Bangladesh has made great strides in improving the health of its population, much more than a country at its level of development can be expected to do. Serious problems still remain in reducing child malnutrition and maternal mortality in particular; nonetheless, the aggregative results achieved in the last three decades are quite impressive. These achievements have certainly have gone a long way towards fulfilling the right to health in Bangladesh. This paper argues, however, that despite overall progress the health sector of Bangladesh suffers from a number of inadequacies that militate against the rights-based approach to health. These include persistent inequities in access to healthcare (including gender inequity, and inequity along the poor versus non-poor divide), lack of meaningful participation of citizens in the running of the health system, and the absence of effective accountability mechanisms through which the providers of healthcare can be held responsible for their actions.
The objective of this paper is to enable the Government of Bangladesh (GOB) to strengthen health systems and improve health services, particularly for the poor. There are two components to the project. The first component is improving health services This component will: (a) improve priority health services to accelerate the achievement of the Health, Nutrition and Population (HNP) related Millennium Development Goal (MDG) targets by scaling up on-going interventions as well as introducing new interventions and (b) strengthen the service delivery system; and the second component is strengthening health systems this component will strengthen health systems. This component will support the GOB’s interventions for strengthening health systems.
This study was descriptive, addressing the general healthcare system of Bangladesh, examining specifically the contrasts between urban and rural health issues to assess possible factors contributing to health problems for rural people, using a particular village as a model. In addition; one hundred prescriptions were evaluated to ascertain the rural prescription pattern. A combination of data collection techniques were used to obtain the necessary information, including available information, interviews, direct observation and follow-ups.
History of development
1970 – 2006 Life expectancy increased from 44 years to 63 years 1970 – 2006 Under-5 mortality rate dropped from 239 to 69 deaths per 1000 live births 1990 – 2006 Percentage of malnourished children dropped from 67% to 48% (by underweight indicator) 2004- HIV prevalence has remained the lowest in the region at less than 0.1% 2006 -Birth Registration Law entered into force – formally tying birth registration to other services
In spite of development successes in the last three decades, with fertility declining from 6.3 to 2.5 children/women, Bangladesh’s population is still projected to reach 200 million by 2050. The health status of mothers and children remains poor. Due to widespread poverty, children (40%) and mothers (30%) suffer from moderate to severe malnutrition. Malnutrition is also a reason for the death of nearly a quarter of children under five. Bangladesh is also at high risk to the spread of HIV/AIDS, despite its low prevalence among the general population, due to a concentrated epidemic among injecting drug users. Bangladesh is considered one of 22 high burden countries for Tuberculosis (TB) and currently has the sixth highest frequency in the world.
Maternal and child health
One in eight women receives delivery care from medically trained providers and fewer than half of all pregnant women in Bangladesh seek ante-natal care. Inequity in maternity care is significantly reduced by ensuring the accessibility of health services. The 2010 maternal mortality rate per 100,000 births for Bangladesh is 340. This is compared with 338.3 in 2008 and 724.4 in 1990. The under 5 mortality rate, per 1,000 births is 55 and the neonatal mortality as a percentage of under 5’s mortality is 57. In Bangladesh the number of midwives per 1,000 live births is 8 and 1 in 110 shows us the lifetime risk of death for pregnant women.
Bangladesh is a rural-based country with about 80% of the people living in villages. There are 68 000 villages where 40-45 million rural people out of 98 million live in poverty. Bangladesh is a developing country with a very poor health status. Bangladesh has yet to develop a health service infrastructure to cater for the majority of people. Life expectancy is 56 years and the infant mortality rate remains high at 91 per 1000 live births. Infectious diseases including diarrhea are still T-cry much prevalent.
At the lowest tier of the government administrative system (the union lex-el) is the health and family welfare centre, serving a population of 15 000-20 000 and staffed by a medical assistant, a family welfare visitor and a diploma pharmacist. Ideally: these facilities should offer basic free health services to some percentage of rural people. However, because of unethical practices such as charging unauthorized fees, this does not always occur. But to some extent, awareness regarding family planning and immunization programs has grown among rural people because of massive campaigns and services by- both government and non-government organizations including health and family welfare centers.
Sanitation in Bangladesh
Water supply and sanitation in Bangladesh is characterized by a number of achievements and challenges. The share of the population with access to an improved water source was estimated at 98% in 2004, a very high level for a low-income country. This has been achieved to a large extent through the construction of hand pumps with the support of external donors. However, in 1993 it was discovered that groundwater, the source of drinking water for 97% of the rural population and a significant share of the urban population, is in many cases naturally contaminated with arsenic. It gradually emerged that 70 million people drank water which exceeds the WHO guidelines of 10 microgram of arsenic per liter, and 30 million drank water containing more than the Bangladesh National Standard of 50 microgram per liter, leading to chronic arsenic poisoning. On the other hand, surface water is usually polluted and requires treatment.
Taking arsenic contamination into account, it was estimated that in 2004 still 74% of the population had access to arsenic-free drinking water. Another challenge is the low level of cost recovery due to low tariffs and poor economic efficiency, especially in urban areas where revenues from water sales do not even cover operating costs. In rural areas, users contribute 34% of investment costs, and at least in piped water schemes supported by the Rural Development Academy recover operating costs. Sanitation faces its own set of challenges, with only 39% of the population estimated to have had access to adequate sanitation facilities in 2004. This is actually a doubling of the 20% share in 1990. A new approach to improve sanitation coverage in rural areas, the community-led total sanitation concept that has been first introduced in Bangladesh, is credited for having contributed significantly to the increase in sanitation coverage since 2000. Access to Water and Sanitation in the Bangladesh (2010)|
Family Planning program was first introduced in the country in the early 1950s through voluntary efforts and the Government took Family Planning as a Government program in 1965. Recognizing the importance of reducing Fertility Rates Government attached top priority on Family Planning program. The Family Planning Program has evolved through a series of development phases and has undergone changes in strategy, structure, content and goal. The Government deployed Family Welfare Assistant (FWA), initiated Social Marketing Program to promote contraceptive and involved number of NGOs to provide client-centered Reproductive and child health and Family Planning services. The Government adopted Population Policy recently. The goal of population policy and Maternal and Child Health includes Reproductive Health services and to improve the living standard of the people.
The priority objectives of the program are:
* To reduce Maternal Mortality Rate (MMR), Infant Mortality Rate (IMR), Total Fertility Rate (TFR)
* Male involvement in reproductive health.
* Increase acceptors of clinical and long acting methods.
* Special program for low performance area.
* Decrease discontinuation of contraceptive.
* Care for adolescent health.
* Encourage delayed marriage.
Health policies and strategies
The cornerstone of national health policy is the Health and Population Sector Strategy introduced in 1998. Priority is given to ensuring universal accessibility to and equity in healthcare, with particular attention to the rural population. MCH receives priority in the public sector, and reproductive health has recently become a priority concern. There has been improvement in the government financial allocation for health. Efforts are being made to develop a package of essential services based on the priority needs of clients, to be delivered from a static service point, rather than providing door to door visits by community health workers. This is a major shift in strategy and will require complete reorganization of the existing service structure. This is expected to reduce costs and increase efficiency as well as meet “peoples’ demand”. Privatization of medical care at the tertiary level, on a selective basis, is also being considered.
E-health initiatives in Bangladesh:
The Government of Bangladesh has a wide range of specific programmes to gradually improve the e-health infrastructure and its use in the country. It includes administration and management of health services, collection and exchange of health service data, performance analysis of vertical programmes, population surveys, professional communication, supporting medical education and research, telemedicine, e-records, etc. In fact, the e-health initiative in Bangladesh began in 1998 when the Ministry of Health & Family Welfare (MOHFW) undertook the Health & Population Sector Programme (HPSP) to enhance efficiency of programme implementation.
What have been the outcomes of your e-health initiatives?
(a) Personnel managers are able to make decisions more quickly with respect to personnel placement. (b) Better monitoring of the progress of health programmes and achievements of health MDGs. (c) Increasing understanding of the importance of e-health by the policy-makers. Government–NGO collaboration in Bangladesh
Constitutionally, the state is responsible for providing basic health care to its population. The Government of Bangladesh (GOB) therefore runs an extensive network of hospitals and dispensaries, but the services suffer from shortages of resources and mismanagement, and lack of accountability. Furthermore, in hard-to-reach areas, health care services are either absent or inaccessible. This situation has led NGOs and other voluntary organizations to grow and to take responsibility for providing much of the country’s health and social welfare services. Current estimates suggest that NGOs provide services to almost one-quarter of the total population. Bangladesh has probably the most active NGO sector in the world, with over 6000 registered NGOs. Of that, about a quarter is considered active.
Two – the Bangladesh Rural Advancement Committee (BRAC) and the Grameen Bank – are very large with nationwide capacity and coverage. Most NGOs pursue a dual strategy, addressing poverty (through micro-credit schemes) as well as providing service delivery programmes, particularly for education, agriculture, health and other related areas. These organizations generally follow the target-group approach, giving greater priority to the poor and other vulnerable groups. There is growing recognition that NGOs have considerable power to improve health-seeking behavior and the capacity of the community.
NGOs are considered to be in a better position to impose user fees that can lead to cost recovery and community participation. They are thought to be closer to the people and more aware of community needs. Their success in economic empowerment of the poor, polio eradication, sanitation, environmental conservation and in non-formal education programmes have strengthened both the government’s and community beliefs that NGOs can effectively contribute to achieve national targets Achievements to meet the demands of MDGs
Bangladesh has been doing an excellent job in heath sectors. It is one sector in which Bangladesh has achieved many targeted goals. The progress that Bangladesh has made, and the outcome that Bangladesh has got will be explained below. For a country, development of health is more important than being economically developed. Keeping that in mind, in September 2000, UN Millennium Summit introduced MDGs. The full form of MDG is Millennium Development Goal. It was adopted by 189 nations. There are eight MDGs. These are –
Goal1. Eradicate extreme poverty and hunger
Goal2. Achieve universal primary education
Goal3. Promote gender equality and empower women
Goal4. Reduce child mortality
Goal5. Improve maternal health
Goal6. Combat HIV/AIDs, malaria and other diseases
Goal7. Ensure environmental sustainability
Goal8. Develop a global partnership for development
In these eight indicators, we can see that Goal4, Goal5, Goal6 and part of Goal1 can easily relate with the health issues of Bangladesh. Considering Goal1, poverty and hunger are interrelated. The poverty gap ratio has been decreased dramatically to 9.0. So the rate of hunger is automatically reduced as well. Secondly Goal4, Bangladesh is on track with regard to achieving this goal. Significant strides have been made in all three indicators and tend sustains, the country will meet the 2015 target well ahead of schedule.
Then again, considering Goal5, although the maternal mortality ratio is on track, it remains a challenge for Bangladesh to sustain the rate given the socio – economic factors that affect the goal. Also the percentage of skilled birth attendants is low. Lastly, Goal6, Bangladesh has made some progress in combating malaria with the number of prevalence dropping from 42 cases per 100000 in 2001 to 34 in 2005. Out of 52 MDG targets, Bangladesh is on track on 19 of them; and 14 of them need attention.
In regard to access and availability of quality services the public health sector governance cannot be termed as ‘good’. The health care system in Bangladesh is operating within a complex political administrative environment. The politicized administrative structure which lies at the root of our misgovernance reflects governance failure in the health sector.
The major steps that need to be implemented, are the strengthening planning and management capabilities across the health service system; improvement in the logistics of drug supplies and equipment to health facilities at district and lower levels; improvement in the production and quality of human resources for health; a system to ensure regular maintenance and upkeep of existing health facilities; universal access to basic healthcare and services of acceptable quality; improvement in medical education; improvement in nutritional status, particularly of mothers and children; prevention and control of major communicable and non-communicable diseases; Strong policy and regulatory framework.
Existing policies need to be reviewed and revised for improving accessibility, affordability and quality of services and for further improvements in affordability, quality and safety of drugs and rational use of drugs. New policies on public and private sector mix and financing of services need to be formulated, protection and preservation of the environment; more training institute for graduate and postgraduate study with proper practical facilities should be established, decentralization of management through devolution of authority and the adoption and maintenance of healthy lifestyles and the development of a comprehensive people oriented plan to improve and assure the quality of health services be provided.
Furthermore, more hospitals and medical personnel as well as its good combination are required for providing services to all citizens. Empirical scientific investigation on assessing need for hospital beds, health workforce, medical equipment, drugs and diagnostic services should be carried out. For an efficient resource allocation in the public hospitals as well as reimbursement to the private ones, it is important to estimate the disease-specific treatment cost and case-mix of patients in different hospitals.
Community clinics in all unions can be established. Efficiency in the use of health sector resources should be improved. Health and Family Planning co-ordination should be improved. Public health facilities such as pure drinking water and sanitation should be improved. Private sector health insurance may be encouraged. Increase awareness of diabetes, hypertension, strokes and obesity, which could assume pandemic proportions in the next two decades.
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