HEALTH POPULATION AND FAMILY WELFARE

21.1 Introduction

21.1.1 Bangladesh�s population estimated to be 123.80 million in January 1997, is growing at the rate of 1.75 per cent per annum. In 1973, when the country launched its First Five Year Plan (1973-78), population was 74 million and the rate of population growth was then 3.0 per cent per annum. In a span of twenty three years, the population growth rate was reduced by 1.2 percentage points, while adding 49 million more people. Without any family planning and multisectoral population programmes, Bangladesh would have around 140 million people today. In the mid-seventies, Bangladesh was Asia�s fifth and World�s eighth most populous country. Now, it ranks as the sixth and ninth respectively indicating that the family planning programmes had a more than average success in Bangladesh. In 1975, contraceptive prevalence rate (CPR) was reported to be 8.5 per cent (BFS, 1975) as against the present estimate of 48 per cent, (DHS,1995) showing an average increase of 1.8 per cent per annum since then. In 1989, total fertility rate (TFR) and CPR were estimated at 4.9 and 32.0 per cent respectively (BFS and CPS, 1989). Corresponding figures for 1995 are 3.4 and 48 per cent respectively. Bangladesh has achieved this progress against the backdrop of low literacy rate, low status of women and low income per capita and so on. Despite this, one must note that due to past high fertility and falling mortality rates, Bangladesh�s population has a tremendous growth potential built into its age structure. Still population below 15 years is around 43 per cent of the total population; and women of reproductive age (15-49 years) represent 46 per cent of the total female population. The maternal and infant mortality rates are reported to be 4.5 and 78 per thousand live births respectively. Life expectancy at birth has increased to 58.1 years for male and 57.6 for female compared with the 1991 level of 55 and 54.5 years respectively.

21.1.2 Providing medical care is the constitutional obligation of the government. The Constitution mandates 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- (a) the provision of the basic necessities of life, including food, clothing, shelter, education and medical care." The Government of Bangladesh, since Independence, has been investing substantially in the institution building and strengthening of health and family planning services in the country, giving special attention to the vast population that resides in the rural areas. The main thrust of the health programmes has been the provision of primary health care (PHC) services which has been recognised as a key approach to attain �Health for All� by the year 2000 (HFA/2000 A.D.). Bangladesh has accepted the goal and reiterated firm political and social commitment to achieve it based on the Primary Health Care Strategy declared in Alma-Ata in 1978. The present government is committed to complete the unfinished health agenda of the government of Bangabandhu for establishing health complexes in each Union and modern hospitals in each Upazila. Modern medical care services will be expanded and made available at affordable cost for the welfare of the poor and protection of the vulnerable. Necessary and appropriate steps will be taken to modernise the indigenous medical system as well.

21.1.3 In response to the changing health situation of the country, reforms in the health sector particularly in the areas of management structure, service delivery mechanisms and utilisation of both public and private sector resources are called for urgently. Major efforts will be required for health protection through appropriate legislation and effective enforcement.

21.1.4 The Government of Bangladesh is committed to achieve the overall objectives of the "World Summit for Children", and the "Programme of Action of the International Conference on Population and Development (ICPD)" held in Cairo in 1994. Thus, the health and population sector vision will be to provide adequate basic health care for the people of Bangladesh and to slow down population growth and to be responsive to clients� needs, especially those of children, women and the poor.

21.1.5 As with the global scenario of changes in health, the spectrum of health situation has also been changing in Bangladesh over time. Rapid population growth, increasing urbanisation and major shifts in disease patterns prevailing in the country contribute to these changes. Resurgence of malaria, kala-azar and other emerging and re-emerging diseases are a few examples of these changes, whilst the risks of STD, HIV/AIDS and other infectious diseases menacing public health are fast increasing. Increase in the incidence of cardiovascular diseases, renal disorders, mental illnesses, cancer and conditions related to substance abuse, smoking and alcoholism, increasing traffic and industrial accidents, etc., exacerbate the disease burden of the population. On the other hand, environmental degradation due to air, water and industrial pollution and deteriorating living conditions also pose significant adverse impact on public health . Increased concentration of arsenic in subsoil water reported recently in some areas of the country also poses a potential public health hazard. Bangladesh will continue to experience epidemiological transition witnessing the phenomenon of coexistence of both age-old infectious and emerging new diseases. Diseases related to metabolic disorder, malnutrition, tuberculosis, reproductive health, diarrhoea, respiratory tract, etc., will continue to exert major impact on the health status of the population.

21.1.6 In the field of population planning, there has been a considerable success which is now being acclaimed at home and abroad. However, even if the current programme momentum continues and NRR-1 in 2005 is achieved, the country will have to wait another 40-45 years to stabilise its population around 210 million. Any delay in achieving its demographic goal means a heavy time-penalty and serious implications for Bangladesh�s socio-economic development. Given the nature of the task that lies ahead, population continues to remain as the nation�s number one problem as well as the number one cause of poverty.

21.2 Implications of Population Growth

21.2.1 Due to a large base of young age population, future growth potential in Bangladesh is indeed very high. In the short run, even under the optimistic assumption of NRR-1 by the year 2005, there will be a net increase of 8.8 million people by the end of the Fifth Plan period over the 1997 level of 123.8 million ; while in the long run, say, by the year 2020, there will be a net increase of 42.74 million people. Given the current status of economy, such an increase of population will have several adverse implications for our socio-economic development.

21.2.2 First, the most serious implication of population growth will be observed in the social sector . For instance, the number of enrolled students in primary education was 17.3 million in 1995 giving 92 per cent net enrolment rate while teacher-student ratio was nearly 1:70. The government is committed to ensure universal primary education and improve teacher-student ratio to 1:50; it will require almost double the present level of resources to provide more teachers, class room facilities, equipment and institutions. Secondly a dismal scenario can be observed also in the health sector where both primary and specialised health care services are still inadequate. Here, a serious demand for services exists for doctors, nurses, medicine, hospital care, and so on. At present, doctor - population ratio is 1:5506; hospital bed-population ratio is 1: 3231 and per capita health expenditure is Tk. 135 per annum. If the existing facilities are to be improved upto a minimum satisfactory level, then per capita health expenditure to cover the entire population will have to be doubled. Thirdly, there will be an immediate impact on land. At present, population density is 850 persons per sq.km which will further increase to 913 persons in 2002 and 1,130 persons in 2020 per sq.km adversely affecting existing man-land ratio of 1:18 decimal. Due to population increase, this will further deteriorate which means that the number of landless people will increase tremendously further aggravating the poverty situation. Fourthly, the total land space of which only two-thirds is presently arable will be attenuated further. This will have an obvious adverse impact on per capita food production and food availability for the growing population. At present, the government�s annual import bill for foodstuff is Tk. 5,600 million. If the targeted production level is not reached by 2002, the government�s import bill for food items will increase substantially, which it will have to provide at the expense of development in other sectors of the economy. Fifthly, due to population growth momentum, number of working age population (15-59 years) is projected to increase from 66.6 million in 1997 to 80.2 million in 2002; 98.0 million in 2010; and 109.1 million in 2020. Hence, the economy will have to create more job opportunities to employ its working age population to generate income and thereby alleviate poverty. Lastly, increase in population will adversely affect both GDP and GNP growth per capita. In this backdrop, the nation has no other option but to pursue a population policy to achieve NRR-1 by the year 2005 .

21.3 Review of Fourth Plan

Health

21.3.1 At the dawn of Independence the health status of the population of Bangladesh was at a very low point having a life expectancy of mere 45 years with a crude death rate (per 1000 population) of 20.9. Out of every 1000 infants born, 150 of them would not have lived beyond the age of 1 year. There were very few health facilities and health professionals in the country.

21.3.2 Over the 25 years of independence, the health situation of the population has improved quite remarkably. Smallpox, malaria and cholera have been eradicated or are no longer major killers. Life expectancy at birth reached 58 years in 1995. Total fertility rate was reduced from 6.3 in 1975 to 3.4 in 1995. The crude death rate dropped from 12.0 in 1990 to 9.0 in 1995 and is expected to decline further. Due to the recent success in the EPI programme which had a coverage of over 66 per cent in 1995, infant mortality rate declined to around 78 per 1000 live births in 1995. Similarly, the under-5 mortality dropped from over 210 in the mid-1970s to 133 per 1000 live births in 1995. In terms of physical facilities, there were 897 hospitals (610 in the public sector and 287 in the private sector) of different categories with 34,786 beds (27,544 in the public sector and 7,242 in the private sector) with one bed for every 3,450 persons in the country in 1995. With regard to health and medical professionals, the country so far produced 24,638 graduate doctors by 1995 giving a doctor-population ratio of 1:4,870. The doctor-nurse ratio was 2:1. In case of nurse-population ratio, the position was 1:10,714.

21.3.4 Evaluation of physical progress

a. In order to meet the requirement of the overall objectives of the health sector, various programmes were undertaken during the past plans. One of the major programmes was the development of physical infrastructures like thana (now upazila) health complexes (THC), district hospitals, medical college hospitals and other specialised institutes and hospitals throughout the country. As a first referral centre for PHC, it was planned to establish a total of 397 THCs in the country of which 374 have now been completed. Of the total 64 districts, 60 district hospitals have so far been constructed. These hospitals have the bed capacity of 50-200 each. Some of them are already upgraded to 250-bed hospitals.

b. Thana health complexes (THC): In order to bring the health service delivery system including the primary health care services, to the door step of the rural people, the programme for development of a comprehensive network of health infrastructure in rural areas through the establishment of one thana health complex in each thana was continued during the Fourth Plan period. Under the programme, 397 THCs were planned to be established of which altogether 390 health complexes had so far been made functional. Specialised services in the fields of medicine, surgery, gynae, anesthesia and dentistry are provided in each thana health complex. Supply of essential drugs and vaccines has further been improved and cold chain instituted in each THC to maintain the quality and effectiveness of drugs and vaccines.

c. Union health and family welfare centres (UHFWCs) : The network of institutional facilities starts from the union level where there is a Health and Family Welfare Centre (UHFWC) for providing outpatient services. There are at present a total of 4,062 Union health facilities of which 2,700 UHFWCs are under the Family Planning Wing and 1,362 Union Sub-centres/Rural Dispensaries are under the Health Wing.

d. Hospitals and clinics : The number of hospital beds has increased significantly over the years. At present, there are about 34,786 hospital beds giving a bed-population ratio of approximately 1:3,450. With the decentralisation of administration and upgradation of sub-divisions into districts, the existing hospitals required upgradation and modernisation with adequate diagnostic and treatment facilities as referral hospitals for primary health care. The programme included upgradation of 36 erstwhile sub-divisional hospitals into 50 bed ones and modernisation of nine 100 bed hospitals. The existing Medical College Hospitals, Rehabilitation Institute and Hospital for the Disabled (RIHD), Institute of Cardiovascular Diseases (ICVD) and Ophthalmological Institute were further developed. Hospitals at Comilla, Khulna, Jamalpur and Bandarban were completed. The Cancer Institute and the IPGMR were also completed.