Championing Care | Bangladesh’s health sector through the years

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Economic strength and a wealth of health resources are known to be crucial drivers to the success of healthcare sectors worldwide. Most countries who boast of strong healthcare systems often have these two propellants backing them up. However, one country that may have proved this theory wrong is Bangladesh. Outperforming many of its South Asian neighbours, Bangladesh has made praiseworthy progress in the healthcare sector, ever since the independence year, 1971. Given that the country is only 50 years old and was essentially a hard-hit nation when it gained its independence, Bangladesh has often been called a “positive deviant” for exceeding expectations despite widespread challenges. According to “The Lancet”, one of the most revered medical journals of England, Bangladesh’s admirable success in this sector is “one of the mysteries of global health.” The country has received around 16 international awards and prizes, out of which, three were United Nation awards for the incredible development in the health sector. According to the foreign secretary of Bangladesh, Masud Bin Momen, a good way to describe the healthcare system of Bangladesh is “good health at low cost”.

Some particularly notable milestones in the history of the health sector in Bangladesh are its achievements in mass inoculation for different, preventable diseases, reducing mother, infant and below-5 mortality rates, family planning, and, to some extent, child nutrition.

In keeping with article 15 of the constitution of the People’s Republic of Bangladesh, where it states that “It shall be a fundamental responsibility of the State to attain, through planned economic growth, a constant increase of productive forces and a steady improvement in the material and cultural standard of living of the people, with a view to securing to its citizens the provision of the basic necessities of life, including food, clothing, shelter, education and medical care.”, the country undertook family planning through fertility regulation right after gaining independence in 1971. According to the National Population Census of 1974, the total fertility rate (TFR) per female stood at 6.9. By 1989, it saw a decline and stood at 5.1 while by 1996 it was down to 3.3 births per female. After a 10-year hiatus in fertility during the 1990s, the TFR further declined to 2.3 births in 2011. The most recent data shows that in 2019 the TFR in Bangladesh was 2.0, at par with Sri Lanka and Nepal, whereas the TFR in India was at 2.3, and in Pakistan at 3.3.

The other success story associated with Bangladesh’s health sector is the one on mass inoculation. In 1979, Bangladesh devised a supremely effective national immunization campaign called the Expanded Programme on Immunisation (EPI). The program gathered speed after 1985 when Bangladesh committed to immunize every child in the country by the next 5 years, to the UN, thereby reaching universal child immunization. According to research, by 2017, 89% of children between the ages of 12–23 months were fully immunized against major vaccine-preventable diseases such as tuberculosis, diphtheria, pneumonia, measles and others.

One of the Millennium Development Goals that Bangladesh had committed to, was reducing maternal and child mortality, and in it, the country has progressed in leaps and bounds, even receiving a UN Award for the same, in 2010. As per data pertaining to 2019, the under-5 mortality rate was 28 per 1000 live births. Infant and neonatal mortality rates stood at 21 and 15, respectively. Where global life expectancy was 72 years, Bangladesh, thanks to the above mortality rate reductions stood at 73, above all but one South Asian country- Sri Lanka which was topping the charts at 76 years.

Child nutrition is a problem that is being faced by most developing countries in the world, with successes and failures constantly warring against each other, hindering progress. Bangladesh recognizes the dilemma, and it has taken steps to mitigate malnutrition, demonstrating a steady improvement in the last decade. The stunting (impaired growth due to lack of nutrition) rate among children under the age of five has dropped down 10% from 41.3% in 2011 to 31%in 2018, and wasting (low weight for height) has gone down from 15.6% to 8.4%. While the development has been consistent, it is still not enough and more needs to be done for these figures to fall lower.

Bangladesh boasts one of the best health networks in the public sector. As per recent data, there are 47,678 domiciliary workers with 13,907 community clinics at ward level, 4,646 union level facilities, 424 upazila health complexes, 59 district hospitals, 18 medical college hospitals and 12 specialized institute hospitals, as well as other facilities. Despite the large set up, shortages of human resources, shortages of the specific skill sets, and scarcity of equipment, medicines and other supplies hinder stakeholders from maximizing the optimum level of output from this set up.
A longstanding challenge with the public health sector of Bangladesh has been the lack of public expenditure on this sector. This year, the country’s allocation to the health sector is only 5.14% of the total budget and less than 1% of GDP, despite Covid challenges. Public expenditure on health in Bangladesh is one of the lowest, not only in the world, but also compared to other lower middle-income nations averaging 2.8% or even the South Asian average of 2.1%. The country not only has a concerningly low expenditure rate on the sector, the expenditure is also not divided judiciously among all geographical and residential divisions.

Taking advantage of this disparity, is the private health sector of Bangladesh with healthcare facilities under the Directorate General of Health Services (DGHS) being 2,258 registered private hospitals and 5,321 clinics. Hospital beds amount to 54,660 under DGHS and 91,537 under private owned hospitals. As privately owned medical establishments require people to pay for their services out of their own pockets, Bangladesh seems to be something of a “negative outlier” among similar, low income (LIC) or low middle-income (MLIC) countries. Statistics report that the percentage of out-of-pocket (OOP) spending on healthcare for this country stands at a giant 72% compared to other LICs (39.6%) and other MLICs (39.4%). This spells bad news for the poor of the country as it implies that the country is not beside its disadvantaged population in financially supporting their basic healthcare rights. Currently, OOP expenses make up roughly 67% of a household’s total expenses.

In its war against the mighty COVID-19, Bangladesh has dedicated a number of beds and ICU beds in all of its government run hospitals and quite a lot of private hospitals as well. In addition, when the cases peaked, the country built some isolation centres and hospitals fully dedicated to patients of Covid-19. Tackling an unprecedented crisis such as this is an arduous task for any government, and Bangladesh too, faced its challenges with testing, contact tracing, isolating people and the expected challenges with doctor availability per patient. Inoculation campaigns are ongoing in Bangladesh and the government is working to get its hands on the vaccines through agreements with producing nations fast in order to immunize as many of its population as it can against the deadly pandemic.

One of the few contingency measures that came out strongly from Bangladesh during the pandemic era is telemedicine. Online activities as a whole saw a rise in Bangladesh during the months long lockdowns and in the interim, mobile applications were launched, 29 solely for telemedicine, two online helplines were dedicated only to foreign workers, 16 different portals and websites were created, 10 kinds of covid testing tools and seven chatbots were constructed for a variety of medical and other emergency purposes. One of the more outstanding applications is the one called COVID-19 DSS (Digital Surveillance System), where a user provides their information to an AI system. The system can then create awareness, help with digital screening, patient identification, identifying high risk COVID zones, and to integrate and analyze crucial data. The COVID BD tracker application is another risk assessment software that specializes in predicting probable rates of infection in a person.

Bangladesh is said to have undertaken a “pluralistic” health system where resources from public funds were passed on to non-governmental organizations to work in the country’s health sector. This backing from development partners like the UN, World Bank and Asian Development Bank have been a pivotal source of funds generation for the country’s health sector. For instance, WHO, as part of its response efforts has helped to provide Bangladesh with 200 oxygen concentrators, 400 pulse oximeters, 100 venturi masks, and 100 nasal cannulas to 17 district hospitals, as well as 65 patient monitors to 10 Covid specialized health facilities. Similarly, the World Bank and the ADB have agreed to aid the country with $100 million each for emergency Covid response.
While Bangladesh has seen incredible success in its health sector in a very short time, the major challenge that remains to be conquered is its overall spending in this area. While optimists argue that Bangladesh’s outstanding achievements have come in spite of this low per capita GDP spending, experts do recognize inequities and vulnerabilities within the country, despite its progress. The government may argue that it has increased its healthcare spending in the face of the global pandemic, but in essence, the increase in the healthcare sector has only increased from 257.3b to 292.5b, marking a nominal increase of 13.7% increase. In fact, without the support of non-governmental bodies, the year’s health allocation may have rested at 4.8% of the entire budget, instead of the 5.14% it now allotts.

Covid-19 has come as a fresh perspective for Bangladesh and its leaders, shining light on the glaring cracks and issues within its systems such as shortages in the areas of trained human resources, medical equipment, and supplies. Experts feel that even outside the pandemic, increased funds are required to mitigate these crucial shortcomings. As Bangladesh strides towards attaining the Sustainable Development Goal (SDG 3) for Universal Health Coverage and becoming a middle-income nation, it may see a decline in financial support from its development partners which the government would have to work to cover on its own. The country, known for its determination to survive the worst, may well come out shining in the years ahead, once it addresses these challenges.

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