The climate crisis and a rising burden of non-communicable diseases is a deadly combination in countries like Bangladesh. Investing in robust primary healthcare and sharpening the focus on preventive care is the most efficient, cost-effective solution.
Women living in Itna, Bangladesh, are receiving healthcare services at their doorstep through telemedicine. Photo: Abdullah Al Kafi © BRAC 2022
“My mother died recently. It was devastating. What was just as devastating, though, was admitting that her death brought relief. She’d had diabetes for years and the insulin cost nearly a third of my income,” said Manzur Haque, his gaze firmly focused on the rice field next to us, so he didn't have to look me in the eye.
I met Manzur—a young farmer in his 20s—a few months ago, on a visit to Nilphamari in northwestern Bangladesh. Nilphamari is one of the country’s most climate-vulnerable districts.
His mother died of heatstroke last year. She had been living with diabetes, high blood pressure, and poor kidney function for a decade. Manzur single-handedly managed all her medical costs.
Last year, during a severe heatwave, she suffered a heat stroke. Manzur took her straight to the nearest hospital, but their resources were limited, and her co-morbidities restricted the medicines that could be administered. She died a day later from multiple organ failure.
A looming health and climate crisis
While in Nilphamari, I visited the single-room medical outpost in the same village. It was nearly 40°C—temperatures that would have been rare just a decade ago. They’re now normal—Bangladesh faced 76 days of extreme heat between 15 May 2023 and 15 May 2024—and that number is only expected to rise.
Something else I saw, that would have been rare in the past, were the queues of people waiting for treatment for hypertension, respiratory illnesses, and heart disease. These non-communicable diseases (NCDs) now account for 67% of deaths in Bangladesh.
This trend is not limited to Bangladesh; NCDs are rising globally, and the rise is exacerbated by climate-related impacts. A 2023 study projected a 162% increase in extreme-heat associated cardiovascular deaths in the US by the middle of the century.
The link between climate change and health is a particularly deadly combination in the global south, where affordable services remain out of reach for many—especially those in the most climate-vulnerable areas.
Understanding a complex web of contributing factors
Although countries like Bangladesh have been spending on healthcare—the country’s public health expenditure increased more than five-fold between 2011 and 2024—it still has the world’s sixth highest rate of out-of-pocket health expenditure, and some of the poorest quality of care.
This is at least partly due to where that investment is going. Spending has been characterised by a focus on large facilities, primarily hospitals, and—much more recently—community clinics. While some 80% of the population of Bangladesh now lives within a 30-minute walk of a clinic, far less effort has gone into ensuring those facilities meet people’s needs—and, more importantly, how to prevent diseases in the first place. This is where primary healthcare can play a crucial role, supporting people to make lifestyle and dietary changes before they get locked into a lifetime of expenditure.
Bangladesh’s current network of community clinics provides primary healthcare services through a government community healthcare provider, with complex cases referred to NCD spaces in government hospitals. Although a good idea in theory, the challenge is that the number of people coming in often overwhelms the single doctor stationed in the hospital booth. There is a simple fix: BRAC has found that having a community health worker equipped with digital health tracking apps at both the community clinic and in the hospital’s NCD space considerably increases the quality and coverage of care.
A community health worker with young mothers in Bangladesh. Photo: © BRAC 2019
There are other simple fixes. BRAC’s community health worker programme, which reaches approximately 80 million people in Bangladesh, not only has health promotion, prevention, and linkage to primary healthcare services at its core, but serves as the first line of defence against climate-related health issues, providing early warnings before crises, educating communities about emerging diseases, and ensuring continuity of care during crises. It plays a vital role as a surveillance system, tracking and reporting cases so that trends can be spotted early, which was particularly useful during covid-19, and more recently during dengue outbreaks.
Bangladesh is the canary in the coal mine
NCDs are already the number one killer in the world, and are only predicted to rise due to worsening nutrition, sedentary lifestyles, air pollution, and ageing populations. For countries like Bangladesh, on the frontline of the climate crisis and with some of the least access to primary healthcare services, the impacts will hit even harder. Lack of access to public services already funnels people into expensive private facilities—in Bangladesh, the cost of private facilities generally starts at 10 times the price of public services—which will increasingly lead people to cut back on other vital expenditure, or income-generating activities, to cater to sick family members. In a devastating trifecta, the areas with the worst access to healthcare are also often the most climate-vulnerable and are increasingly the poorest.
There are many examples across the global south of how strengthening primary healthcare systems leads to demonstrable returns. Brazil’s investments in its community health worker programme, for example, increased the use of primary healthcare services by 450%, with the strongest impacts seen in the poorest communities. Costa Rica, which has made public health central to the delivery of medical care, has higher life expectancy than the United States,, with one-sixth of the per-capita income.
Tuberculosis is a good case study for the impact of strengthening primary healthcare in Bangladesh. Treatment coverage was 20% in 2000; it’s now 79.9%, and 95% of cases are successfully treated. Community health workers go door-to-door to check for symptoms, refer patients for tests, and, if diagnosed, supervise care.
A strong primary healthcare system, starting at the community level, is considered the most efficient and cost-effective way to achieve universal health coverage (UHC) —that is, in simple terms, every person, everywhere, having access to quality healthcare without suffering financial hardship. There are simple, low-cost, and incredibly effective examples of how this can be done all across the global south. Investing in this is not just good health policy, but an urgent climate adaptation strategy.
BRAC’s community health worker providing counselling and health screening during a household visit. Photo: © BRAC 2020
Our path to UHC cannot be paved solely with hospital beds and clinic walls. While we race to build more facilities, the true revolution in healthcare lies not in better treatment of illnesses, but in preventing them in the first place. By redirecting our resources and attention toward preventive care—from regular health screenings and early detection, to education and awareness campaigns for healthier life choices—we get much better at stopping diseases before they require medication. The most powerful pill, after all, is the one we never need to take.
The opinions expressed are those of the author and do not necessarily reflect the position of Re:solve Global Health.
Asif Saleh is the executive director of BRAC. He brings multisectoral experience in senior leadership roles in private, public, and non-government arenas, with a proven track record of effectively managing development programming, operational and financial sustainability, and building effective partnerships.
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