Health systems are complex and no simple recipe exists for success.
The pace of growth of Bangladesh’s health sector is most ‘striking’ among South Asian countries despite spending less on this sector than several neighbouring countries, says a British medical journal The Lancet.
In its recent issue, the influential journal says Bangladesh made ‘enormous’ health advances despite a difficult start after 1971 War of Independence.
The country “now has the longest life expectancy, the lowest total fertility rate, and the lowest infant and under-5 mortality rates in south Asia”, the journal pointed out.
In an article ‘Health transcends poverty in Bangladesh’, researchers identified several factors that put the country on track to achieve the health-related Millennium Development Goals.
Researchers were particularly impressed with Bangladesh’s achievement as they pointed out “health systems are complex and no simple recipe exists for success”.
It attributed the success in cutting mortalities as well as the rate of childbirths to the high-level political commitment to health since independence, the ability to innovate and adapt to resource limitations, transport infrastructure, female empowerment and education.
The journal says Bangladesh’s under-5 mortality has fallen to 65 per 1000 live births in 2006 from 202 in 1979.
The expansion of health-care coverage ensured more than 75 percent children younger than 1 year are ‘fully immunised’, and the total fertility rate declined close to the replacement level.
The Lancet researchers made comparative case studies between 2009 and 2011 in Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu with their neighbours and looked at how and why each region accomplished changes in the health sector with low costs.
The effort has been made after 25 years of the Rockefeller Foundation published “Good health at low cost” in 1985 to discuss why some countries or regions achieve better health and social outcomes than others at a similar level of income and to show the role of political will and socially progressive policies.
For Bangladesh, it says the high-level of political commitment in health has endured despite major political changes, including transition from military to civilian rule.
“... and has been facilitated by institutional continuity of civil servants and by partnerships between government and the non-governmental sector—an extender of government exemplified by the Bangladesh rural advancement committee”.
In specific they identified four health policies in Bangladesh for the ‘striking’ success.
First, they noted prioritising family planning in the population policy. “A separate directorate was created within the ministry of health and family welfare that secured sustained investment and developed innovative community-based interventions”.
Second, the first drug policy in 1982, that Lancet says, established a list of mainly generic essential drugs, and the Gonoshasthaya Kendra NGO “provided a model for small-scale integrated primary care”.
After the drug policy, the government established an essential drugs company in 1983 to produce and distribute drugs within the public sector.
This investment eventually led the booming of private pharmaceutical industry, Lancet says, by the 1990s, more than 80 percent of essential medicines were produced locally resulting in price stability that “ensured essential medicines are affordable”.
The journal also noted the government’s effort to coordinate donors’ projects by introducing sector-wide approach in 1998.
The third policy it noted was the human resources particularly the creation of health assistants and family-welfare assistants.
“Early recruits were male fieldworkers who were engaged in vertical programmes against smallpox and malaria in the 1960s and early 1970s; later they were joined by female health assistants.
“They work mainly in rural areas, delivering immunisation, health education, and distribution of essential medicines and contraceptives. Family welfare assistants were introduced in 1976.
“These workers are married woman who visit other married women of reproductive age in their homes to offer advice on contraception and provide free family-planning supplies.
“They are supported by a rapidly expanding network of primary health centres and a strengthened supply system”.
The Lancet says Bangladesh also pursued ‘progressive’ policies outside the health sector, including education and female empowerment.
Strengthening of the transport infrastructure and widening of access to electronic media facilitated access to health facilities and information.
Bangladesh's disaster preparedness, based on inter-sectoral planning, has also improved health system resilience.
Finally, it noted that Bangladesh has prioritised research and development.
“Innovations range from medical interventions—such as widespread implementation of oral rehydration solution, zinc to treat diarrhoea, and integrated management of childhood illness—to organisational responses, such as novel models of service delivery”.