcement and implementation. As the older adult The COVID-19 pandemic revealed gaps in policies, systems, and services population grows at a needed to ensure access to basic health resources by older adults. Older people in Bangladesh have been disproportionately affected by COVID-19. The faster rate, challenges case fatality rate is 1.4 percent for those younger than 60 years (World Bank 2021), are starting to emerge 4.5 percent for adults over 60, and 13.4 percent for adults over 80. The health care system was simply not prepared to meet their unique needs during this recent in the areas of health crisis. and social services. Bangladesh is one of 20 developing countries with the largest populations of older adults—defined as 60 or older—in the world (Bangladesh Bureau of Statistics 2015). By 2025, Bangladesh, along with China, India, Indonesia, and Pakistan, will account for about half of the world’s entire older adult population. By 2025, one in 10 Bangladeshis will be 60 or older, and by 2050, that number will be one in five (Kabir et al. 2013). Given this rapid increase in the older population, aging is emerging as an important issue in Bangladesh because of its potential long-term impacts on the country’s development trajectory and on its public service and health sectors. Bangladesh’s health sector, as of yet, is not fully prepared to support the needs of an aging population. As the older adult population grows at a faster rate, challenges are starting to emerge in the areas of health and social services. For one thing, as people age, the risk of developing non-communicable diseases (NCDs), which are costly for families in resource-poor countries to treat or manage, rises substantially (Sarker 2021). Such chronic conditions and multi- morbidity among older adults raise the demand for health care (Acharya et al. 2019). The diminishing physical and cognitive functions of the aging population, and hence their increasing dependency on others, can be expected to further increase the burden on families providing care (Kabir et al. 2013).7 Compounding this, Bangladesh’s health system will need to face the additional challenge of protecting older people from impending climate- related threats in the future. Climate change is poised to become the leading 16 SILVER OPPORTUNITY CASE STUDIES global risk factor for excess mortality (WHO and UN DESA 2022). Already prone to flooding, Bangladesh is expected to experience a significant increase in the frequency, duration, and intensity of heat stress, flooding, and landslides (World New policies across Bank 2022). This increase in natural disaster activity will disproportionately the health and social impact the more vulnerable among the population, especially older adults (WHO and UN DESA 2022). Exposure to extreme weather events, especially those that sectors are needed require immediate evacuation, will likely take a toll on their physical and mental to support this older health (World Bank 2022)—and the country largely is not prepared for this. adult population. New policies across the health and social sectors are needed to support this older adult population. Following the initiation of the UN’s Decade of Healthy Ageing (2021–2030), the World Health Organization (WHO) led a global collaboration of governments, international agencies, civil society, and other stakeholders to focus on improving the lives of older people. One consensus that emerged from these collaborations is WHO’s recommendation that governments adopt the highest level of political commitment to ensuring that their populations live long lives in good health—in short, to invest in their human capital. To address the basic need of health care for all, WHO recommends primary health care (PHC) as a foundation for UHC (WHO 2022a). PHC facilities in Bangladesh are not oriented toward the health care needs of older adults. In 2013, Bangladesh developed a policy establishing the State’s responsibility to secure the basic rights of older adults (Sarker 2021). However, in reality, this population must commonly contend with inadequate health care facilities, a lack of financial support, and negligence. The Government should therefore start planning for an appropriate pension system and a health insurance scheme to cover their financial needs. Most importantly, in alignment with WHO’s recommendations, the Government needs to address the health care needs of the aging population through a PHC system while planning for assisted-living facilities, adult day care centers, and other living supports (Bangladesh Bureau of Statistics 2015). Currently, Bangladesh’s health care system focuses on curative care for acute illnesses and is not very effective in addressing long-term care for chronic illness. Moreover, older adults need a wide range of health care services incorporated in a one-stop location, which is not currently available at Bangladesh’s PHC facilities. SILVER OPPORTUNITY CASE STUDIES 17 1.1 Case Study Objective This study aimed to explore the capacity of PHC services to provide integrated, long-term, people-centered care to older adults in Bangladesh. Based on the findings, recommendations were formulated regarding the integration of lifelong chronic disease care for older adults in PHC services. This study explores the capacity of Bangladesh’s PHC services to provide integrated, long-term, people- centered care for older adults and outlines recommendations to improve the care infrastructure for aging adults through a more integrated health care approach at the PHC level. 18 SILVER OPPORTUNITY CASE STUDIES SILVER OPPORTUNITY CASE STUDIES 19 This survey will not only inform the plans of the MoH, but also, will provide key insights for World Bank work in the country, region, and worldwide. 20 SILVER OPPORTUNITY CASE STUDIES 2. METHODS Two main methods were used to conduct the situational analysis of care for older adults in Bangladesh: a scoping literature review and primary data collection. Two main methods A desk review of global and Bangladeshi research on aging populations was were used to conduct conducted. Following this, stakeholder consultations and key informant interviews were organized with government bureaucrats, health professionals the situational who provide chronic care, and development partners. Additionally, field visits analysis of care were conducted to understand and evaluate procedures and practices at the PHC facility level. Table 1 summarizes the sources of primary and secondary evidence for older adults informing this case study. in Bangladesh: a scoping literature review and primary data collection. SILVER OPPORTUNITY CASE STUDIES 21 Table 1: Overview of methods SECONDARY DATA PRIMARY DATA FACILITY VISITS STAKEHOLDER KEY INFORMANT CONSULTATIONS INTERVIEWS Keywords: Rural Areas Personnel • Bangladesh Subdistrict: a) Chronic disease • MOH&FW policymakers • Demographics • 2 UzHCs management • Managers • Aging population b) NCDC program • Chronic disease service • Seniors/Older persons Union/ward: providers • Health needs •1 USCs Personnel • Health care a) Program personnel from Topics • PHC Community level: the DGHS involved in deciding • Long-term care related • Social care • 1 Community clinic policy financing b) Facility managers and • Digital health Document types: Urban health service providers (UzHC • Health workforce • Reports • 1 Government facility – subdistrict and below) and competency • Case studies • 1 Private facility urban PHC providers. • Drug supply, vaccines, • Learnings c) Development partners technologies, and assistive • Research articles Checklist providing NCDC devices • Protocols • Physical infrastructure implementation support and • Service delivery • Guidelines • Furniture innovating in urban and rural • Program regulation and • Manuals • Drugs areas evaluation • Logistics Sources: • Electricity • International • Running water organizations • Cleanliness inside and • Research institutes outside • Government of • Safety Bangladesh • IEC materials 22 SILVER OPPORTUNITY CASE STUDIES A desk review of research and policy literature related to population aging in the global and Bangladeshi contexts was undertaken. Relevant literature was identified through Google searches and supplemented with bibliography search of key policy documents. Reports, case studies, lessons learned, and articles from peer-reviewed journals focusing on older adults were identified. Literature was also collected from the websites of the UN and other international organizations and research institutes. Reports, protocols, guidelines, and manuals related to aging population that were not available online were obtained from the Bangladesh government. Bangladesh- specific literature was selected based on content related to demographic patterns, chronic diseases contributing to the mortality and morbidity profile of the population, health care policies for older adults, strategies, action plans, protocols, and the PHC system. Primary data collection consisted of stakeholder consultations, key informant interviews (KII), and PHC facility visits. Facility visits PHC services in rural Bangladesh are provided by facilities at three levels: subdistrict, union and ward, and community level. Respectively, these include upazila health complexes (UzHCs), union subcenters (USCs), and community clinics. In consultation with the Non-Communicable Diseases Control (NCDC) program, two UzHCs, one USC, and one community clinic were selected and visited. To assess urban PHC facilities, one government facility and one private facility were visited. See Annex 1 for the list of facilities visited. Observation of the facilities was completed using an observation checklist, which was prepared by contextualizing WHO’s Age-friendly Primary Health Care Centre Toolkit and an age-friendly hospital checklist developed by Ahmadi et al. (2015) (WHO 2008a; Ahmadi et al. 2014). Consultations with managers and available service providers were completed following the consultation guidelines. The readiness of the PHC facility to provide long-term care for an aging population and SILVER OPPORTUNITY CASE STUDIES 23 aging-friendly infrastructure was considered during the facility visit. See Annex 2 for the observation checklist. Primary data collection consisted Stakeholder consultation of stakeholder Stakeholders directly related to chronic disease management and the NCDC consultations, key program were selected for consultation. The participants included program personnel from the Directorate General of Health Services (DGHS) involved in informant interviews, deciding policy; facility managers and health service providers from upazila and primary health health complexes (subdistrict) and below-level facilities; and urban PHC providers. The second stakeholder category were development partners care facility visits. supporting the Government in the NCDC program implementation and other innovative approaches in both urban and rural areas. The consultations were conducted in person, and they followed interview guidelines. Only one consultation was conducted online. The consultation guidelines used were developed following the literature review to explore issues related to financing, digital health, competency of health workforce, supply of drugs, vaccines, technologies, assistive devices, service delivery, regulation, and an evaluation of the program related to care for older adults. Key informant interviews (KIIs) Key informants were selected for interview based on their roles and responsibilities in the NCDC program and care for older adults, and their willingness and availability to participate in the study. Participants included policy makers from the Ministry of Health and Family Welfare (MOH&FW), managers, and chronic disease service providers. The interviews were mostly conducted in person following the interview guidelines; few were conducted online. Similar to the consultation guidelines, the interview guidelines were developed to focus on the themes that emerged from the literature review: financing, digital health, workforce competency, supply of drugs and equipment, service delivery, 24 SILVER OPPORTUNITY CASE STUDIES regulation, and program evaluation. The list of stakeholders (Annex 3), key informants (Annex 4), and the guidelines for consultations and interviews (Annex 5) provide additional detail. This case study has some limitations, partly attributable to study methodology and various logistical constraints. For example, although extensive consultations with key stakeholders were conducted to explore the current policy, program, and PHC issues, the study focused on the public sector’s aging care delivery system because it is still in its nascency, with many opportunities for growth. Logistical challenges limited the number of field visits, and thus a purposive, convenience sample of health facilities was selected for primary data collection. Data analysis Qualitative data were collected through literature review, field visits, key stakeholder consultations and KIIs. Data collection through stakeholder consultations and KIIs was continued until the point of saturation. All data collected were compiled and analyzed along the thematic areas of a) financing; b) innovation (in digital health, competency of health workforce, supply of drugs, vaccines, technologies, assistive devices, service delivery); c) regulation; and d) evaluation, as described in the FIRE framework (Figure 1).   SILVER OPPORTUNITY CASE STUDIES 25 Figure 1: The FIRE Framework for Building Integrated Services for Older Adults around Primary Health Care Source: Hou (2023) 26 SILVER OPPORTUNITY CASE STUDIES SILVER OPPORTUNITY CASE STUDIES 27 28 SILVER OPPORTUNITY CASE STUDIES 3. FINDINGS This section begins with a brief overview of Bangladesh’s aging population, followed by analysis of the research through the FIRE Framework themes of Bangladesh’s finance, innovation, regulation, and evaluation. aging population is increasing in size. 3.1 The landscape of care for older adults in Bangladesh Bangladesh’s aging population is increasing in size. The population census data analysis shows that the percentage of the population 60 years and above has gradually increased between 2001 and 2022, and currently sits at nearly 9.3 percent (Figure 2) (Bangladesh Bureau of Statistics 2022). Figure 2: Gradual increase in percentage of population 60 years and above based on census year data Source: Bangladesh Bureau of Statistics, Statistics and Informatics Division, Ministry of Planning, Government of the People’s Republic of Bangladesh SILVER OPPORTUNITY CASE STUDIES 29 In Bangladesh, life expectancy is increasing, which means that the relative proportion of the population over 60 will continue to grow. Currently, life expectancy at birth is 73 years (World Bank 2023). As life expectancy increases, the Currently, life number of years lived after age 60 also increases. expectancy at birth is 73 years (World Population age structure Bank 2023). As life Bangladesh has a large proportion of youth ages 15-19 expectancy increases, the number of years The 2022 census revealed that the largest proportion of the population is the age group 15–19 years (10.3 percent) and the lowest is ages 95 and above (less than lived after age 60 also 1 percent). It is worth noting that the youth population (ages 15–24) made up increases. 18.16 percent of the population in 2011 and increased to 19.11 percent in 2022 (Bangladesh Bureau of Statistics 2022). Figure 3 shows the age–sex pyramid in 2011 and 2022. The 2022 pyramid shows a shrinking base with a bulge in the lower- middle. Figure 3: Bangladesh Age-Sex Pyramid (millions) in 2011 and 2022. Source: Population & Housing Census 2022: Preliminary Report. 30 SILVER OPPORTUNITY CASE STUDIES Bangladesh’s low mortality and fertility is expected to cause a population boom in 2051 Population trends reveal that Bangladesh is currently in Stage 3 of the demographic transition, as it shifts from falling mortality-low fertility (Stage 3) to low mortality- low fertility (Stage 4). This shift will result in a significant increase in the over-60 population in 2051 (Figure 4) (Nabi 2012). Figure 4: Bangladesh Age-Sex Pyramid (millions) in 2001 and 2051. Source: Nabi (2012). By 2100, the population age structure will be transformed As Figure 6 shows, the 1990 population pyramid of Bangladesh shows a country still at Stage 1 of the demographic transition: a pyramid with an expansive broad base and successive narrowing of the population cohort size with increasing age. In demographic terms, this shape represents high fertility (high population growth rate) combined with high mortality (low life expectancy), and hence a significantly smaller older population relative to the total population. SILVER OPPORTUNITY CASE STUDIES 31 The 2019 population pyramid shows a country that has passed through Stage 2 (high fertility rate plus declining mortality rate leading to high population growth) and is entering Stage 3 of the demographic transition—a declining population growth rate caused by a combination of a fertility rate that is now beginning to decline, and a rapidly fallen mortality rate due to higher life expectancy (over 70 years). The 2100 projected population snapshot, created using forecasted data from the 2017 Global Burden of Disease Study (GBD 2017 Disease and Injury Incidence and Prevalence Collaborators 2018), shows a Stage 4 demographic transition “pyramid” that no longer even looks like a classic wide-based pyramid. Its narrow base and upper bulge reflect a dramatic demographic change that represents a combination of low fertility (low birth rate) and low mortality (high life expectancy) that lead to negative population growth and a significantly larger older population relative to the general population (Figure 5) (IHME 2022; Saroha 2018). Figure 5: Bangladesh’s population age structure for males and females in 1990, 2019 (reference scenario), and 2100 (reference scenario) Source: GBD 2017 Disease and Injury Incidence and Prevalence Collaborators (2017). 32 SILVER OPPORTUNITY CASE STUDIES In 30 years, one in five Bangladeshis will be 60 or older As of 2019, over 13 million people in Bangladesh are over 60 years (eight percent of the total population). An increase to 21.9 percent (about 36 million) in 2050 is expected (Table 2) (HelpAge International n.d). Table 2: Key figures in Bangladesh’s aging population in 2019 and 2050 and 2100 (reference scenario) 2019 2050 Population aged 60 and above (total) 13,109,000 36,871,000 Population aged 60 and above (% of total population) 8.0 21.9 Older women aged 60 and above (% of total population) 3.88 11.55 Life expectancy (males) 70.48 78.11 Life expectancy (females) 74.11 81.45 Old-Age Dependency Ratio (Age 65+ / Age 15-64) 7.7 23.5 Rural older people aged 60 and above (% of total population) 3.46 Urban older people aged 60 and above (% of total population) 1.4 Older persons living alone aged 60 and above (% of total population aged 60+) 1.77 Source: HelpAge International. SILVER OPPORTUNITY CASE STUDIES 33 Burden of disease in Bangladesh Globally, the three Bangladesh is bearing the double burden of NCDs and communicable diseases (CDs) leading causes of premature death, According to WHO, the proportional mortality (percent of total deaths, all ages, both sexes) from NCDs is gradually increasing and currently accounts for 70 percent regardless of the of all deaths, an increase of 3 percent since 2018 (Figures 6 and 7). The probability level of economic of premature mortality from NCDs is 19 percent (WHO 2011; 2014; 2018a; 2022d). development, are Figure 6: Proportional mortality from NCDs has been gradually increasing in Bangladesh ischemic heart PERCENTAGE OF DEATHS FROM NCD disease, stroke, and 80% chronic respiratory 70% disease 70% 60% 67% 50% 59% 52% 40% 30% 20% 10% 0% 2011 2014 2018 2022 Source: WHO (2011; 2014; 2018a; 2022d) 34 SILVER OPPORTUNITY CASE STUDIES Figure 7: Proportional mortality from different causes in 2018 in Bangladesh PROPORTIONAL MORTALITY IN 2018 7% 26% 67% NCD Communicable, maternal, perinatal, nutritional conditions Injuries Source: World Health Organization (2018) Globally, the three leading causes of premature death, regardless of the level of economic development, are ischemic heart disease, stroke, and chronic respiratory disease (UNFPA and HelpAge International 2012; Lopez and Mathers 2006). These three diseases are also the leading causes of death among older adults. In low- and middle-income countries, the primary disabling conditions among population groups ages 60 and older are visual and hearing impairment, dementia, and osteoarthritis (Figure 8) (WHO 2008b). SILVER OPPORTUNITY CASE STUDIES 35 Figure 8: Estimated prevalence of disability (millions) for leading disabling conditions among population groups ages 60+ in low- and middle-income countries Arthritis and 50 hypertension are the 43,9 45 40 39,8 most common multi- 35 31,4 morbidities. 30 25 19,4 20 15,1 15 11,9 10 8,07 ,9 7,0 5,7 4,8 5 3,0 0 Disabling Conditions Source: World Health Organization (2008). Arthritis and hypertension are the most common multi-morbidities. A study conducted in Bangladesh to explore the prevalence and pattern of multimorbidity among those 60 and older examined nine chronic health conditions. The study revealed the most common disorder to be arthritis (57.5 percent) and hypertension (38.7 percent) (Table 3) (Khanam 2011). 36 SILVER OPPORTUNITY CASE STUDIES Table 3: Frequency (prevalence per 100 people) of nine individual chronic health conditions used in defining multimorbidity by sex (n=452) CHRONIC HEALTH TOTAL POPULATION WOMEN (N=248) P VALUE* CONDITION NO % NO. % NO. % Arthritis 260 57.5 113 55.4 147 59.3 0.231 Hypertension 175 38.7 74 36.3 101 40.7 0.192 Impaired vision 161 35.6 8 3.9 153 61.7 <0.0001 Signs of thyroid hypofunction 48 10.6 18 8.8 30 12.1 0.166 Obstructive pulmonary 31 6.9 27 13.2 4 1.6 <0.0001 symptoms Symptoms of heart failure 21 4.6 13 6.4 8 3.2 0.088 Hearing impairment 11 2.4 2 1.0 9 3.6 0.062 Obesity 11 2.4 3 1.5 8 3.2 0.186 Stroke 4 0.9 1 0.5 3 1.2 0.388 *p-value is for the test of difference between men and women Source: Khanam, M. A. et al. (2011). SILVER OPPORTUNITY CASE STUDIES 37 Despite a large NCD burden, there is a lack of NCD-geared policies. To begin the process of health system strengthening, it is important to collect and examine population-based mortality data by cause. To determine the major causes of death To begin the process among adults, and their health care seeking behavior, a study was conducted of health system in the Matlab subdistrict in rural Bangladesh during 2003–2004. Of 2,397 deaths examined, 613 were of adults ages 15–59 years and 1,784 were older adults (≥60 strengthening, years). CDs were the cause of 18 percent of the deaths, NCDs 66 percent. The it is important to proportion of NCDs increased with age. The leading NCDs were diseases of the circulatory system (35 percent), neoplasms (11 percent), diseases of the respiratory collect and examine and digestive system (10 percent and 6 percent, respectively), and endocrine and population-based metabolic disorders (6 percent). Injuries and other external causes accounted for another 5 percent of deaths (Alam 2010). mortality data by cause. The study findings revealed that although NCDs were responsible for 66 percent of all deaths, there are no NCD-specific policies in place. This study underscores the importance of chronic disease prevention and management in a country’s national health agenda. 3.2 Financing for older adult care The lack of health care budget allocation is a significant problem in Bangladesh. In 2019–2020, the health care budget was equal to 1.02 percent of GDP. In neighboring Sri Lanka, the health care budget was 3.9 percent of GDP, and 10.6 percent in the Maldives, in 2016 (Murshid and Haque 2020). The public expenditure on health, population, and nutrition (HPN) has remained stagnant for several years in Bangladesh, at 0.7 percent of GDP, and needs to be increased according to the Government’s eighth Five Year Plan, July 2020–June 2025. The plan recommends increasing the HPN public expenditure and emphasizes the need for health 38 SILVER OPPORTUNITY CASE STUDIES insurance subsidies for older adults. The prospective plan outlines a gradual increase in public health spending to 2 percent of GDP by fiscal year 2041. It also suggests that health policy should include universal access to health insurance Increasing national schemes at affordable prices to achieve UHC by 2030 (General Economics health spending to Division 2020). promote preventative The financing review revealed some important gaps in the planning and allocation care can be a of healthcare funds, including the following: budget allocation for facilities is based on the number of beds and the bed occupancy rate, which excludes outpatient measure to mitigate utilization; the management of medicines is inefficient and paper-based; and the the potential cost Operational Plan (OP) allocation for senior-related care is targeted only toward health workforce (HWF) training. The financing findings are detailed below. of expensive NCD curative treatment. Increasing national health spending to promote preventative care can be a measure to mitigate the potential cost of expensive NCD curative treatment. According to the World Data Atlas, in 2019, per capita healthcare spending was USD46 in Bangladesh (World Data Atlas n.d.). A World Bank study revealed that the NCD control budget was small, just 4.2 percent of the health sector program, and equivalent to 6.8 Bangladesh Taka (BDT) (USD0.082) per capita (World Bank 2019). This per capita NCD allocation is below the WHO’s estimated cost of implementing the full set of “best buy” interventions (USD1.50 per person per year in lower-middle-income countries). The World Bank report emphasized the importance of adequate financing for an NCD response, including alternate financing for the protection of households. The report also recommended a long-term human resource strategy to respond to changing service needs, and additional taxes on tobacco, alcohol, and sugar-sweetened beverages (World Bank 2019). A study in Bangladesh in 2020 calculated that the estimated annual medication cost per patient with hypertension, diabetes, and cholesterol was USD18, USD29, and USD37, respectively. The total annual cost for the hypertension control program, for example, was estimated at USD3.2 million, equal to USD2.8 per capita or USD8.9 per eligible patient. The largest cost share (USD1.35 million or 43 percent) was attributed to the cost of medication, followed by the cost of provider time for treatment (38 percent). The study recommended scaling up PHC SILVER OPPORTUNITY CASE STUDIES 39 to prevent cardiovascular disease (CVD) through task-sharing, that is, shifting selected tasks from doctors to nurses and community health workers (CHWs) (Husain 2022). This recommendation could be applied to other control programs The needs of the to increase the effectiveness of the program while containing costs. aging population are A Bangladeshi study conducted in 2017 on the cost of diabetes care revealed often overlooked in that the average annual cost of diabetes mellitus treatment is USD864.7 per NCD financing and patient. After factoring in hospitalization costs, this total increases 4.2 times (Afroz 2019). The cost of medicine accounted for 60.7 percent of the direct management. cost; hospitalization costs accounted for 27.7 percent. Use of insulin, longer treatment duration, and the presence of complications all significantly influenced the average annual cost per patient. The report recommended lifestyle modifications to manage diabetes, prevent comorbidities, and reduce cost. Rahman, Gasbarro, and Alam (2022) found that Bangladesh’s out-of-pocket expenses increased by more than 50 percent between 2005 and 2016, across all households (NCD-only: USD95.6 to USD149.3; NCD and non-NCD: USD89.5 to USD167.7) (Rahman 2022). Families with NCDs suffered more from the lack of financial risk protection (FRP) and catastrophic health expenditure (13.5 to 14.4 percent), especially those in the lowest quintile households. The needs of the aging population are often overlooked in NCD financing and management. The current Noncommunicable Disease Control Operational Plan allocated an estimated budget of approximately USD140 million, with a focus on the reduction of morbidity and mortality from major NCDs (Directorate General of Health Services 2017). The NCDC operational plan design emphasizes the prevention and management of the major NCDs (cardiovascular diseases, chronic respiratory diseases, diabetes and cancer). However, emphasis on aging care is insufficient. As noted earlier, the senior care-related budget allocation was specific to HWF training and awareness creation. Insufficient inputs include a shortage of drugs. Consultation with the upazila Health and Family Planning Officer (UH&FPO) and team revealed that ºthe budget allocation for Medical and Surgical Requisites (MSRs) is 40 SILVER OPPORTUNITY CASE STUDIES approximately 13.1 million BDT (USD122,000) for the 2022–2023 fiscal year. The budget allocation is based on inpatient capacity (number of beds) and utilization rates (bed occupancy rate). The assessment does not include outpatient care provision or patient turnover, which as stated earlier, amounts to a significant gap in the data used to inform the budgeting and allocation process. 3.3 Innovation for older adult care WHO advocates for a PHC approach and community involvement to ensure integrated people-centered health services (IPCHS) for older adults. A review of care in rural PHC facilities in Bangladesh showed that NCD care is available but there are no designated protocols for older adults. In urban settings, PHC is provided by the Ministry of Local Government, Rural Development and Cooperatives (MOLGRD&C), and the Ministry of Health and Family Welfare (MOH&FW), which focuses on maternal and childcare. Very limited palliative and rehabilitative care is present in Dhaka or in certain other cities. The private sector provides older adult care at the secondary and tertiary levels, which is comparatively expensive. Additionally, the District Health Information System (version 2) (DHIS2) did not disaggregate data on older adult care. The detailed findings are shared below. An inclusive, holistic approach is needed for older adult health care. WHO encourages the PHC model as the baseline to address the needs of aging populations. National healthcare policies, plans, and regulatory frameworks should be developed in a way that supports healthy aging from birth to older adulthood. Too often the emphasis of healthcare policy and interventions is predominantly or even exclusively on the early years; but as demographics shift globally, healthcare policy and provision must also shift to prioritize good health at every age. Individuals, families, and communities should be engaged in health system management SILVER OPPORTUNITY CASE STUDIES 41 because they are often the primary providers of care for older adults in home settings. The health and social needs of older adults should be assessed and integrated into people-centered health care design. In addition, the health Integrated people- workforce needs to be trained in information communication technologies centered health (ICT) and older adult care (WHO 2018b). Integrated people-centered health services for older adults should be organized around comprehensive health needs services should be rather than treatment and maintenance of individual diseases. IPCHS should also organized around provide flexibility to accommodate social preferences. This strategy focuses on the provision of clinical services, with a view toward improving the health of people, and comprehensive acknowledges the critical role people’s preferences and needs should play in shaping health needs rather service provision and utilization (WHO 2018c). than treatment and In 2019, the World Bank released a report addressing NCDs, which are responsible for maintenance of 63 percent of disability-adjusted life years in Bangladesh. The report emphasized the importance of reorienting the health system toward integrated care for older adults individual diseases. with chronic conditions through a standardized and decentralized approach. The report further recommended that shared responsibilities between health care providers, community members/family members, and patients would be optimal to achieve a successfully integrated approach (World Bank 2019).33 Seniors in rural areas face mental health service gaps as there is no designated health care package for older adults in rural PHC facilities. It was observed that even in settings where patients receive support for managing NCDs and other chronic diseases, few services address the growing needs of mental health support, including but not limited to counseling. The PHC protocol emphasizes drug dispensing and drug-compliance-related counseling for NCDs but lacks a specific mention of mental health counselling (Non-Communicable Disease Control Programme 2018a). No mental health care was available in the UzHC visited for observation, a finding that aligns with a recent study (Islam et al. 2022). No designated health care for older adults was found in rural PHC facilities. Similarly, it was noted that the allocation of resources was not based on demand from the union subcenter. This is supported by a recent study from the Health Economics Unit that indicated similar results (Health Economics Unit and MOH&FW 2000). See Annex 7 for detailed findings. 42 SILVER OPPORTUNITY CASE STUDIES Public PHC in urban areas does not focus on NCD primary care. Urban PHC is provided by the MOH&FW and the MOLGRD&C through urban local government institutions (city corporations and municipalities). Health service provision is supplemented by development partner supported nongovernmental organizations (NGOs) and the private sector. Due to the limited resources of city corporations and the limited scope of MOH&FW, the public sector faces difficulties in providing quality PHC. Though the mandate of urban PHC is to provide a full essential services package (ESP), the services are focused on maternal and child health (MCH), and sexual and reproductive health (SRH). Primary care for NCDs is not prioritized in urban areas. In government facilities, protocol-based NCD management and older adult care is absent. In a few urban areas, DGHS, supported by development partners, has taken an innovative approach by providing a full range of ESPs, including NCD care, to all groups, for extended hours in PHC facilities. However, protocol- based NCD management, or health care that is specific to older adult needs, is absent. Very limited palliative and rehabilitative care is present in Dhaka and some other cities. Various organizations (NGOs, philanthropic, and community- based) provide the older population with food and housing, but very few of them provide health care services. Although available, older adult care in the private sector is expensive. The private sector provides a full range of care for older adults, but this is expensive. Some organizations provide health insurance coverage for employees to supplement private health care expenses, but the coverage is very limited in scope and typically ends at retirement. Private health care is not available for free or reduced rates, even as a part of corporate social responsibility. Mechanisms for digital data collection are in place but data are not disaggregated for adults by age. NCD data are collected and managed as per the national protocol under the NCDC program for hypertension and diabetes control, but different development partners support such activities with different types of software. For example, Resolve to Save Lives uses the opensource Simple App, whereas International Centre for Diarrheal Disease Research, Bangladesh (icddr,b) and Health and Education for All (HAEFA) use proprietary, non-open SILVER OPPORTUNITY CASE STUDIES 43 source software developed specifically for the organization. This leads to fragmentation of data collection and limits the potential for data sharing and data analysis across platforms. There is no support system for caregivers Encouragingly, some software programs are synchronized with the DHIS2 to share data. The NCDC program is further exploring different software to determine and family members which one to adopt and scale up to support national data collection. However, who are providing disaggregated data of older adult patients were absent in DHIS2. elderly family The HWF is not fully competent in delivering aging care. The NCDC program members with long- provides training to the HWF and orientation to managers to ensure NCD management at PHC facilities. The program applies a team-based approach with term care. task shifting and task sharing. However, the HWF is not trained to deliver aging care. Also, there is no support system for caregivers and family members who are providing elderly family members with long-term care. The supply of drugs and diagnostics for NCD management at PHC facilities is unreliable. PHC protocols are followed, and insulin, inhalers, and antihypertensive, antidiabetic, antiplatelet, lipid-lowering drugs have been added to the supply list, along with electronic blood pressure monitors and glucometers. However, equipment or assistive devices for long-term aging care are yet to be included in the supply list of PHC facilities. Ensuring supply chain management for older adult-care-related drugs, diagnostics, and logistics remains a challenge. Usually, NCD drugs are supplied from the NCDC operational plan and shortages occur mostly in the last quarter of the year. However, sometimes the UzHCs receive drugs from different OPs. There is no automation of the drugs and logistics management system. Moreover, 75 percent of drugs in Bangladesh must be procured from Essential Drugs Company Limited (EDCL), which often fails to supply enough drugs. The health workforce shortage negatively impacts the quality of service delivery. The NCDC program leads NCD control and management, including risk factor prevention activities. NCD corners were renovated in about 200 UzHCs to ensure protocol-based management of hypertension and diabetes 44 SILVER OPPORTUNITY CASE STUDIES through a team-based approach. Protocols have been developed for chronic respiratory disease management (asthma and chronic obstructive pulmonary diseases), cervical cancer screening, palliative care, and other diseases, including guidelines for disability. Community clinics (CC) are mandated to provide refills of antihypertensive drugs to increase drug compliance through a more reliable, continuous supply. However, health workforce shortages impact the translation of the policy into practice. During KIIs, one program personnel shared the following view: “Refilling of NCD drugs from CC will be helpful for the patients. However, additional HWF should be added in CC. Otherwise, the follow-up and refilling activity will be hampered.” All patients, including older adults, who have hypertension and Type 2 diabetes receive management for their condition from NCD corners. But the health worker shortage has led to a lack of monitoring and supportive supervision to ensure quality of care. One stakeholder highlighted the acute shortage of health workers when they shared the following: “There are only 10 program personnel in NCDC program at DGHS. With these few officers it is difficult to conduct routine monitoring and supportive supervision of the NCD corners all over Bangladesh.” No policy, strategy, or costed action plan related to older adult health care has been developed to integrate older adult long-term care into PHC. At the national level, the Government is planning to establish a geriatric hospital in Dhaka. One geriatric ward was established at Dhaka Medical College Hospital, but at the time of this study it was not operational. At PHC facilities, patients receive services for common ailments that affect older adults—such as oral and eye concerns, osteoarthritis, chronic kidney conditions, chronic obstructive pulmonary disease, dementia, depression, and multimorbidity. However, there is no arrangement for a one-stop shop that can SILVER OPPORTUNITY CASE STUDIES 45 meet the health needs of an older adult all in one convenient physical location. The NCDC program is in the process of developing the National Guideline on Integrated Geriatric Health Care at PHC Level. One program personnel shared the following: “Addressing health care of aging population was not a priority at the beginning of the sector program, only now we are focu- sing on aging care. We will be starting orientation and training of the health care provider once the guideline is ready.” The NCDC program issued a circular to PHC facilities to treat patients ages 60 and older as priority. Although the circular prescribes the prioritization of care for older adults at the PHC level, implementation guidelines that clearly spell out the set of services that are specific to elder care are still necessary. Secondly, to ensure successful implementation, the Government will need to institute a scaled- up monitoring system. Currently, these two critical components are missing, as evidenced by the following view: “We issued the circular to provide extra support to the ≥ 60 patients at the PHC facilities. However, we have no idea what is the implementation status as we couldn’t do follow-up yet.” Regarding implementation of older adults care at PHC facilities, one stakeholder shared this: “Starting off by implementing a pilot project of integrated long- term care for the elderly would have been very helpful for us, because we don’t have much experience.” 46 SILVER OPPORTUNITY CASE STUDIES 3.4 Regulations for older adult care In Bangladesh, some older adult social protection policies exist, although health care-related policies, strategies, and action plans for seniors are largely nonexistent. The 2020 Midterm Review (MTR) report emphasized HWF training for facility and home-based geriatric, palliative, and physiotherapy care. The NCDC operational plan highlighted a few services specific for older adults, but facility- wide service provision was not clearly articulated in the essential services package. The 69th World Health Assembly adopted a global strategy and action plan on aging and health and called on partners to a) support and implement the strategy and plan, b) improve the wellbeing of older persons and their caregivers with services, c) support research and innovation, d) exchange knowledge and innovative experiences, and e) actively work on advocacy for healthy aging over the entire course of the person’s life (WHO 2016). In Bangladesh, policies and legislation are needed to ensure basic rights and improve the quality of life for the aging population. Although there are some health and social protection policies specific to older adults, they are not sufficient to ensure needs of older adults, including housing, transportation, and recreation. Additionally, the general lack of awareness regarding rights of older adults and a lack of enforcement of existing policies are barriers to older people accessing the necessary quality services to support healthy aging. Gaps in the adoption of the Madrid Plan will prevent Bangladesh from achieving SDG 3 by 2030 (HelpAge International n.d.; Ferdousi 2020). Some key legislative and regulatory provisions in Bangladesh relating to care for older adults are summarized below: • The National Policy for Older Persons 2013 – This policy aims to strengthen health care services for older people with age-friendly SILVER OPPORTUNITY CASE STUDIES 47 health centers, referral services, and mobile camps in hard-to- reach areas (Ministry of Social Welfare 2014). Although the policy is in place, implementation has not been made a priority. The In Bangladesh, related laws have not been enforced and the rules under the act have not been formulated. However, some initiatives for financial policies and protection have been taken; for example, a pension system for legislation are needed government employees, retirement benefits, and a social safety net program (old age allowance, allowances for widows and for to ensure basic rights deserted and destitute women, vulnerable group development, and improve the and so on) are in place but with limited coverage. quality of life for an • The Parents Care Act 2013 – The act ensures social security and aging population. protects some of the rights of older adults, such as obliging their children to take care of them and preventing their children from sending them to a care home against their wishes (Government of Bangladesh 2013). However, this law excludes the maintenance of adoptive parents, stepparents, and childless older adults. • Foundation for Development of Older Person Act, 2017 – the Ministry of Social Welfare (MOSW) enacted this law and established the Probin Unnayan Foundation (Elders’ Development Foundation) to ensure that older adults have access to food, clothing, and treatment (Mazumder n.d.). However, the law needs to be amended to ensure comprehensive social service coverage. • The National Health Policy – This is targeted to achieve UHC and deliver quality healthcare services to all at an affordable cost, through a health care program. The policy emphasizes the need to ensure health care for older adults and all types of people with disabilities (MOF&FW 2011). • The Fourth Health Population Nutrition Sector Program (4th HPNSP) – The 4th HPNSP of the MOH&FW emphasizes prevention and NCD management. It includes one NCD indicator in the results framework — namely, “Prevalence of Hypertension among adult population” (Directorate General of Health Services 2017). 48 SILVER OPPORTUNITY CASE STUDIES • The NCDC Operational Plan – The focus of the operational plan is to strengthen the control of NCD risk factors, and to promote the early detection and management of NCDs with ESP expansion. The specific tenets are a) prioritizing older adults, b) providing support and assistance with assistive devices, and c) approaching older adults in ways that promote respect and dignity. The listed activities include a) HWF training on older adult service provision, b) arranging seminars and workshops with stakeholders to obtain their buy-in, c) dissemination of outreach documents to create awareness in the community, and d) conducting research on innovative approaches to provide older adult care. However, facility-wide, senior service provision is not mentioned (MOF&FW 2016). • The 2020 Midterm Review (MTR) report of the 4th HPNSP – The 2020 MTR report revealed that the NCDC program has started implementing the “national protocol for management of hypertension and diabetes” with screening at CCs and management at UzHCs (Non-Communicable Disease Control Programme 2018). The report highlights the fact that mental health care at PHC facilities is almost nonexistent. To address disability, the report recommends disability-friendly physical facilities and coordination with the MOSW. Further recommendations call for greater investment in NCD medicines as per protocol, customization of DHIS2 to capture NCD service data, and HWF training for facility and home-based geriatric, palliative and physiotherapy care (MOF&FW). While efforts have been made to bring together multiple stakeholders across both the health and the non-health sectors to collaborate on health care, they have not been as successful as expected. The MOH&FW is responsible for ensuring delivery of the ESP through the rural and urban PHC system and referral care at secondary and tertiary facilities. Currently, the health care system is not adequately resourced or optimally prepared to implement integrated older adult care due to a lack of timely planning, increasing patient volume, inadequate provider competencies, rising costs coupled with limited resource and a lack of clearly defined service provision guidelines at the facility level and reporting lines for accountability. SILVER OPPORTUNITY CASE STUDIES 49 Additionally, the operational plan is implemented by the NCDC program with insufficient numbers of health workers, which hampers monitoring and field-level management. Currently, the health care system is not The NCDC program developed the Multisectoral Action Plan (MSAP) for prevention and control of the shared risk factors. However, the program faces difficulties in adequately resourced coordination with non-health sector stakeholders (Non-communicable Disease or optimally prepared Control Programme 2018b). to implement A National Multisectoral Coordination Committee (NMNC) was formed to integrated older implement the action plan, with the NCDC program of DGHS as the secretariat. The committee included about 30 ministries, institutes, and organizations. However, adult care. regular committee meetings did not occur as planned. One stakeholder shared their views as follows: “Coordination with the non-health sector is a challenge and wi- thout involvement of all stakeholders, shared risk factor control is not possible.” 50 SILVER OPPORTUNITY CASE STUDIES 3.5 Evaluation of older adult care programs Due to a shortage of human resources, the NCDC program is unable to effectively monitor and evaluate NCDC activities. The program should consider evaluating the readiness of the service delivery system (SDS) to implement the Integrated Care for Older People (ICOPE) following WHO guidelines. To support the implementation of ICOPE, WHO conducted a research project—the ICOPE implementation pilot program—in four locations: Canillo in Andorra, Chaoyang in Beijing, China, Occitanie in France, and Rajasthan in India. The pilot features three phases: ready, set, and go. The research and report will help countries, including Bangladesh, to evaluate the readiness of the service delivery system (SDS) to implement ICOPE nationally (WHO 2018c). The NCDC program implements hypertension and diabetes management from the NCD corner of UzHCs, which is a long-term care program. Evaluation and ongoing monitoring of this program will ensure quality of care, coverage, and access. However, the shortage of HWF in the NCDC program makes the evaluation component a significant challenge. SILVER OPPORTUNITY CASE STUDIES 51 52 SILVER OPPORTUNITY CASE STUDIES 4. STUDY RECOMMENDATIONS The study findings from the literature review, field visits, stakeholder consultations, and KIIs were compiled to formulate the following FIRE recommendations (Table 4). Table 4: Overview of recommendations FINANCING INNOVATION REGULATION EVALUATION FOR DATA- TO INCLUDE INFORMED DECISION TO PROVIDE TO INCREASE EARMARKED BUDGET MAKING, GREATER OVERSIGHT AND TO ADHERENCE TO FOR SENIOR CARE AND ACCESSIBILITY TO CARE ENSURE SUSTAINABLE, PROGRAM OBJECTIVES CROSS-MINISTERIAL VIA TECHNOLOGY, RELIABLE, QUALITY AND PROVIDE QUALITY COLLABORATION TO AND IMPROVED CARE. ASSURANCE. SAVE COSTS. AFFORDABILITY OF DRUGS AND DEVICES. Source: Authors. 4.1 Financing The study identified limited budget allocation to be an important gap in ensuring care for older adults and recommends more funding to implement integrated care. This funding should cover the whole spectrum of preventive, promotive, curative, and rehabilitative activities at the community and facility levels. In addition, consideration should be given to the following: • Implementing output-based budget allocation at the facility, for example, number of NCD screenings, physical activity sessions, health education sessions, and so on, SILVER OPPORTUNITY CASE STUDIES 53 • Establishing clear guidelines with item charge codes to avoid expenditure duplications, and This funding • Supporting a shared-risk model by involving different ministries to should cover the ensure cost sharing and alternate resource utilization. whole spectrum of preventive, promotive, curative, and rehabilitative activities 4.2 Innovation at the community and facility levels. 4.2.1 Digital health Improve record keeping for patient follow-up A dearth of individual and facility-based data, due to poor record keeping, was identified as a major gap. The study recommends immediate digitization of the NCDC program activities. A sound medical information system (MIS), implemented with open-source software, should be established to reduce costs, integrate with the existing DHIS 2 platform, and provide an intuitive user experience for national scaling. The database should maintain individual health records to ensure long-term patient care. It should provide disease tracking, patient follow-up through mobile text messaging, and telemedicine functionality. Importantly, the database must capture facility-based service provision data so that the program can be monitored, assessed, and adjusted to meet patients’ healthcare needs. Establish telemedicine care to increase access All around the world, technology is broadening access to healthcare through telemedicine. The Bangladesh health workforce should be equipped and trained 54 SILVER OPPORTUNITY CASE STUDIES with telehealth tools to extend the effectiveness of in-person visits and provide increased access and specialized care to older adults. 4.2.2 Long-term care for older adults in PHC The lack of good-quality healthcare service delivery was identified as a major concern. In response, the following recommendations are offered: Provide HWF training that is sensitive to older adults The HWF needs training specific to caring for older adults and the health issues that are common to the aging process, including multimorbidity management. Team-based care that utilizes task shifting and sharing can decrease wait times and promote patient-centric care. Strategic planning to grow the HWF to assume key roles such as paramedics, nurses, and midwives would support initial screenings, create space for patient follow-up, and help alleviate the acute HWF shortage. The HWF should also be trained to fill a critical gap in rehabilitative care for older adults with disabilities, and palliative care for terminally ill patients. A thoughtful model would leverage trained health workers to instruct family caregivers to provide support to aging family members in the home. Redesign SDS to center on older adult care The essential services package should be updated to define older adult care at facilities. PHC facilities should ensure a range of high-priority and targeted services, including waived registration fees, separate older adult queues, and free diagnostic services. Gradually, PHC could offer a one-stop service model for older adults through screenings, consultations, diagnostic facilities, medications, and nutrition package. Additional improvements include: • Providing free transportation and referral coordination for emergency patients, • Establishing a community health worker follow-up protocol, and SILVER OPPORTUNITY CASE STUDIES 55 • Collaborating with other national agencies and ministries to offer coordinated services, for example, an older adult registration Health education card that directly links older adults to such benefits as nutritional support services. is a powerful tool in managing and Check for multimorbidity and special health needs mitigating the PHC facilities are an ideal, accessible place for older adults to be assessed for impacts of poor multimorbidity, NCDs, declining mental health, and the complex health status known as geriatric syndrome. This is a group of multifactorial health conditions health. highly prevalent in older people that, although heterogeneous, have shared underlying factors that have synergistic interactions among them and produce a range of cognitive and behavioral impairments and functional limitations, strongly impacting the person’s quality of life. They include frailty, depression, urinary incontinence, polypharmacy, pressure ulcers, malnutrition, dizziness, reduced mobility that sometimes lead to falls, syncope (fainting caused by a fall in blood pressure), and baseline cognitive impairment, commonly including delirium— sudden confusion, disorientation and agitation. Intervention through regular checks at a local PHC can support individuals and families to manage geriatric syndrome and other conditions common to aging, such as hearing loss, vision loss and cataracts, back and neck pain, and osteoarthritis. Offer health education and counseling for patients Health education is a powerful tool in managing and mitigating the impacts of poor health. To facilitate knowledge sharing, PHC facilities should offer regular information sessions on topics such as healthy lifestyle tips, health risk prevention, and the importance of NCD screening in the patient waiting area. Counseling for older patients during visits should be introduced, especially for those dealing with multimorbidity and disability. Community engagement—led by the HWF, multipurpose health volunteers (MHVs), and community and religious leaders—is an effective way to empower and involve both older people and the community in prioritizing good health-seeking behaviors for all residents but especially for older adults. 56 SILVER OPPORTUNITY CASE STUDIES Provide specialized and emergency older adult care at all levels: facility, community, and household Urban PHC facilities do not offer specialized older adult care. This study recommends strengthening the urban PHC system to incorporate older adult care. This should be done by deploying frontline health workers and through better coordination between MOH&FW and MOLGRD&C. Screening and referral of cases requiring follow-up care should be done at the CCs. Home-based follow-up should be introduced to ensure drug compliance, follow-up of older adults with multimorbidity, and the use of assistive devices. Gradually, preventive screenings should be shifted to the household level. Healthcare facilities should offer extended service hours, especially for older adults who need to be accompanied by caregivers. Emergency health care is an important support for population longevity. The currently underutilized union subcenters and UH&FWC should be made fully functional to provide older adult care. Update the list of essential drugs and medical equipment The essential drugs list needs to be updated to support the delivery of the ESP to older adults. The drugs should be affordable, generic, and quality-tested by the Directorate General of Drug Administration (DGDA). Once an older patient is comfortably and successfully established in their medication protocol, the CC or the USC may be the appropriate place for follow-up and prescription refills. In addition, medication should be dispensed in three-month supply quantities to decrease the frequency of facility visits and increase drug compliance. Some assistive devices (eyewear, walking sticks, hearing aids, wheelchairs, prostheses, and so on) should be supplied free or at low cost. Finally, availability of vaccines, diagnostics, consumables, and technologies required by the aging population should be ensured through medical and surgical requisites. SILVER OPPORTUNITY CASE STUDIES 57 4.3 Regulation The study identified gaps in regulation in the field of finance, HWF, supply chain management, and telemedicine. The following is recommended: Establish a training program for managers on financial regulation All managers from the NCDC program and health facilities should receive training in financial regulation, budget management, and other skills to facilitate the financial management of long-term care for older adults. During emergencies, financial management becomes critical because emergencies can impact long-term care. Decentralized expenditure should be encouraged to enable the manager to purchase the required medicines and MSRs to support the older adult care program. Strengthen HWF regulations to improve performance and accountability The recruitment, transfer, deputation, promotion, and other processes related to HWF development to support older adult healthcare should be free from political influence. Proper monitoring and supervision can ensure HWF accountability. Performance-based incentives should be introduced. A regular NCD unit in the DGHS should be established to ensure adequate human resources for program monitoring and supervision. Informal health care providers involved with aging care should be brought under the regulation. Prevent breaks in supply via supply chain management Effective supply chain management will ensure the timely supply of drugs, vaccines, technologies, and MSR needs. In addition, certified pharmacists should manage pharmacies and drug stores to advise on drug compatibility and adverse reactions, particularly for older adults. 58 SILVER OPPORTUNITY CASE STUDIES Ensure quality across services via telemedicine regulations Currently, there are no rules or regulations for quality control of telemedicine services. Proper regulation and quality checks of telemedicine services should be established to protect the aging population from substandard services. Oversee the private sector in providing older adult care The private sector should be subject to regular monitoring and supervision since its share of older adult healthcare in Bangladesh is substantial. Accountability mechanisms and regulatory frameworks for quality control in private sector provision of care for older adults is needed.   4.4 Evaluation The study identified gaps in program evaluation and recommends quality assurance through monitoring and evaluation. At the directorate level, there are only 10 program personnel, who therefore struggle with NCDC program implementation and hardly have the time for country-wide monitoring and supervision or evaluation. One recommendation is to create a district-level NCD medical officer role to regularly monitor and evaluate the long-term care program. The program activities that could be evaluated include the use of protocols and standard operating procedures (SOPs), the availability of trained HWF, database maintenance, regular report generation, clinical audits, and follow-up of referral mechanisms. SILVER OPPORTUNITY CASE STUDIES 59 60 SILVER OPPORTUNITY CASE STUDIES 5. CONCLUSION A rapidly aging population and pre-existing health system challenges mean that Bangladesh needs to strategically plan and reorganize its service delivery Monitoring and system to address the health care needs of older adults. Recent censuses and evaluation of other data show that the aging population in Bangladesh is growing fast both in absolute numbers and in relative proportion. The main factors driving this are programs is necessary declining fertility rates and increasing life expectancy. As a result of population for accountability and aging, Bangladesh faces challenges related to the provision of healthcare and social services for older adults, as well as the potential impact on the country’s economic to meet the evolving growth and development. Alarmingly, there is an absence of aging healthcare- needs of an aging related policies. There is an urgent need to develop older adult care-related policies, strategies, and a costed action plan. This is crucial for laying a healthy population. aging foundation in Bangladesh, a country where more than 10 percent of the population will, it is projected, be 60 or older by 2050. Primary and secondary data reveal health system capacity deficits that will impact the country’s ability to address the health care challenges associated with its demographic shift. The study recommends a redesign of the SDS to support a comprehensive, patient-centered, integrated approach to older adult care, with adequate financing to protect older adults from financial catastrophe and excessive out-of-pocket expenditures. It is imperative to introduce a older adult care program in the PHC setting that emphasizes preventive and promotive care. It is also important to address the inadequate number of urban PHC facilities and their lack of focus on chronic disease management and care for older adults. Monitoring and evaluation of programs is necessary for accountability and to meet the evolving needs of an aging population. The study underscored the importance of developing and training a robust HWF and updating the system infrastructure to ensure high-quality care delivery to older adults. The stakeholder consultation and KIIs revealed that health workers are only minimally trained in older adult, rehabilitative, and palliative care. Specialized older adult care protocols and care pathways are largely nonexistent, pointing to a critical need for protocol-based care to address the older population’s physical and mental challenges and comorbidities. Digitization of individual and facility-based older adult care data can improve information sharing among facilities and ensure comprehensive and coordinated care for older SILVER OPPORTUNITY CASE STUDIES 61 adults. Likewise, upgrading to an electronic supply chain management system can improve the reliable availability of drugs and necessary medical supplies. Bangladesh’s demographic shift Bangladesh’s demographic shift presents an important opportunity to rethink health care delivery to promote healthy population aging. Quality, targeted presents an important healthcare is important to maintain the health and wellbeing of aging population opportunity to rethink groups. Prioritizing infrastructure investment (such as hospitals and clinics), health care worker development and training, and reliable access to medicines health care delivery and other treatments will be critical to Bangladesh’s success. Levers such as to promote healthy strategic financing, innovations in service delivery, regulation, and evaluation and measurement can be deployed to identify and address the continually evolving population aging. needs of the senior population. Bangladesh can leverage this opportunity to address aging-related population health and health system challenges as an entry point into driving necessary health system reform and building a more inclusive and productive society. 62 SILVER OPPORTUNITY CASE STUDIES SILVER OPPORTUNITY CASE STUDIES 63 64 SILVER OPPORTUNITY CASE STUDIES 6. REFERENCES Acharya, S., Ghimire, S., Jeffers, E. M. and Shrestha, N. 2019. “Health Care Utilization and Health Care Expenditure of Nepali Older Adults.” Front. Public Health 7. 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Bangladesh – Current expenditure on health per capita, 1960-2021. https://knoema.com//atlas/Bangladesh/topics/Health/Health-Expenditure/ Health-expenditure-per-capita.   SILVER OPPORTUNITY CASE STUDIES 71 ANNEXES Annex 1: List of facilities observed • Upazila Health Complex (UzHC), Dhamrai • Upazila Health Complex (UzHC), Tungipara • Union Subcentre, Shuapur Dhamrai • Community Clinic, Atimaithan, Roail Union Dhamrai • Tejgawn Health Complex Dhaka Annex 2: Observation checklist The following issues were observed to check the readiness of PHC facility to provide long-term, integrated care for aging population: Physical infrastructure • Entrance with ramp • Railings for staircases • Good lighting in the facility • Wide doors • Floor of the facility not slippery • Toilets are available • Toilet floors are clean and dry • There are grab rails in the toilets • Toilets have doors that open both ways • Signboards in the local language • Letter size on signboards is large and bold Furniture Medicines Logistics Electricity Running water Cleanliness inside and outside 72 SILVER OPPORTUNITY CASE STUDIES Boundary wall around the premises Entrance/exit gate the boundary wall Information, education, communication (IEC) materials Annex 3: List of Stakeholders List of Stakeholders • Health Service Division (HSD), Ministry of Health and Family Welfare (MOH&FW) • Non-Communicable Disease Control (NCDC) Program, Directorate General of Health Services (DGHS) • National Institute of Mental health (NIMH) • Program implementers • Health care providers from the Dhamrai UzHC (RMO, Indoor MO, MO NCD corner, Medicine Consultant, Anesthesia Consultant) • Health care providers from the Tungipara UzHC Annex 4: List of Key Informants • Sanitary Inspector UzHC Dhamrai • SACMO, Shuapur Union Subcentre (USC) • CHCP, Community Clinic (CC) Atimaithan, Roail Union • MHV, Community Clinic (CC) Atimaithan, Roail Union • UHFPO UzHC Tungipara • Civil Surgeon, Dhaka • Assistant Medical Officer, Dhaka South City Corporation • Assistant Medical Officer, Dhaka North City Corporation SILVER OPPORTUNITY CASE STUDIES 73 Annex 5: Guideline for stakeholder consultation and KII • What is your opinion about elderly care-related, national-level documents (national policy, strategy, action plan etc.)? • What is your opinion about the current situation of availability of care for older adults at PHC facilities (focusing on financing, digitization, health workers, service delivery, regulation and evaluation)? • How many staff are there who have the training to provide care to older adults? • Are there enough medicines and logistics to provide care to older adults? • What is your opinion about outpatient utilization? • How do you undertake record keeping and reporting? • What is your view on maintaining quality of care? • What are the challenges you face? • What are your recommendations or suggestions for the way forward? • Do you have any final comments? Annex 6: FIRE Framework The FIRE Framework aims to identify elements or approaches for transforming the health system so that it can meet the needs of older adults, while also providing care to the general population. The framework emphasizes better understanding of (1) the evolving needs and preferences of older adults, and (2) their preferences for care that are jointly influenced by individual health care needs and demographics, national aging care policies and infrastructure, and values and traditions in the society. 74 SILVER OPPORTUNITY CASE STUDIES The overall guiding principle for people-centered, coordinated older adult care is the FIRE framework – Financing, Innovation, Regulation and Evaluation. Annex 7: Findings from the field Rural PHC facilities visit To observe the availability of health care services for chronic diseases for the integrated care of the aging population, a field visit was conducted at three levels of PHC facilities: a) Upazila Health Complex (UzHC), b) Union Subcenter (USC), and c) Community Clinic (CC). The observational findings are as follows: Community clinic (CC) The community clinic is the first level of PHC facility at the doorstep of the community, within a maximum of half an hour’s walking distance from any household. Staffing – The community clinic was run by the community health care provider (CHCP) and there were seven multipurpose health volunteers (MHVs) attached to the community clinic. One health assistant and one family welfare assistant (FWA) were in the organogram of the CC to provide domiciliary services in the catchment population. The health assistant and one family welfare assistant were scheduled to do domiciliary visits three days per work week and provide services in the community clinic for the remaining days. The position of the one family welfare assistant has been vacant for a long time, and there has been no replacement to date. One family planning inspector from the Directorate- General of Family Planning (DGFP) and one assistant health inspector from the Directorate-General of Health Services (DGHS) were responsible to undertaking supportive supervision of the CHCP at least once a week. However, the supportive supervision was infrequent. The health workforce also had not received any older adult-care-related training. SILVER OPPORTUNITY CASE STUDIES 75 Infrastructure – Apart from running water and electricity, most of the items mentioned in the observation checklist were absent. The facility was poorly maintained. Equipment and medicine – There was an electronic blood pressure monitor and a glucometer in the community clinic, but on the day of visit the glucometer strips were out of stock. There was a standard list of 27 drugs for the community clinic, which were supplied from the CBHC OP. The community clinic received a total of 8 boxes of drugs, each box containing all 27 types. Antihypertensive and antidiabetic drugs were not included in the list. Outpatient utilization – Upon checking the register, it was discovered that on, an average, 30 patients visited the community clinic per day, about 7 of whom were 60 years or older. The patients were mostly women and children. The CHCP stated that the most common chronic ailments of older adults were hypertension, diabetes, chronic obstructive pulmonary diseases, and osteoarthritis. Record keeping and reporting – The CHCP used to maintain the register manually for record-keeping and would send the compiled report electronically every day to the District Health Information System version 2 (DHIS2) platform. Reporting was mainly on maternal and child health. Only the number of patients whose blood pressure had been measured was reported daily. Union Subcenter (USC) Staffing – The union subcenter was staffed with one doctor, one sub-assistant community medical officer (SACMO), and one pharmacist. However, during the visit, the pharmacist was deployed in the UzHC. None of the health workforce had received pre-service or in-service training on geriatrics or care for older adults. Physical infrastructure – The USC though constructed many years ago, and there has been no maintenance work since then. The absence of a boundary wall and broken windows created security concerns. 76 SILVER OPPORTUNITY CASE STUDIES Furniture – There were no seating arrangements in the waiting area due to a lack of furniture; even the doctor’s room was without a light or fan. The two-storied building had no running water. Equipment and medicine – The yearly allocation of the medical and surgical requisites (MSRs) was insufficient to stock the USC, which ran out very quickly. The allocation of resources was not based on demand of the USC; rather it followed a list that was more appropriate for higher-level facilities. Outpatient utilization – The staff were found providing health care to the patients during visits because there was community demand for the health services. This was because of the highly strategic location of the USC in the vicinity of a school or the market. The USC visit gave an overall impression that the facility was underutilized due to the nonavailability of required staff, medicines, and logistics. No special arrangement or health services were observed for older adults. Record keeping and Reporting – Record keeping and reporting were both manual and not properly done. The Upazila Health Complex (UzHC) Staffing – Different categories of HWF were present in the UzHC—doctors with graduate and postgraduate certifications, nurses, midwives, paramedics, and so on. However, none of them had pre-service or in-service training on caring for older adults. Infrastructure and furniture – A shortage of rooms and furniture was obvious. The waiting area was crowded with many patients standing and unable to sit because of insufficient space and seating. The NCD corner was small, yet separated into two parts, one to serve outpatients and the other for electrocardiography (ECG) and blood sugar testing. SILVER OPPORTUNITY CASE STUDIES 77 Equipment and medicine – Following the issuance of the drug list, all the drugs were available in the store during the visit. There was a supply of three antihypertensive and two antidiabetic drugs following the national protocol for management of hypertension and diabetes. Outpatient utilization – The UzHC provided primary as well as some secondary health care with the consultants. The NCDC program emphasized management of hypertension and Type 2 Diabetes following the national protocol from the NCD corner. The protocol was developed by contextualizing the WHO package of essential noncommunicable diseases (PEN) intervention. The program trained doctors, nurses and paramedics to provide NCD care adopting a team-based approach with task sharing and task shifting, and emphasized on record keeping in supplied registers. Some of the NCD corners were supported by development partners, who digitally maintain record keeping and individual patient data. During the visit it was found that the NCD corner patients were receiving treatment for hypertension and Type 2 Diabetes. The record keeping was manual; the record did not reflect the number of patients whose hypertension and Type 2 Diabetes was under control. The peak hour for patient flow was 11 am to 1 pm, during which time patient management in outpatient department seemed difficult because there were no staff to maintain the queue. There was neither any separate protocol for older adults nor any special arrangements and health service for them. Record keeping and reporting – In the NCD corner, record keeping was manual, and the NCD-related indicators were poorly captured, but reporting was done electronically once in a month. 78 SILVER OPPORTUNITY CASE STUDIES Urban PHC facilities visit Thana Health Complex Tejgawn, which is within Dhaka City Corporation, was visited. 3.3.2.2 Urban PHC facilities Government PHC for urban areas is provided by the MOH&FW, the Ministry of Local government, rural development and cooperatives (MOLGRD&C), and urban local government institutions (city corporations and municipalities). The other providers are NGOs, development partners, and the private sector. Due to the limited resources of city corporations and limited scope of MOH&FW, the public sector faces difficulties in providing quality PHC. Though the mandate of urban PHC is to provide all the services of the ESP, the services are focused on maternal and child health (MCH) and sexual and reproductive health (SRH). The primary care for NCDs were lacking in urban areas. In the Government facilities protocol-based management of NCD or older adult care was absent. In three city corporations of Bangladesh, an innovative approach has been taken by the DGHS and supported by the development partners. These are PHC centers that provide the full range of ESP, including NCD care, to all groups of the population. However, protocol-based management of NCD or older adult care was absent there. 3.3.2.3 Private and nonprofit sector provision of care for older adults Although several different organizations—NGOs, philanthropic, and community- based—provide the older adult population with food and housing, very few of them provide health care services. The private sector clinics that provide care to older adults charge high out-of-pocket prices. I NCD corners are a dedicated platform at upazila (subdistrict) health complexes (UHCs) for delivering NCD services that were established in 2012 as part of the Government’s new initiative for addressing NCDs. NCD corners are dedicated to providing preventative and curative services for common NCDs and related conditions such as cardiovascular diseases (CVDs), diabetes, and chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD), and screening for certain cancers. SILVER OPPORTUNITY CASE STUDIES 79