Bangladesh indeed has done exceptionally well despite its perennial
limitations. It is one of the few countries which are on track to
achieve both MDGsfour and five. Life expectancy,which is the average
number of years a person in a given societyis expected to live,has
increased by 70 percent since independence. In 1971, the life expectancy
was just over 40 years and now this reached to nearly 70 years.
Interestingly, women have benefited more. Until the 1980s, Bangladesh
unfortunately was one of the few countries in the world where women
lived a shorter life than men. This has now been reversed, with women
living longer than men. In terms of health, Bangladesh's record is
exemplary. The country has reduced its infant mortality rate
tremendously, from 150 in the early 1970s to less than 50 now. Similarly
the maternal mortality ratio has decreased from about 600 to less than
200. This is quite remarkable since it challenges the conventional
wisdom that maternal mortality is directly related to availability of
skilled attendance and facility delivery - both of which are lacking in
the country. Bangladesh's achievement in fertility control is even more
dramatic. The total fertility rate has reduced from about 7.0 in the
early 1970s to 2.3 in 2010. In some areas such as Khulna, the
'replacement level' has already been reached.
Bangladesh has accomplished some public health miracles. Take the
case of immunisation. In mid-1980s only 2 percent of children were
vaccinated. With the government's commitment, and engagement of civil
society organisations, development partners and the media, this climbed
to 70 percent in a mere five years, which prompted Unicef to call it a
'near miracle.' Diarrhoea was a major killer of children and oral
rehydration therapy (ORT) - the treatment of choice - was not available
to the people. BRAC, with technical support from ICDDR,B carried out a
decade-long arduous campaign to teach mothers how to prepare itfrom salt
and molasses. Due to such intensive effortsand subsequent involvement
of the public and private sectors,the usage rate of ORT in Bangladesh is
now the highest in the worldand has become a part of the local culture
in the sense that mothers transmit the knowledge to their next
generation. Our success in family planning is well known and is a cause
of envy for many countries.
Bangladesh is a high burden tuberculosis country. The directly
observed treatment - short course or DOTS - the recommended therapy for
TB, has made impressive progress, exceeding the WHO target of both case
detection and treatment completion. In Bangladesh the government and
NGOs work very closely and the national TB programme is a perfect
example. The above achievements make us proud. But what about the
future? Keeping the momentum going will require a good understanding of
the unfinished agenda and the future challenges. It is true that we have
done well compared to some of our economically better-off neighbours.
But we are still lagging behind Sri Lanka in terms of most indicators.
Sri Lanka's maternal mortality ratio, for example, is less than 30. The
challenges are many and formidable. The decline in some rates such as
neonatal mortality has unfortunately been very modest.
With many of the contagious diseases still persisting, we are faced
with a double burden. The epidemiological and demographic transitions
are bringing the non-communicable and life-style related diseases such
as diabetes, hypertension and cancer into the fore which is further
exacerbated by the ageing of the population. Threats from the newly
emerging infectious diseases such as Ebola, Nipah virus, Bird-flu, etc.
are real. Unfortunately our health system is hardly prepared for these.
Human resource is an unending problem with shortages, misdistribution,
skill imbalance and malfunction. Public investment in health is one of
the lowest in the world here. 63 percent of the expenditure is
out-of-pocket and limits a citizen's access to quality healthcare, and
increases poverty. Lately, there have been some policy guidelines for
achieving Universal Health Coverage by 2032,but no headway is in sight.
Governance of the health sector is a continuing issue mired with raging
corruption and wastage of resources. There has been a limited success in
reducing malnutrition. Bangladesh has one of the fastest growing urban
settlements and about a third of this lives in slums. But there is
little attention given on how to deal with this. NGOs are also working
in urban slums but there is hardly any co-ordination with the public
sector or between themselves. Environmental pollution and climate change
will likely worsen vulnerability, particularly that of the poor. Issues
such as arsenic in drinking water, unfortunately, remain neglected or
forgotten. The gains of the past years are considerablydue to gains in
some of the social determinants of health. Poverty persists - about a
quarter of Bangladeshis are still poor by any standard. Income
inequality is high and is not reducing. Child marriage is rampant and a
shamefully – 60 percentof girls are married off before the age of 18 -
the highest in South Asia. Drowning and road accidents continue to add
to the number of deaths and injuries but no effective strategy is in
place to tackle them.
The writer is Vice Chair of BRAC and Professor of Population and Family Health, Columbia University.
