From ‘Basket Case’ to ‘One of the Great Mysteries of Global Health’: How did Bangladesh become such a success story?

Last week I was lucky enough to attend the UK launch of the Lancet Special Issue on Bangladesh, Innovation for Universal Health Coverage. In addition to this blog, there is also a complete Storify of the event.

Bangladesh is a fascinating case study for this type of review because, in terms of many health and social status indicators, they outperform many of their neighbouring countries despite having a lower GDP. This is particularly surprising as their health system is weak in many respects and is pluralistic, characterised by a range of health service providers from the for-profit and not-for-profit private sectors. Per capita expenditure on health care is $27 and two thirds of payments for health care are out of pocket – meaning that government investment in the health sector is very low. There are only 0.3 doctors/nurses per 1000 population. Despite this Bangladesh is one of six countries which is on-track to achieve Millennium Development Goals 4 and 5 on child and maternal health.

Setting the scene

Dr Mushtaque Chowdhury (Vice-Chairperson and Interim Executive Director, BRAC) set the scene for the meeting, explaining that Bangladesh attained independence in 1971 after a liberation war which had caused millions of people to migrate to India and which destroyed much of the infrastructure of the country. At the time many outsiders were sceptical about the long-term future of the country and suspected that it would remain dependent on outside assistance for many years to come, hence the rather unpleasant label of 'basket case'. However, despite this the country has turned itself around and made great strides in terms of health outcomes.

• Until the late 1980s Bangladesh was one of the few countries in the world where women lived a shorter life than men, but this has now been rectified
• There are high rates of girls' enrolment in school at primary level
• Expanded Program on Immunization (EPI) targets are at 82% (as opposed to 44% for India)
• There is very high use of Oral Rehydration Therapy (ORT) which has been popularised by BRAC who have taught mothers how to prepare it in the home
• In terms of sanitation less than 10% defecate openly (it's 50% in India)
• Bangladesh have already achieved WHO detection and treatment targets related to Directly Observed Therapy Shortcourse (DOTS) for TB
• Total fertility rate has reduced dramatically

Positive influences

Dr Chowdhury explained that the war of liberation changed the way that society looked at inequity and the role of women, leading to a national commitment to improve the life of the poor and marginalised. Health policies such as the 1982 Drug Policy changed the way that drugs were made available and meant that essential medicines became available at a very cheap price. New health centres and other facilities have extended the reach of the health system. Although the population has doubled in the last 30 years, food production has trebled and there are food for education programmes and targeted programmes for the poor and girls. 80% of the poor have access to micro-finance. Women form the backbone of the front-line health worker programme providing primary health care to the people. The government has created spaces for non-governmental organisations (NGOs) to grow and flourish. Finally health research has played a large role in problem solving and there is a history of the implementation of research findings into programmes.

There is still much to do

Despite its successes there are areas of health in Bangladesh which need attention, for example:

• Skilled attendance at birth and facility delivery rates are low, impacting on maternal health
• The country is facing an onslaught of Non Communicable Diseases (NCDs)
• Malnutrition is a major problem, even among richer families

Abbas Bhuiya (Executive Director of ICDDR,B and Co-Director of Research for Future Health Systems) elegantly explained some of the remaining challenges that Bangladesh faces in fixing its health system. The country has a chronic shortage of health care workers, and of the ones that they have only 5% are formally trained and they tend to gravitate to urban areas. Much of the spending on health care and medicines comes from people's pockets rather than from the state or insurance programmes. The country has a weak and inadequate electronic records system, hindering joined up action. Finally, more needs to be done to empower the Ministry of Family Health and Welfare.

But there's a plan

Impressively the authors of the Special Issue are keen that the information that they have shared gets followed up and they have taken proactive steps to see that it happens. The journal contains a Call to Action with the following recommendations:

1. That a national human resources policy and action plan need to be developed
2. That out of pocket spending is decreased through the establishment of a national health insurance scheme
3. That the country build an electronic health information system
4. That the capacity of the Ministry of Health and Family Welfare is strengthened so that they have the clout to appropriately influence decision making
5. That a supra-ministerial council on health is created

A learning platform is being developed to make sure that there is advocacy with non governmental organisations, the media, the government, academia and development partners to operationalise and monitor action.

Let's hope those close-to-community providers of health care who labour at the front lines of delivery are fully and comprehensively involved in this action as it is rolled out. Given Bangladesh's past performance in mobilising a plural and diverse set of health care actors, we have much to be hopeful for.

Blog by Kate Hawkins, who manages communications and research uptake for REACHOUT. The REACHOUT programme is an international research project helping to understand and develop the role of close-to-community providers of health care in preventing, diagnosing, and treating major illnesses and health conditions in rural and urban areas in Africa and Asia. Sabina Rashid, the co-Principle Investigator for the REACHOUT Bangladesh team is an author of one the Lancet papers on child survival.