health transcends poverty: the bangladesh experience

Copyright © Westminster European 2011

Key messages

• Bangladeshbecameanationin1971 withthetransitiontoindependence actingasanimportantcatalystfor healthreform.

• HealthpolicyinBangladeshhas enduredpoliticalchangewhile constantlyadaptingtoaddressnew issues.

• AsayoungcountryBangladeshwas apioneerinitsstrongnationalfamily planningprogramme,whichresultedin adramaticdropinfertility.

• Governmentengagementwithnon- governmentalorganisations(NGOs) andnon-stateprovidershashelpedto meettheneedsofalargepopulation.

• Bangladeshisaninnovatorinhealth policiesandintestingandadaptinglow- costtechnologiesinthehealthsector.• Othercontributingfactorsto Bangladesh’shealthachievements havebeenimprovedliteracy,economic developmentanddisasterpreparedness.

First published in 1985, the Good health at low cost report sought todescribe how some developing countries were able to achieve betterhealth outcomes than others with similar incomes. An iconic publicationof its day, it highlighted the linkages between the wider determinantsof health and their impact on health outcomes using country casestudies. In an extension to the original analysis, recent research exploresfive new countries asking why some developing countries are able toachieve better health outcomes. With chapters focusing on Bangladesh,Ethiopia, Kyrgyzstan, Tamil Nadu (India) and Thailand, ‘Good healthat low cost’ 25 years on has identified a series of inter-linking factors,within the health system and beyond. This first briefing in the series focuses on findings from Bangladesh.

‘Good health at low cost’ 25 years onDuringthepast40years,Bangladeshhasmadeenormousadvanceswithbasicpopulationandhealthindicators,whicharenowonaparwith,orbetterthan,itsneighbourswhohavehigherpercapitaincome.Bangladesh’shealthgainscanbeattributedtoaseriesofeffectivehealthsectorstrategiesandpolicyprocesses,andtoastrongemphasisondeliveryofhealthandfamilyplanningservicesatthecommunityandhouseholdlevel.Bangladeshhaspromotedlow-costtargetedtechnologiesandproveninterventionsandpoliciesthathaveplayedasignificantroleinimprovinghealthoutcomes.

Bangladesh’shealthgainshavebeenmadewithrelativelylowtotalhealthexpenditurewhencomparedregionally,3.4%ofGDPorUS$12percapitain2007.

Achieving better health in Bangladesh

‘Good health at low cost’ 25 years on What makes an effective health system? Page 01

‘Good health at low cost’ 25 years onWhat makes an effective health system?

Sincebecominganationin1971,Bangladeshhasmadehugestridesinimprovingitspopulation’shealth.Comparedwithothercountriesintheregion,Bangladeshhasamongthelongestlifeexpectancyformenandwomen,thelowesttotalfertilityrateandthelowestinfant,under-5,andmaternalmortalityrates.Between1994and2008,lifeexpectancyincreasedfrom58yearsto66years.Infantmortalityhasdeclineddramaticallyfrom85deathsper1000livebirthsinthelate1980sto52deathsper1000livebirthsbetween2002and2006.Therehasbeenadramaticdecreaseintotalfertilityamongwomenaged15–49years.Hugeimprovementsinunder-5mortalitymeanthatBangladeshisontracktoachieveMDG4toreduceunder-5mortality.

Paths to SuccessOurresearchshowsthatafundamentalfactorinbetterhealthoutcomesinBangladeshhasbeenpoliticalcontinuity.Bangladeshhasdemonstratedastrongcommitmenttohealthasanationalpriorityandasahumanright.Thispoliticalcommitmenthastranscended

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Chittagong

Dhaka

Khulna

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MYANMAR

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Health transcends poverty:the Bangladesh experience

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‘Good health at low cost’ 25 years on What makes an effective health system? Page 02

Further readingChapter 3, Health transcends poverty: the Bangladesh experience. In Balabanova D, McKee M and Mills A (eds). ‘Good health at low cost’ 25 years on. What makes an effective health system? London: London School of Hygiene & Tropical Medicine, 2011. Available at http://ghlc.lshtm.ac.uk

AcknowledgementsICDDR,B gratefully acknowledges the contributions of the Rockefeller Foundation and of our partners from the London School of Hygiene & Tropical Medicine for making this work possible. The authors are grateful to the many past and present health leaders in Bangladesh who served as key informants to this work as well as the grassroots level workers who shared their valuable time and knowledge with us.

The opinions expressed are those of the authors and do not necessarily reflect the views of the London School of Hygiene and Tropical Medicine.

Readers are encouraged to quote material from this briefing in their own publications by acknowledging the original source.

This policy briefing was edited by Pamoja Consulting www.pamoja.uk.com

politicalpartypoliticsand,despiterapidchangesinthepoliticallandscapeandinkeyactors,manypolicieshavebeensustainedforasignificantperiodoftime.AnotherfactorinBangladesh’ssuccesshasbeenthegovernment’sabilitytocollaboratewithnon-stateactors.ThegovernmentviewsNGOsasawayofextendingtheirreach,particularlyintheimplementationofnationalstrategiesandpolicies.NGOshavedevelopedstrongcapacityandinnovativedeliverymodelsthathavepromptedatwo-waylearningexchangebetweengovernmentandnon-governmentalentities.

Policiesthathavebeenpivotalinimprovingthepopulation’shealthinclude;thePopulationPolicy(1976),whichpioneeredacommunitybasedinterventionthatbroughtfamilyplanningservices,includingcontraceptivesandeducation,directlytoindividualhouseholds.TheDrugPolicy(1982),whichincludedcategorisingandprocuringessentialmedicinesandtheestablishmentoftheEssentialDrugsCompanyLimited.Thisledtothedomesticproductionofdrugsappropriatetolocalneeds,savingthecountryapproximatelyUS$600000million.Finally,theSectorWideApproach(SWAp)(1998),facilitatedbytheWorldBank,hasreducedduplicationandfinancialwasteinthehealthsectorandhassimplifiedtheprocessofprogrammedevelopmentandimplementation.

Bangladesh’shealthsystemwasdevelopedalongtheHealthforAllmodelwithnationwidenetworksofhealthcarefacilities,

familyplanningandchildwelfarecentresandanimmunisationprogramme.Insightfulinvestmentsinhumanresourcesandinnovativedeliverymethodshaveresultedinuniversalcoverageofprimaryhealthcareservices;with21,000healthassistantsand23,500familywelfareassistantsservingcommunitiesandruralhouseholdsacrossthecountryprovidinghomevisits.

Bangladeshisagloballeaderindevelopinglow-costinterventionssuchastheuseofzincinthetreatmentofchildhooddiarrhoea,oralrehydrationsolution,deliverykits,tetanusvaccinationsforpregnantwomen,andiodizedsalt.Theseinterventionshavebeenrolledoutlocally,scaledupandevenusedinotherdevelopingcountries.Bangladesh’sstrongemphasisonchildhoodimmunizationhasprovidedalmostuniversalaccess.

Finally,non-health,povertyreductioninitiativeshaveplayedanimportantfactorinBangladesh’sprogress.Participationinmicrocreditprogrammeshasbeenconnectedtobetterchildsurvivalandtheexpansionofelectricitycoverage,androadinfrastructurehasassistedtherolloutofimmunizationprogrammestoruralareas.Anincreaseinnetprimaryeducationenrolmentfrom74%in1991to87%in2005hasresultedinimprovedliteracyrates.Theeconomicandsocialpositionofwomenhasimprovedinlinewitheducation,income-generatingactivities,accesstomicrofinanceandemploymentinthegarmentindustry.Bangladesh’sdisasterpreparednesshasshowntheworldthatithastheabilitytoplan,coordinateandimplementcrisisaction.Thisdemonstratesthegoodgovernancestructuresthatexistacrosspublicsectors.

Lessons learned and future challengesConsideringthatBangladeshcameintobeingasoneofthepoorestnationsintheworld,ithasmaderemarkableprogressinimprovingthehealthofthepopulationsince1971.Thishasbeenachievedagainstabackdropofstrongpoliticaldirection,leadershipandeffectivehealthstrategies,whichhasdriventhehealthagendaforwardresultinginawidereachingprimaryhealthprogramme.Notablesuccesseshavebeenachievedinreducingfertility,andimprovingaccesstovaccinationsandotherbasicinterventions,oftendeliveredbyNGOs.

Theseriesofinter-linkingfactors,asintheotherstudycountries,thathavemadeBangladesh’shealthsystemsuccessfulinrealisingbetterhealthforitspopulationcanbeexpressedbyfourwordsallbeginning

withC–referredtoasthe4C’s.TheyareCapacity(theindividualsandinstitutionsnecessarytodesignandimplementreform),Continuity(thestabilitythatisrequiredforreformstosucceed),Catalysts(theabilitytoseizewindowsofopportunity)andContext(theabilitytotakecontextintoaccountinordertodevelopappropriateandrelevantpolicies).

Whilegreatprogresshasbeenmade,newapproachesthatincorporateinnovation,whilerespondingtochangingculturalandsocioeconomicrealities,mustbedeveloped.InordertocontinuemakingimprovementsinthehealthofthepopulationBangladeshmustre-committorelativelylow-costandlesscomplexinterventionsthataddressanincreasinglyagingpopulationandasignificantincreaseinnon-communicablediseases,whicharecurrentlynotprovidedforinthepublichealthcaresystem.Thenumberofskilledbirthattendantsneedsbeincreasedandimprovementsmadeinthedeliveryofbasichealthinterventionstohard-to-reachurbanslumcommunities.

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