Bangladesh’s ‘paradoxical’ health outcomes: Lancet

In its first ever series on Bangladesh after similar studies on China, India, Pakistan and Africa, the journal says the mobilisation of communities, gender equity, and a commitment to universal healthcare are some of the lessons that others can learn from Bangladesh to make a difference. But authors warned against complacency as diseases are changing their patterns, and malnutrition remained all pervasive along with poverty. “We still face the dual burden of infectious and chronic diseases. So we have to learn. Lancet shows we have done well in the past,” series co-leader Prof Abbas Bhuiya of the International Centre for Diarrhoeal Disease and Research (ICDDR,B) in Dhaka, told bdnews24.com. The six part series takes a comprehensive look at one of the “great mysteries of global health” and takes note of the successes. It points out the challenges involved in achieving universal health coverage, making sure people will not slip into poverty due to healthcare costs. It lists successes such as reducing maternal and child deaths, increasing immunisation coverage as well as life expectancy, and controlling tuberculosis. However, a second wave of innovation would be needed to progress to a universal health coverage. Bangladesh’s President Md Abdul Hamid has launched the series in Dhaka on Thursday. The journal said outstripping neighbour India, and Pakistan from which it won independence, Bangladesh cut maternal deaths by 75 percent since 1980 and halved infant deaths since 1990. Life expectancy has increased to 68.3 years. Series co-leader Prof Mushtaque Chowdhury, also vice-chairperson of the world’s largest NGO, BRAC, said Bangladesh’s success ‘convincingly’ defied the expert opinion that reducing poverty and increasing health resources were the ‘key drivers’ of improving health. According to the Series, what set Bangladesh apart was its ‘pluralistic’ health system in which many stakeholders including the private sector and NGOs were “encouraged to thrive and experiment”. This led to rapid improvements in accessing essential services such as diarrhoea treatment, family planning, vitamin A supplementation, and vaccination coverage. The report noted that research paid back in Bangladesh, despite the fact that at the national level the government could not develop a research institute. The Lancet credited the ICDDR,B for its groundbreaking researches and innovations. Research- driven knowledge helped in strengthening the health-system, the journal said, an eye-opener for the Bangladesh government which is traditionally known for paying little attention to researches. Bangladesh was seen as a ‘pioneer’ in scaling up community-based approaches to take key health interventions to the household level. For instance, the tuberculosis cure rate rose to more than 90 percent, among the highest in the world, from less than 50 percent when community health workers were engaged by NGOs. Female health workers' door-to-door services helped raise the use of contraceptives to 62 percent, with a rapid fall in total fertility rate to 2.3 in 2010 from 6.3 after independence in 1971 – a rate that Lancet says was ‘unparalleled’ in countries with similar levels of development. Other factors that made a big impact included a strong focus on reducing gender inequality through pro-poor and pro-women development programmes like education and microfinance, and improvements in natural disaster preparedness and response. But with nearly half of its under-5 children underweight and pregnant mothers anaemic, malnutrition still remained a big challenge for Bangladesh, along with access to primary care. “The stark reality is that the prevalence of malnutrition in Bangladesh is among the highest in the world. Nearly half of the children suffer from chronic malnutrition,” said a series leader, Prof Lincoln C Chen, President of the China Medical Board in Cambridge. “Moreover, over a third the population –more than 47 million— live below the poverty line, and income equality is widening”. Despite free services to the poor, Lancet suggested the strengthening of poorly equipped public health sector, with a reported shortage of 800,000 doctors and nurses.

While the urban population grew to 28 percent from about 5 percent over last 40 years, urbanisation was also seen as a challenge. If current trends continued, by 2050 roughly 100 million people will be urbanised putting tremendous pressure on already inadequate water, sanitation, and primary health-care services. The last paper of the series suggested reforms involving “a multipronged strategic approach that assures affordable, equitable and high-quality care in the context of the current pluralistic health system”. As much of Bangladesh’s success has centred on progress towards the MDGs, the Editor-in-Chief Richard Horton commented: “The future looms heavily in a small country with such a huge population, amid continuing deep poverty and inequality. “An obesity epidemic is emerging among the urban middle class. The proliferation of unregulated, low-quality, and high-cost private practitioners is also a cause for present concern." As national elections approach in January, the Editor-in-Chief writes, “The country’s vulnerability to climate change, rapid urbanisation, persistence of poverty and inequality, and low quality of life and income levels will be major political challenges. "Bangladeshis have shown enormous creativity, resilience, and energy in the past. They will need to continue to do so again in the future,” he concluded.