Health and nutrition status in Bangladesh: UNICEF
UNICEF
Bangladesh has seen impressive progress in health and nutrition in the last few decades.
Initiatives to prevent illness have substantially reduced six vaccine-preventable and diarrhoeal diseases that killed hundreds of thousands of children even two decades ago. Malnutrition has been steadily declining by 1-2 per cent each year, though the level remains high.
Since 1997 the prevalence of vitamin A deficiency in children has been sustained below the threshold that indicates a public health problem. This is largely due to the high coverage of vitamin A supplementation.
The infant mortality rate (IMR) declined from 87 per 1,000 live births in 1989 to 56 per 1,000 live births in 2001. The under-five mortality rate (U5MR) also dropped from 133 to 82 per 1,000 live births over the same period.
The total fertility rate (TFR), contraceptive prevalence rate (CPR) and birth-spacing have all improved, and trends are generally positive.
Factors Affecting Health
Injury
Malnutrition
Public health
There are three major factors that affect the rates of death and disease in children in Bangladesh: injury, malnutrition and public health, including arsenic contamination of the water supply and HIV/AIDS.
Injury
While mortality due to communicable and other vaccine preventable diseases has decreased significantly, deaths due to injuries, especially drowning, have remained constant over the last three decades.
The proportion of deaths that are attributable to drowning among children aged 1-4, has increased from 9 per cent in 1983 to 53 per cent in 2000. Drowning is the predominant cause of injury-related mortality in this age group.
Malnutrition
Malnutrition in children, adolescents and women is a major concern. Despite progress, levels of malnutrition in Bangladesh are amongst the highest in the world, and this is a major cause of death and disease in children and women. In addition to causing individual tragedies like maternal and child mortality, malnutrition exacts heavy costs from the health care system through excess morbidity, increased premature delivery, and elevated risks of heart disease and diabetes. The economic consequences of Bangladeshs malnutrition problem are profound, resulting in lost productivity and reduced intellectual and learning capacity.
A number of challenges in health and nutrition remain. These are:
Improving health care-seeking behaviour such as education, awareness-raising and skills building in recognizing and treating pneumonia and obstetric emergencies.
Rapid urbanization which creates conditions that make slum dwellers vulnerable to disease as a result of problems of sanitation, hygiene and the supply of clean water.
The emergence of arsenic in tube well water, leading to arsenic poisoning.
The potential for HIV/AIDS to develop into a major problem.
Action on a range of fronts to reduce the number of deaths from accidents.
Arsenicosis The widespread incidence of arsenic contamination of water creates health problems for whole communities. Long-term exposure to low concentrations of arsenic in drinking ground water causes painful skin lesions and can result in cancers of the skin, lungs, bladder and kidneys. Tackling the problem means identifying who is suffering from arsenic poisoning (arsenicosis), monitoring water quality, helping communities to find alternative sources of safe water and enabling households to treat water themselves, to make it safe.
HIV/AIDS There are an estimated 13,000 adults living with HIV in Bangladesh. This is below 1 per 1,000 adults in the general population, and less than 1 per cent among vulnerable groups. But despite the low incidence, Bangladesh is considered a high-risk country for several reasons, including:
sustained high-risk sexual behaviour
very low use of condoms
high incidence of self-reported sexually transmitted infections among vulnerable groups
high levels of HIV/AIDS in the two neighbouring countries, India and Myanmar
the high proportion of young people, who constitute one third of the population the highest in the region. There are signs that initiatives to change behaviour are having an impact. This is reflected in declining syphilis rates among female sex workers in some cities and brothels, and in declining needle and syringe sharing rates among intravenous drug users (IDUs). This work needs to be extended to cover more regions and more of the at risk population.
Activities
UNICEFs activities in the sphere of health and nutrition are based on the rights of individuals, with the aim of addressing their changing needs at different stages of their lives.
The activities have been designed in the context of the Ministry of Health and Family Welfares Health and Population Sector Programme (HPSP), National Nutrition Project (NNP) and Health, Nutrition and Population Sector Programme (HNPSP).
Nutrition
Bangladesh made substantial progress in reducing malnutrition between 1990 and 2000, with the proportion of underweight children falling from 66.6 per cent to 51.1 per cent, and the level of child stunting falling from 65.5 per cent to 48.8 per cent. If this current rate of improvement continues, the percentage of underweight and stunted children will be halved by 2015. Nevertheless, the prevalence of child stunting and underweight in 2000 are still very high according World Health Organization (WHO) criteria. Chronic energy deficiency in non-pregnant women declined from 52 per cent in 1996-97 to 45 per cent in 1999-2000, but is still very high. Low birth weight is estimated to affect 30-50 per cent of infants.
Since 1997, the prevalence of night blindness, an early indicator of vitamin A deficiency, has been maintained below the 1 per cent threshold that indicates a public health problem. This success has largely been due to the vitamin A supplementation programme, which increased in coverage from 41 per cent in 1993 to over 85 per cent in the second half of the decade by linking the distribution of vitamin A capsules with the NIDs. Coverage of iodized salt increased from 19 per cent in 1993 to 70 per cent in 1999, and correspondingly, the prevalence of iodine deficiency fell from 69 per cent to 43 per cent.
While these findings are encouraging, they mask the fact that infants and children continue to consume diets that are grossly inadequate in vitamin A, iron and other micronutrients. This is indicated by surveys in early 2003 , which found that anaemia, which is largely due to iron deficiency, affects about 50 per cent of children under five, a level that denotes a severe public health problem. Breastfeeding is rarely exclusive for the first six months of life, and complementary foods are often introduced too early or too late and are of poor quality.
The nutritional status of adolescent girls and women is a key factor in the persistence of malnutrition in Bangladesh. Children are much more likely to be of low birth weight and to remain malnourished throughout their lives if their mothers were malnourished during adolescence and prior to and during pregnancy. Malnourished children are physically weak, they lack resistance to disease, they do less well at school, they are less productive as adults and they remain vulnerable for the rest of their lives.
In Bangladesh, malnutrition is caused by multiple factors. The immediate causes are diseases and inadequate intake of food. The underlying causes of malnutrition include the inability of households to grow and/or purchase sufficient food for their needs; poor maternal and child-care practices, including inadequate breastfeeding and complementary feeding for infants and young children and inadequate provision of food for adolescent girls and pregnant and lactating women.
These are compounded by delays in recognizing the signs of malnutrition or disease and in seeking care for children and women, inadequate access to quality health services, including family planning, immunization and medical services and poor access to sanitary facilities and potable water.
Future Challenges
Iodine Deficiency Disorders
Intensify advocacy for EPI, IMCI malnutrition and EmOC.
Take advantage of changes in local government to improve the health of women and children.
Complete the development of communication strategies for EPI, UCI and CIDD and implement those strategies.
Phase out vertical interventions of ARI and CDD while intensifying IMCI.
Address the issues of accidents and injuries, especially drowning.
Reduced Mortality
Both the ARI and CDD programmes were expanded to become nationwide by the end of 1995. UNICEF also supported a nationwide Oral Rehydration Therapy Communication Campaign (ORTCC) from 1996-1999 and Local Level Initiatives to promote improved care-seeking practices for ARI in 2001-2002. Caregivers knowledge on the three golden rules of ORT increased from 5 per cent in 1996 to 49.2 per cent in 2000.
The reported ARI patients who received care from trained providers and hospitals almost doubled between 2000 and 2001.
Deaths of under-fives due to diarrhoea were reduced from 260,000 in 1995 to approximately 45,000 in 2003. Death due to pneumonia fell from 150,000 in 1991 to 95,000 in 2003.
The implementation of Integrated Management of Childhood Illnesses (IMCI) started in 2001 with pilots in three sub-districts.Bangladeshis now in the expansion phase of IMCI implementation. Currently IMCI is being implemented in 18 sub-districts and will cover the whole country in phases by 2011.
Expanded Immunization
The Expanded Programme on Immunization (EPI) is the most successful public health intervention in Bangladesh, and has contributed significantly to reducing mortality and morbidity from vaccine-preventable diseases. The service delivery mechanism of EPI throughout the country has been used as the role model and a platform to deliver other interventions.
It is estimated that a total of 1.2 million deaths have been prevented from 1987-2000 through EPI services. More than 95 per cent of infants receive BCG vaccine on first contact. However, the coverage gradually falls with subsequent doses. Nationally, 63 per cent of infants receive all antigens at the right time and at appropriate intervals.
The elimination of neonatal tetanus is progressing well. Pregnant women and women of childbearing age are provided with tetanus vaccine through EPI.
A survey conducted in 1986 found neonatal deaths due to tetanus were 41 per 1,000 live births. By 2000 this had fallen to 2.3 per 1,000 live births. According to a survey in 2000, neonatal tetanus accounts for fewer than 10,000 neonatal deaths a year.
It is also estimated that some of the districts have reached the elimination goal, however, this needs to be validated through survey.
Polio Eradication
There has been intensive effort to eradicate polio fromBangladesh. Indigenous transmission of wild poliovirus has been controlled for the last 3.5 years through National Immunization Days (NIDs) and the establishment of a certification standard surveillance system.
With the last case of wild polio virus transmission recorded in August 2000, Bangladesh has progressed towards polio-free status. Successful National Immunization Days (NIDs), emphasis on the Expanded Programme On Immunization (EPI), and continuing Acute Flaccid Paralysis (AFP) surveillance, all need to be maintained in order to achieve certification of the country as polio-free, as there still is wild polio virus transmission across the border with India.
Iodine Deficiency
Between 1981 and 1997, a programme to administer injected iodated oil was implemented in districts with high rates of Iodine Deficiency Disorder (IDD). Universal Salt Iodization (USI) was then found to be more practical. In 1989, the Government of Bangladesh passed a law making it mandatory for all edible salt to be iodized.
Fortification of salt with iodine was initiated in 1990 to meet the urgent need for a cost-effective and sustainable intervention for the Control of Iodine Deficiency Disorder (CIDD). This activity, initiated after careful trials, also complied with a global recommendation for USI.
Two prototypes of Salt Iodization Plants (SIPs), one made in India and the other in Bangladesh, were tested. Then SIPs were produced by a local Bangladesh firm with UNICEFs financial assistance, and distributed to salt factories in 14 districts.
Quality control is a key element in Universal Salt Iodization (USI) in Bangladesh. The project has put together a kit that can measure the iodine content at field level. This is packaged with other devices in a portable box and is now even exported to other countries.
Every factory has been provided with this kit and all factory managers and plant operators have been trained in plant operation, salt law and iodine testing procedures. However, quality control remains the main concern and there is a clear need for strengthened monitoring and supervision systems.
Despite substantial progress in salt iodization over a short period, a 1996 survey showed that only 4.8 per cent of samples taken from 138 factories were properly iodized and that much of the salt was not being appropriately packed.
The same survey reported that only 22 per cent of rural households and 19.1 per cent of urban households had adequately iodized salt.
However, as a result of various information, education and communication activities that have been undertaken to improve awareness of the importance of iodized salt among consumers, retailers and wholesalers, there were relatively high levels of consumer knowledge about the benefits of iodized salt. In 1999, a UNICEF survey indicated that the proportion of households consuming iodized salt had risen to 71 per cent.
Monitoring and evaluation of USI has played a key role in CIDD in Bangladesh. In 1999, based on the recommendations arising from an intensive review of USI quality control system by BSCIC and UNICEF, a comprehensive monitoring and quality control system was implemented. A standardized monitoring form is now used for each salt factory and the data is computerized.
Detailed status reports for each factory are now being assessed with the use of the monitoring data set and a standardised supervisory checklist has been developed for periodic use by Bangladesh Small and Cottage Industries Corporation (BSCIC) inspectors.
USI in Bangladesh has strong political commitment and administrative support from the Government.
The private sector gradually started to take over financial responsibility for procuring potassium iodate after July 2000 to ensure financial sustainability of USI, based on a phased takeover plan.
