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THE ROAD TO BETTER HEALTH CONDITIONS IN BANGLADESH
WORLD BANK
Bangladesh has
covered many miles on the road toward reduced fertility and
childhood mortality in its first three decades since
independence in 1971. It is the only country among the 20
poorest that has recorded a sustained reduction in birth rates
over the past 15 years. On average, in the 1990s women had 3.3
birthsone-half the number in 1974. Infant mortality has dropped
from about 140 to 88 per 1,000 live births. The government's
strategy is now directed toward reducing the high levels of
maternal illness and deaths, tackling malnutrition, and
consolidating and sustaining the gains already made.
For more than 25 years, the World
Bank has had an important connection with Bangladesh's
achievements in reducing fertility. The Bank's consistent
attention to maternal health issues during this time has been
one of the driving forces behind the government's commitment to
an essential package of services that addresses broader maternal
health issues.
Embarking on the Journey
The World Bank's dialogue with
Bangladesh on health and population issues began in 1973.
Initially the Bank helped mobilize support from six cofinanciers;
since then, additional donors have been engaged in follow-up
projects, each of which has almost doubled the amount of money
invested. These development partners are now organized into a
consortium, with the Bank acting as coordinator on various
aspects of the projects. The Bank also represents the consortium
in health policy dialogues with the government.
The Bank's initial involvement with lending to Bangladesh for
health, population, and nutrition began in 1975 with a US$15
million credit from the International Development Association
(IDA), the World Bank's concessionary lending affiliate, for the
Population I project, which lasted until 1982. Four more
projects, all supporting the government's five-year plans,
followed.
First Milestones
Population I, which focused on
reducing fertility, led to a marked increase in the use of
contraceptives. By involving a number of donors, it kept
attention focused on the population program. It eventually
became the vehicle for ongoing dialogue with the government.
Population and Family Health II (197986; US$32 million)
succeeded in consolidating, strengthening, and expanding the
activities started under Population I. The project assisted the
government in implementing its program, which included
components for delivery of family planning and maternal and
child health services and for communication, training,
monitoring, evaluation, research, and women's development. The
project was crucial for sustaining increased contraceptive use.
Kay Chernush/The World Bank
Health care instruction at a
training institute for family welfare visitors
Population and
Family Health III (198692; US$78 million) gave greater attention
to the issue of maternal health, while continuing the program
activities included in the second project. The third project
achieved its objectives of lowering birth rates and, to a more
limited extent, reducing the high number of infant deaths, but
the goal of reduced maternal mortality remained elusive.
The Bank's assistance to Bangladesh
continued with Population and Health IV (199198; US$180
million), which aims to sustain lower birth rates while further
improving infant, child, and maternal health. As this project
comes to a close, Bangladesh is close to achieving complete
national coverage by community health workers; 21,000 health
assistants and 23,500 family welfare assistants are providing
family planning and limited primary health care services to
communities. Contraceptive use has increased during the project,
and infant mortality has dropped; maternal mortality has been
more difficult to measure. Despite extensive training of
traditional birth attendants under the project, 75 percent of
pregnant women still do not receive prenatal care or assistance
from a trained attendant when giving birth. A follow-up project
to address broader reproductive health needs is being prepared.
On the Right Path
The outlook for reducing fertility
and child mortality was first assessed in 1980 and 1983 in the
studies "Fertility and Its Regulation in Bangladesh" and
"Population and Family Planning in Bangladesh: A Survey of the
Research," both prepared jointly by the Bank and the
government.1 A 1992 study, "The Determinants of Reproductive
Change," reviewed the demographic history of Bangladesh, with
particular attention to evidence of reproductive changes in the
postindependence period.2 Bangladesh's success in reducing
fertility demonstrates that comprehensive programs supported by
true commitment at the highest levels can work in spite of
severe constraints, including widespread poverty.
Kay Chernush/The World Bank
A visit to a family planning
clinic
The evidence
suggests that all major socioeconomic strata have modified their
reproductive behavior. Regular household visits by family
planning workers have played a major role in the dramatic
increase in contraceptive use, and outreach efforts can play a
decisive role in creating a receptive environment for achieving
declines in fertility. The report concluded that while the
family planning program of Bangladesh has been successful, the
demand for family planning is fragile; societal constraints on
contraceptive use still exist and must be addressed by a
comprehensive program.
Maintaining the Pace
The government of Bangladesh has
also been increasingly concerned with nutrition-related health
problems. Nutritional indicators in Bangladesh are among the
worst in the world9 out of 10 children are malnourished, every
other child is stunted, and some 600 children die daily from
causes related to malnutrition.
In close collaboration with the
United Nations Children's Fund (UNICEF), the Bank is supporting
the Bangladesh Integrated Nutrition Project (BINP) with a
US$59.8 million IDA credit. This pilot project initiated a
national program of nutrition with the ultimate goals of
reducing malnutrition, so that it ceases to be a health problem,
and improving the health status of the population, especially
children under five, women, and adolescent girls. The project
uses community-based, participatory activitiessuch as growth
promotion, nutrition counseling, and targeted supplementary
feeding for malnourished women and childrenas a way of changing
behaviors and attitudes relating to decisions about nutrition.
Nongovernmental organizations (NGOs) are key to implementing
this community-based approach, which builds on NGOs' capacity
for social mobilization, training of health workers, and
supervision.
In the pilot areas, the core
community-based nutrition activities have begun to have an
impact on severe malnutrition among children ages 0 to 24
months; 92 percent of these children are covered by the
growth-monitoring program, and 90 percent of the village
committees participate in decisionmaking. Furthermore, severe
malnutrition among children in that age group in the project
area has declined from above 20 percent to around 3 percent in
just two years, 199597. The project has been highly successful
in enabling rural women to improve household decisions about
nutrition and in getting them out of their homes to actively
participate in activities likely to improve their own
well-being. The project's success has coincided with growing
social concern about nutrition and growing political commitment
to tackling the problem, setting the stage for nationwide
replication of the project. The Bank is assisting the government
in developing a 10-year vision, intermediate goals for
eradicating malnutrition from Bangladesh and an investment
program to address these aims.
The Home Stretch
The new Health and Population
Program project is a participatory project designed with input
from a task force that included the government, health care
providers, community representatives, NGOs, and other
stakeholders. The goal of the program is to improve the health
and family welfare status of the women, children, and poor of
Bangladesh by providing client-centered services. The design is
based on lessons learned over 20 years of experience and uses a
broadly based approach to address both institutional capacity
and service delivery coverage issues. The government has given
priority to an essential package of services, which reorients
the focus toward reproductive and maternal health and also
includes child care, communicable disease control, and limited
care for common conditions and injuries. Family planning and
health services that were traditionally delivered separately
would now be delivered through a "one-stop" unified mechanism
that meets clients' needs more efficiently. Through its
sectorwide approach, the various development partners are
helping the government to target scarce public resources to
high-priority areas and implement health policy reforms. Key
reforms to be undertaken during this project include revising
the National Drug Policy, moving toward a sustainable
public-private mix for provision and financing of health care
services, expanding cost recovery for public-sector services,
adopting a Client Bill of Rights, addressing gender issues
through all project components, and maintaining the high level
of stakeholder participation that characterized project
preparation. Measures for dealing with the serious problem of
arsenic-contaminated groundwater in some rural areas will be
supported by the project.
A New Direction
The government now needs to address issues of financial
sustainability and transition to more decentralized approaches
to managing and financing the health sector. These complex
issues are addressed in the government's 1997 Health and
Population Sector Strategy, prepared by the Ministry of Health
and Family Welfare with assistance from development partners and
through consultation with NGOs, among others. The strategy
provides the road map for the government's new program to
continue Bangladesh's journey toward better health conditions
for its people.
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1. World Bank. 1980. "Fertility
and Its Regulation in Bangladesh." South Asia Region, Health,
Population, and Nutrition Unit, Washington, D.C.; World Bank,
1983. "Population and Family Planning in Bangladesh, A Survey of
the Research," South Asia Region, Health, Population, and
Nutrition Unit, Washington, D.C.
2. World Bank. 1992. "The Determinants of Reproductive Change,
Population and Health Sector Study." World Bank, South Asia
Region, Health, Population, and Nutrition Unit, Washington, D.C.
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