mph Bangladesh

Healthcare

Healthcare System in Bangladesh

HIGHLIGHTS

Ministry of Health and Family Planning, GoB controls the health care system in Bangladesh in it’s total geography covering vast rural & urban areas. Back in 80s the rural healthcare facilities comprised sub-district health centers, family welfare centers and rural dispensaries which were poorly administered due to lack of infrastructures as well as ensuring availability of medical professionals. The situations have not changed till date to any significance. However, private/ non-government healthcare organization proliferated significantly over last two decades that largely meet healthcare needs of this 160 mio population country.

Stakeholders in Bangladesh Healthcare Market & their influence:
Stakeholders Expected changes / developments Implications /Actions
Payors  Private market, no reimbursement No influence on industry or service provider
Lack of market opportunity  Not viable option at given healthcare structure
Small market segment public hospital  
Wholesalers  Distributors for upcountry markets No influence on industry or service provider
Drives brands through discounting Manipulative trade channel for manufacturer
Shrinking business opportunity   
Pharmacists Dispenses according to prescription Single key role player in dispensing
Increased  focus by companies Trade campaigns, business partnering, substitution, retail chains
Strengthening of Association Influencing voice on the industry
General Physicians (GP) Continue as first line health service provider  & major prescriber pool High frequency of visits & reminders
Extension to rural population  Marginalize Rural Medical Practitioners
Values relationship and quality image of mfg.
Specialists Growing & KOL (Key Opinion Leader) segment  High frequency of visits & reminders
Drivers of disease management Shift of marketing focus from GPs
Shift of GP patient population Trend setters to disease mgt & KOLs for new launches 
Hospitals Geographical expansion  Shift of patient from doctors chamber
Enhancement of facility Price pressure, trade discounting & KAM implementation
Patients Growing awareness on quality & healthcare facility  Importance on quality 
Patient Advocacy Groups Patient clubs and health awareness programs

 

However, govt. healthcare support services extends from primary to tertiary level healthcare support system not equally distributed throughout the country. Capital city Dhaka and Port City Chittagong hosts most of the large govt. healthcare institutions. There are 15 Govt. Medical College hospitals (and growing) throughout the country providing quality medical education; some of them (DMC, CMC, RMC etc.)  approved by GMC, UK. However, some more new govt. medical college hospital already started Student admission recently. Besides, there are 48 private medical college running in different parts of the country for years, a few of them running for decades. For higher education, govt. approved 2 other Medical University (Chittagong & Rajshahi) apart from BSMMU.

 

 

 

Pharma

 

Pharma Market - Bangladesh

Bangladesh Pharmaceutical industry is the most technologically developed manufacturing sector and 3rd largest industry for contribution to government's revenue. This pharma industry contributes approx. 1% of the total GDP of the country. Out of many, about 250 pharmaceutical manufacturers are, although, around 40% companies are in operation and they produce >500 generic drugs. This market is highly concentrated as top 20 companies produce 85% of the revenue.

According to IMS, the retail market size is around BDT 118 billion as on 2014 where as it was around BDT 47 billion in 2008. It should be noted that IMS report points to the retail-level sales of pharmaceutical products not the institutional businesses (government and other organizational purchases) or export numbers.

Local pharmaceutical companies focus primarily on branded generics, mostly using imported APIs (Active Pharmaceuticals Ingredient). Unlike the international market, this generics constitute about 85% of the drugs sold in Bangladesh and 15% are patented drugs. Bangladesh produces as much as around 97% of it’s national consumption and thereby can be said to be self-sufficient in medicine production.

Presently, 15 Bangladeshi companies are involved in API (active pharmaceutical ingredients) production, The proposed API park is under development, in Munshiganj, about 40 kilometres from the capital. This park will accommodate 40 API industries with central effluent treatment plant and incinerator and other modern facilities. 

 

TRIPS Implications

Being LDC, Bangladesh will continue to enjoy patent-free production rights domestically until 2016 and limited exporting advantage. Having said that, as long as Bangladesh has to import APIs however, they will have to buy these from firms which are compliant with TRIPS laws and hence will have to incorporate the higher royalty patent price for these.

TRIPS also allow Bangladesh to export drugs patent free. The advantages that TRIPS does offer is somewhat offset by the pace and aggressiveness of the Indian and Chinese generic market, where companies can produce drugs, even including the patent costs, at an enormously competitive rate. As the days are counting, Bangladesh may export to any country if the drug is not under patent only until 2016. However, Least-developed country (LDC) members of the WTO will be allowed to maintain maximum flexibility in their approach to patenting pharmaceutical products until at least 2033, following a decision taken by the WTO’s Council for Trade-Related Aspects of Intellectual Property Rights (TRIPS) on 06 November '15 as published on WTO website.

 

Further reading: 

WTO members agree to extend drug patent exemption for poorest members.

 

 



 

   

Birth control / Contraception / Fertility control / Spacing or Family Planning

Birth-control-banner

Birth Control

Overview

Birth Control, also known as contraception, is designed to prevent pregnancy. Birth control methods may work in a number of different ways. These include

  • Preventing sperm from getting to the eggs - condoms, diaphragms and intrauterine devices (IUDs) work this way
  • Keeping the woman's ovaries from releasing eggs that could be fertilized - birth control pills work this way
  • Sterilization, which permanently prevents awoman from getting pregnant or a manfrom being able to get a woman pregnant
Your choice of birth control should depend on several factors. These include your health, frequency of sexual activity, number of sexual partners and desire to have children in the future. Your health care provider can help you select the best form of birth control for you.
Birth Control Methods

Birth Control Methods

Reversible or Temporary methods

Irreversible or Permanent methods

Intrauterine Contraception

Copper T intrauterine device (IUD) and Levonorgestrel (hormonal) intrauterine system (LNG IUD)

Female Sterilization - Tubal ligation or tying tubes

Hormonal Methods

  • Combined oral contraceptives
  • Emergency contraceptive pill
  • Progestin only pill
  • Implant
  • Injection
  • Patch
  • Vaginal ring

Transcervical Sterilization

Barrier Methods

  • Male Condom
  • Female Condom, Cervical Cap / Diaphragm
  • Spermicides

Male Sterilization - Vasectomy

Natural family planning or fertility awareness.

Includes Calendar or Rhythmic method, Basal Body Temparature awareness etc.

How effective the methods are?

The effectiveness of birth control methods is critically important for reducing the risk of unintended pregnancy. Effectiveness can be measured during perfect use, when the method is used correctly and consistently as directed, or during typical use, which is how effective the method is during actual use (including inconsistent and incorrect use).

The best way to reduce the risk of unintended pregnancy among women who are sexually active is to use effective birth control correctly and consistently. Among reversible methods of birth control, intrauterine contraception and the contraceptive implant remain highly effective for years once correctly in place. The effectiveness of the contraceptive shot, pills, patch and ring, and barrier and fertility awareness-based methods, depends on correct and consistent use”so these methods have lower effectiveness with typical use.

For each method of birth control, effectiveness with typical use is provided below. We present this as the percent of women who experience an unintended pregnancy within the first year of typical use (also known as the failure rate).

 

Hormonal Methods

 

Combined Oral Pill



Combined oral contraceptives contain the hormones estrogen and progestin. It is prescribed by a doctor. A pill is taken at the same time each day.

If you are older than 35 years and smoke, have a history of blood clots or breast cancer, your doctor may advise you not to take the pill. Typical use failure rate: 9%.

For locally available formulation refer to,


OCP

Progestin Only Pill (mini pill)

Unlike the combined pill, the progestin-only pill (sometimes called the mini-pill) only has one hormone, progestin, instead of both estrogen and progestin. It is prescribed by a doctor. It is taken at the same time each day. It may be a good option for women who can't take estrogen. Typical use failure rate: 9%.

For locally available formulation refer to,


Mini pill

Hormonal Patch

This skin patch is worn on the lower abdomen, buttocks, or upper body (but not on the breasts). This method is prescribed by a doctor. It releases hormones progestin and estrogen into the bloodstream. You put on a new patch once a week for three weeks. During the fourth week, you do not wear a patch, so you can have a menstrual period. Typical use failure rate: 9%, but may be higher in women who weigh more than 198 pounds.

Hormonal-patch

Vaginal Ring

The ring releases the hormones progestin and estrogen. You place the ring inside your vagina. You wear the ring for three weeks, take it out for the week you have your period, and then put in a new ring. Typical use failure rate: 9%.

 

Vaginal-ring

Emergency Pill

Emergency contraception is NOT a regular method of birth control. Emergency contraception can be used after no birth control was used during sex, or if the birth control method failed, such as if a condom broke.

  • Women can have the Copper T IUD inserted within five days of unprotected sex.
  • Women can take emergency contraceptive pills up to 5 days after unprotected sex, but the sooner the pills are taken, the better they will work. There are three different types of emergency contraceptive pills available in the United States. Some emergency contraceptive pills are available over the counter.

Emergency Pill

Implant The implant is a single, thin rod that is inserted under the skin of a women's upper arm. The rod contains a progestin that is released into the body over 3 years. Typical use failure rate: 0.05%. Implant hormone
Injection Women get shots of the hormone progestin in the buttocks or arm every three months from their doctor. Typical use failure rate: 6%. BC Inj

Barrier Methods

 
Male Condom
Worn by the man, a male condom keeps sperm from getting into a woman's body. Latex condoms, the most common type, help prevent pregnancy, and HIV and other STDs, as do the newer synthetic condoms. Natural or lambskin condoms also help prevent pregnancy, but may not provide protection against STDs, including HIV. Typical use failure rate: 18%. Condoms can only be used once. You can buy condoms, KY jelly, or water-based lubricants at a drug store. Do not use oil-based lubricants such as massage oils, baby oil, lotions, or petroleum jelly with latex condoms. They will weaken the condom, causing it to tear or break.

 

 

Condom

Female Condom

Worn by the woman, the female condom helps keeps sperm from getting into her body. It is packaged with a lubricant and is available at drug stores. It can be inserted up to eight hours before sexual intercourse. Typical use failure rate: 21%, and also may help prevent STDs.

Cervical cap & Diaphragm

Each of these barrier methods are placed inside the vagina to cover the cervix to block sperm. The diaphragm is shaped like a shallow cup. The cervical cap is a thimble-shaped cup. Before sexual intercourse, you insert them with spermicide to block or kill sperm. Visit your doctor for a proper fitting because diaphragms and cervical caps come in different sizes. Typical use failure rate: 12%.

Cx cap

Spermicides These products work by killing sperm and come in several forms”foam, gel, cream, film, suppository, or tablet. They are placed in the vagina no more than one hour before intercourse. You leave them in place at least six to eight hours after intercourse. You can use a spermicide in addition to a male condom, diaphragm, or cervical cap. They can be purchased at drug stores. Typical use failure rate: 28%. Spermicides

Natural Methods

 
Overview

Fertility awareness-based methods (FAMs) are ways to track ovulation, the release of an ovum (egg), to prevent pregnancy.

Understanding your monthly fertility pattern  can help you plan to get pregnant or avoid getting pregnant. Your fertility pattern is the number of days in the month when you are fertile (able to get pregnant), days when you are infertile, and days when fertility is unlikely, but possible. If you have a regular menstrual cycle, you have about nine or more fertile days each month. If you do not want to get pregnant, you do not have sex on the days you are fertile, or you use a barrier method of birth control on those days. Failure rates vary across these methods. Overall, typical use failure rate: 24%.

Different Fertility Awareness-Based Methods

There are several methods you can use to predict when you will ovulate.

  • Calendar Method ” You will chart your cycles on a calendar.
  • Cervical Mucus Method: You will check the changes in your cervical mucus every day for the first part of your cycle until you are sure you have ovulated.
  • Temperature Method: You will take your temperature in the morning every day before you get out of bed.

It is most effective to combine all three of these methods. Together, they are called the symptothermal method.

  • Standard Days Method: You will track your cycle for several months to be sure that your cycle is always between 26 and 32 days long. Never longer or shorter. Then, you will not have unprotected vaginal intercourse on days 8 -19.
Calender Method

To prevent pregnancy, women can keep track of their menstrual cycles and abstain from unprotected vaginal intercourse when they are most likely to become pregnant. The methods you can use to do this are called fertility awareness-based methods (FAMs). One way that women track their fertility patterns is called the calendar method.

Some women also track their fertility patterns when trying to get pregnant to know when they should have unprotected vaginal intercourse.

With the calendar method, you need to keep a record of the length of each menstrual cycle in order to determine when you are fertile. You can use an ordinary calendar. Circle day one of each cycle, which is the first day of your period. Count the total number of days in each cycle. Include the first day when you count. Do this for at least eight cycles (12 is better).

Cycle Record

1st Day of Period

No. of Days in Cycle

 Jan. 20

 29

 Feb. 18

 29

 Mar. 18

 28

 Apr. 16

 29

 May 12

 26

 June 9

 28

 July 9

 30

 Aug. 5

 27

 

Don't use the calendar method if all your cycles are shorter than 27 days. Chart Your Calendar Pattern

To predict the first fertile day in your current cycle

  • Find the shortest cycle in your record.
  • Subtract 18 from the total number of days.
  • Count that number of days from day one of your current cycle, and mark that day with an X. Include day one when you count.
  • The day marked X is your first fertile day.

To predict the last fertile day in your current cycle

  • Find the longest cycle in your record.
  • Subtract 11 days from the total number of days.
  • Count that number of days from day one of your current cycle, and mark that day with an X. Include day one when you count.
  • The day marked X is the last fertile day.

Example:

Predicting your first fertile day. If your shortest cycle is 26 days long, subtract 18 from 26. That leaves 8. If day one was the fourth day of the month, the day you will mark X will be the 11th. That's the first day you're likely to be fertile. So on that day, you should start abstaining from sex or start using a cervical cap, condom, diaphragm, or female condom.

Predicting your last fertile day. If your longest cycle is 30 days, subtract 11 from 30. That leaves 19. If day one was the fourth day of the month, the day you will mark X will be the 22nd. That's the last day you're likely to be fertile during your current cycle. So you may start to have unprotected vaginal intercourse after that day.

In this example, the 11th through the 22nd are unsafe days. All the others are safe days.

Fertility Calendar

The calendar method can only predict what are most likely to be safe days. It is especially risky if your cycles are not always the same length. That's why it should always be used with other methods. Do not have unprotected intercourse on any day that the calendar method says is unsafe.

This information is not meant as a substitute to professional advice.

 

 

Cervical Mucus Method

The hormones that control your cycle also make the cervix produce mucus. It collects on the cervix and in the vagina. And it changes in quality and quantity just before and during ovulation. With personal instruction, many women can learn to recognize these changes. Instruction is usually given one-to-one. This method is also known as the ovulation method or the Billings method.

The Mucus Pattern

During your period, your flow covers the mucus signs.

After your period, there are usually a few days without mucus. These are called "dry days." These may be safe days if the cycle is long.

When an egg starts to ripen, more mucus is produced. It appears at the opening of the vagina. It is generally yellow or white and cloudy. And it feels sticky or tacky.

Usually, you will have the most mucus just before ovulation. It looks clear and feels slippery ” like raw egg white. When it can be stretched between the fingers, it is called spinnbarkeit ” German for stretchable. These are the "slippery days." It is the peak of your fertility.

After about four slippery days, you may suddenly have less mucus. It will become cloudy and tacky again. And then you may have a few more dry days before your period starts. These are also safe days.

Mucus Pattern

You can check your mucus in several ways. Do what is most comfortable for you. Check several times a day. You can,

  • Wipe the opening of the vagina with tissue before you urinate. Check the color and texture.
  • Check the color and texture of the discharge on your underpants.
  • Put clean fingers into the vagina and check the color and texture of the mucus on them.

This method isn't the best for women who don't produce much mucus. Women who ovulate on day seven or eight may also have too little mucus.

A woman's mucus pattern may be altered by,

  • breastfeeding
  • cervical surgery ” especially with cryotherapy or electrocautery
  • douches or other "feminine hygiene" products
  • perimenopause
  • recent use of hormonal contraceptives, including emergency contraception
  • spermicide
  • sexually transmitted infections
  • vaginitis

Safe Days Using the Mucus Method

Do not have unprotected vaginal intercourse on your unsafe days.

  • The days of your period are not safe days, especially during short cycles. The flow can cover the mucus signs.
  • In a long cycle, the dry days after your period may be safe.
  • Days that are not safe begin two or three days before the first sign of slippery mucus. They last for about three days after slippery mucus peaks. Safe days may begin after peak slippery mucus drops off and is cloudy and tacky again. But the dry days that follow are even safer.

It's best to abstain from unprotected vaginal intercourse for at least one whole cycle before you start to use this method for birth control.

The Two-Day Method

The Two-Day Method is a mucus method. It works best for a woman who is sure she can tell whether or not she has secretions. To use the method, she asks herself two questions:

  • Do I have cervical mucus today?
  • Did I have cervical mucus yesterday?

If she can answer "no" to both questions, it is considered a safe day for unprotected intercourse. Women who use this method may have only 12 safe days in each of their cycles.

Effectiveness

  • Of 100 couples who use the cervical mucus method correctly for one year, 3 will have a pregnancy.
  • Of 100 couples who use the Two-Day Method correctly for one year, 4 will have a pregnancy.
Temparature Method

Your body temperature is lower during the first part of your cycle. It usually rises slightly after ovulation when an egg is released. Your body temperature stays elevated for the rest of your cycle. It falls again just before your next period. Tracking your temperature every day can help you know when you ovulate. To prevent pregnancy, you will not have unprotected vaginal intercourse until three days after you ovulate each cycle.

You will need to chart your basal body temperature (BBT) every day. BBT is the temperature of the body when it is completely at rest. It varies slightly from person to person. Before ovulation, 96° to 98°F is normal for most women. After ovulation, 97 to 99°F is normal.

The changes will be in fractions of a degree ” from 1/10 to 1/2 a degree. So it's best to get a special, large-scale thermometer that only registers 96° to 100°F. It will be much easier to read. Basal thermometer should be available with drugstores. Some basal thermometers are to be used in the mouth and some are to be used in the rectum. Rectal thermometers are generally more reliable. Whatever you choose, be sure to take your temperature the same way every day.

Taking Your Temperature

Take your temperature every morning as soon as you wake up. Do it before getting out of bed, talking, eating, drinking, having sex, or smoking. Keep the thermometer in place for five full minutes. Read it to within 1/10 of a degree. Record the reading.

Charting Your Temperature Pattern

You must record every reading. You can get charts from your health care provider or women's health center. As each day's reading is put on the chart, you will begin to see a pattern. The rise in your temperature may be sudden, gradual, or in steps. The pattern may vary from cycle to cycle.

Your BBT may change when you are upset or don't get enough sleep. Illness, stress, jet lag, and smoking may also affect your body temperature. So can drinking more than you're used to or using an electric blanket. Putting these kinds of events on your chart can help you understand the pattern.

At first, you should have help to read your chart. A doctor, nurse, or family planning specialist can do that for you. In time, you'll have the confidence to use the chart by yourself. Be sure to chart at least three months before relying on this method.

Safe Days Using the Temperature Method

The safe days are those that are not fertile days. They are safe for unprotected vaginal intercourse if you are trying to prevent pregnancy. They begin after the temperature rise has lasted for at least three days. They end when the temperature drops just before your next period begins.

The temperature method is quite good at telling when ovulation has happened. But it can't predict when it will happen. So, you have to make sure that sperm is not waiting in your body when it does happen. It is best to treat as unsafe all the days of the first part of your cycle. This is from the start of your period to the start of the fourth day of your next rise in temperature. You can combine BBT with another method to try to predict when ovulation will happen. This can increase the number of your safe days.

After a while, you may become sure that you can tell what days are safe. If so, you may not have to take your temperature every day. You can go without taking it from the start of your safe days to the start of your next period.

Fertility Pattern

In order to know when you are most likely to get pregnant, you have to become familiar with your menstrual cycle.

Before pregnancy can begin, a woman's egg must join with a man's sperm. This is called fertilization. For a healthy woman, there are days when fertilization can happen. There are days when it can't. And there are some days when it's unlikely ” but still possible. To begin a pregnancy, a woman can have vaginal intercourse ” without protection ” during the days when it's possible for the egg and sperm to join. We call those days your fertile days.

A woman's fertile days depend on the life span of the egg and the sperm. Her egg lives for about a day after ovulation. Sperm can live inside her body for about six days.

A woman has a chance of her egg joining a sperm about seven days of every menstrual cycle.

  • This includes the five days before ovulation.
  • It includes the day of ovulation.
  • It also includes the day or two after ovulation ” even though it's less likely to happen then.

Menst-Cycle

Knowing when your fertile days will happen can help you avoid a pregnancy. It can also help you plan one. The key is to figure out when you will ovulate. This will let you figure out the other fertile days that come before and after you ovulate. Then you can track your fertility pattern ” the days of the month when you are fertile and the days of the month when you are not. You must do this carefully. Women don't all have the same fertility pattern. And some women have different patterns from one month to the next.

Effectiveness of this method (FAM)

Effectiveness is an important and common concern when choosing a birth control method. Like all birth control methods, fertility awareness-based methods (FAM) are more effective when you use them correctly.

Twenty-four out of every 100 couples who use fertility awareness-based methods each year will have a pregnancy if they don't always use the method correctly or consistently. Always practicing these methods correctly will make them more effective.

How well fertility awareness-based methods work depends on both partners. That's why it is important for both to learn about the methods and support each other in their use.

These methods can work best for you if you,

  • have received careful instruction
  • have only one sex partner and he is as committed to fertility awareness-based methods as you are
  • have the discipline you need to check and chart your fertility signs
  • don't mind abstaining or using withdrawal, a cervical cap or diaphragm, a sponge, spermicide, or latex or female condoms on your unsafe days.
Disadvantage of FAM

Fertility awareness-based methods (FAM) may not work for you if you,

  • have more than one sex partner.
  • have a sex partner who isn't as committed to fertility awareness-based methods as you are.
  • don't want to keep close track of your safe days.
  • are not able to abstain or use another method for at least 10 unsafe days during each cycle.
  • take medicine that may affect reading the signs of these methods.

Do not depend on tracking your fertility if you

  • have irregular periods.
  • have a partner who is not cooperative.
  • have a sexually transmitted infection or frequent abnormal vaginal discharges.
  • cannot keep careful records.

It may be more difficult to track your fertility if you are breastfeeding, are a teenager, or are getting close to menopause. The hormone shifts may make the signs unpredictable.

Don't switch to a fertility awareness-based method after using a hormonal one, such as the pill. The hormones will affect your cycle. Use a method without hormones while you're learning to track your fertility.
| See effectiveness of contraceptive methods from U.S. CDC  |    

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