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Bangladesh's commendable advances in healthcare

Syed Mansur Hashim
ONCE touted as a "bottomless basket" by an American statesman in the early years of its journey as an independent nation, today, the country has a vibrant economy that has grown at an average of 6% per annum over the last decade; it is a major player in the world apparel industry, and it is known for its innovative microcredit programme that is being replicated on a grand scale in various continents outside Asia.
Bangladesh deserves to be known for another reason, i.e. in the area of healthcare. The country has made enormous advances in life expectancy and child health. The fertility rate has seen commendable reduction and high levels of immunisation coverage have been achieved; which in turn, has led to unprecedented reductions in maternal and child mortality. All these are indicators of the revolutionary change that has been experienced in the health sector. But then such improvement did not fall out of the sky. The fact that the country's policymakers had the foresight to make health a national priority, which happens to be enshrined into the constitution, effectively guaranteeing every citizen the "right" to healthcare proved to be visionary.
These steps taken early on in its journey as a newly-independent nation contributed to significant decrease in total fertility among women aged 15-49. In the mid '70s, total fertility was 6.6 births per woman aged 15-49 years; in 1994, it was 3.4; and by 2007, it was 2.7 (according to Bangladesh Demographic Health Survey, 2007). Similarly, as per
WHO statistics (2010), infant mortality has declined dramatically from 85 deaths per 1,000 live births in the late '80s to 52 deaths per 1,000 live births over the period 2002 to 2006, i.e. a reduction of 63% over a period of two decades. Again, huge improvements in "under-5" mortality have taken place: from 202 per 1,000 live births in 1979 to 133 in 1989 to 94 in 1995 in 2006. Consequently, Bangladesh is on track to achieve MDG4 to reduced under-5 mortality. Another area
deserving special mention is the reduction is in maternal mortality across the board, i.e. both national and sub-national studies. Studies conducted in the '60s point to maternal mortality standing between 600 800 deaths per 100,000 live births. A national survey conducted in 2001 (Bangladesh maternal health services and maternal mortality survey 2001) reported a decline from 514 deaths per 100,000 in the mid '80s to 322 per 100,000 in the late '90s.
These advances were made possible since Bangladesh, like many other
South Asian countries, has a public system run by the state and a large non-state sector that play a major role in the delivery of health care services. The latter includes NGOs and private providers of modern and indigenous medicine. In the 1970s, the government developed a public health system along the Health for All model, with a nationwide network of hospitals, health complexes, family welfare centres, sub-centres, and Expanded Programme for Immunisation Out-
reach clinics. At the same time, a parallel network of family planning and maternal and child welfare centres was established, in some cases contracting NGOs to provide services. Some 2,000 NGOs work in Bangladesh and their activities are mainly concentrated in the rural areas, with recent expansion into semi-urban and urban slums. The non-state sector provides the overwhelming majority of outpatient curative care, while the public sector is used for a larger proportion of hospital deliveries and preventive care.
Despite worthy progress made in a number of health-related areas, significant challenges remain. One major drawback naturally revolves around shortage of skilled manpower, i.e. doctors, paramedics and nurses. This is evident by the fact that 90% of children suffering from acute respiratory infection and/or diarrhoea must obtain service from the private sector and not public sector. This is partly because of the lack of qualified health providers in rural areas. It is also because the Essential Services Package does not cover non-communi-cable diseases and health workers are not trained to manage these conditions; consequently for these health issues, people routinely turn to unlicensed providers for treatment.
Yet at the end of the day, Bangladesh stands out as a country that has taken giant steps in healthcare. Long before the emergence of contemporary global health initiatives, the government placed strong emphasis on the importance of childhood immunisation as a key mechanism for reducing childhood mortality. The Expanded Programme on Immunisation (EPI) in Bangladesh is considered to be a health system success because of its remarkable progress over the last two decades. It provides almost universal access to vaccination services, as measured by the percentage of children under 1 year of age who receive BCG (a vaccine against tuberculosis). This increased from 2% in 1985 to 99% in 2009. Coverage of other vaccines has also improved substantially (Bangladesh EPI coverage evaluation survey, 2009).
The writer is Assistant Editor, The Dally Star.