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The Lancet Bangladesh Series

Exceptional achievement despite chronic poverty

Star Health Report
Exceptional improvements in the survival of infants and children under 5 years of age, life expectancy, immunisation coverage and tuberculosis control in Bangladesh are part of a remarkable success story for health in the South Asian countries, according to a major new series published in The Lancet. This is despite low spending on healthcare, a weak health system and widespread poverty. The Lancet is one of the most prestigious and leading medical journals of the world and believed to be the most persuasive scientific heritage to guide and influence public health policies and strategies of the future.
"Over the past 40 years, Bangladesh has outperformed its Asian neighbours, convincingly defying the expert view that reducing poverty and increasing health resources are the key drivers of better population health", explains Series coleader Professor Mushtaque Chowdhury from BRAC in Dhaka, Bangladesh. "Since 1980 maternal mortality has dropped by 75%, while infant mortality has more than halved since 1990, and life expectancy has increased to 68.3 years — surpassing neighbouring India and Pakistan."
According to the series, what sets Bangladesh apart is its pluralistic health system in which many stakeholders including the private sector and NGOs have been encouraged to thrive and experiment. This has led to rapid improvements in access to essential services such
as diarrhoea treatment, family planning, vitamin A supplementation, and vaccination coverage.
"Promoting an open culture of researchbased innovation has made Bangladesh a pioneer in scaling up community-based approaches that have brought key health interventions to every household, making huge inroads into improving maternal and child health and reducing population growth", explains Series co-leader Professor Abbas Bhuiya from ICDDR,B.
One striking example is tuberculosis treatment. By mass deployment of community health workers, cure rates escalated from less than 50% to more than 90% — among the highest in the world.
Another is contraceptive use. By recruiting female health workers to deliver door-to-door family planning sendees, Bangladesh has achieved high (62%) contraceptive prevalence and a rapid fall in fertility from 6.3 births per woman in 1971 to 2.3 in 2010 — a rate unparalleled in other countries with similar levels of development.
Less successful have been attempted improvements in poverty reduction, maternal and child malnutrition and access to primary care. "The stark reality is that prevalence of malnutrition in Bangladesh is among the highest in the world. Nearly half of children have chronic malnutrition. Moreover, over a third the population (more than 47
million) live below the poverty line, and income inequality is widening", says Professor Bhuiya.
Additionally, more needs to be done to address the poorly-equipped public health sector which, although free to the poor, faces a reported shortage of 800000 doctors and nurses. They point out that every year 4-5 million people are pushed into poverty because they have to pay for health sendees directly, partly due to the rapid growth of the unregulated, low-quality, high-cost private sector.
"Arguably the most daunting challenge is the health of poor people living in urban areas", says Professor Chowdhury. "In the last 40 years, the proportion of the population living in urban areas has risen from around 5% to 28%. This is projected to grow to more than 50% by 2050 — roughly 100 million people — putting tremendous pressure on already inadequate water, sanitation, and primary health-care services."
Shamim Ahmed, an author of the special Lancet series said, "This is certainly a logical concern that if equity fails to take its due place in the development process then the targeted sustainability will be heavily flawed and will corrupt the system that considers only number of cases reduced or per capita income increased!"
The authors conclude by setting out a plan to create a second generation of health-system innovations that will guide Bangladesh towards universal health coverage.