Bangladesh is a resource-poor country in South Asia with one of the highest population densities in the world. Following a series of political and economic crises during the 1970s, the country has made rapid improvements in health and social development. Bangladesh succeeded in meeting a number of the United Nations’ Millennium Development Goals, including narrowing the gender gap in school enrollment and reducing the headcount ratio and under-five mortality rate. The maternal mortality ratio declined by 40 percent during the last decade. One of the main contributors to the country’s progress has been a strong family planning program—the total fertility rate currently stands at 2.3 children per woman, compared with 2.6 in Nepal and 3.8 in Pakistan.Health and population of Bangladesh: An overview
Mohammed Abul Kalam, PhD
Bangladesh is a resource-poor country in South Asia with one of the highest population densities in the world. Following a series of political and economic crises during the 1970s, the country has made rapid improvements in health and social development. Bangladesh succeeded in meeting a number of the United Nations Millennium Development Goals, including narrowing the gender gap in school enrollment and reducing the headcount ratio and under-five mortality rate. The maternal mortality ratio declined by 40 percent during the last decade. One of the main contributors to the countrys progress has been a strong family planning programthe total fertility rate currently stands at 2.3 children per woman, compared with 2.6 in Nepal and 3.8 in Pakistan.
Over the last 45 years since independence Bangladesh has made lot of strides in the Health Sector. The Constitution of Bangladesh, Article 15(a) and Article 18(1), has provided top priority to public health and nutrition as a state policy of governance. To implement the obligation of the constitution and expectation of the people at large, governments had taken initiatives in the past to prepare a pragmatic health policy for the nation. Visibly there is proliferation in health infrastructures - medical colleges, medical university, private medical colleges, private clinics, private hospitals, district hospital, rural health centers and community clinics. Many NGOs are also engaged and contributing toward health care delivery system. Much progress has been made in the pharmaceutical sector providing affordable medicine, intravenous fluids, anti-cancer drugs etc. There is also increased awareness in the general public on health issues. National and private level campaigns are ongoing to promote mental and child health, vaccination programmes, mass deworming programmes, use of safe water and latrines, hand washing etc. Bangladesh has made significant improvement in health sector, which make it an example for other developing countries even though being a resource poor country. Over the last decades key health indicators such as life expectancy and coverage of immunization have improved notably, whilst infant mortality, maternal mortality and fertility rates have dropped significantly. Bangladesh stands out as a country that has taken giant steps in healthcare. Long before the emergence of contemporary global health initiatives, the government placed strong emphasis on the importance of childhood immunization as a key mechanism for reducing childhood mortality.
It is apparent that the method of change needs to broaden beyond the redefinition of policy objectives and discussions of the ideological orientation of the health care system. Without institutional or structural change it is expected that existing organizational structures and management systems will be able to strengthening the weak and fragile National Health Care Delivery System and improving its performance. Health sector reform will therefore be concerned with defining priorities, refining policies and reforming the institutions through which those policies are implemented. As a result, the need for creative solutions to deal with urgent and intractable problems can easily get lost in discussions about the rights and wrongs of particular strategies. Bangladeshs population estimated to be 162.9 million in mid-2016 and will be 186.5 million in mid-2030; and 202.2 million in mid-2050 (Population Reference Bureau 2016). In 1973, when the country launched its First Five-Year Plan (1973-78), population was estimated to be 74.0 million and the rate of population growth was then 3.0 per cent per annum. In 1975, contraceptive prevalence rate (CPR) was reported to be 8.5 per cent (BFS, 1975) as against the present estimate of 52 per cent, (DHS, 1999) 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 in 1999 are 3.3 and 52 per cent respectively. Bangladesh has achieved this progress against the backdrop of low literacy rate (54%), low status of women and low income per capita US $ 350 and so on. Now women (15-49 years) using modern methods of contraception are about 54 percent and all methods (both modern and traditional) are 62 percent (BDHS 2014). According to Bangladesh Sample Vital Statistics 2016, the estimated crude death rate was 5.1 per 1,000 people. The rate was 5.7 in rural areas and 4.2 in urban areas. This rate has shown a decline from 5.3 in 2012 to 5.1 in 2016. The crude birth rate, which is the simplest measure of fertility, has been estimated at 18.7 per 1,000 in 2016 compared to 18.8 in 2015. The child birth rate (CBR) fell from 18.9 in 2012 to 18.7 in 2016. The rural CBR, as expected, is higher than the urban CBR: 20.9 versus 16.1. The general fertility rate worked out to 69 per 1,000 women with a much higher rate (79) in rural areas compared to 57 in urban areas. Male children show a somewhat greater decline in the infant mortality rate (IMR) (20.6%) than their female counterparts (12.5%). The decline in the IMR is more pronounced (17.6%) in rural areas than in the urban ones (9.7%). In conformity to with this decline in the IMR, the neo-natal mortality rate also fell from 21 deaths per 1,000 live births in 2012 to 19 deaths per 1,000 live births in 2016 without revealing any significant sex differentials. The area of residence did not influence the neo-natal mortality rate. The post-neo-natal mortality rate, which nearly remained static over the last three years, was around nine deaths per 1,000 live births. Child mortality was estimated to be 1.8 deaths per 1,000 children in 2016, which is marginally lower than the previous years rate. The rate, however, fell from 2.3 in 2012 to 1.8 in 2016, registering an almost 22 per cent decline in five years.
Under-five mortality, too, showed a similar decline, coming down from 42 deaths per 1,000 live births in 2012 to 35 deaths in 2016. The report said the maternal mortality ratio had shown a consistent fall over the last five years, from 2.03 maternal deaths per 1,000 live births in 2012 to 1.78 in 2016. The enumerated population showed a sex ratio of 100.3 in a total of 479,597 males and 478,316 females. The overall sex ratio has shown a moderate decline over the last five years from 104.9 in 2012 to 100.3 in 2016 (BSVS 2016).
The age structure of the population was still conducive to high fertility with 30.8 per cent of the countrys total population being under 15 years. The dependency ratio recorded a notable fall from 80 in 2002 to 54 in 2016, a decline of over 32 per cent in 15 years. The rates, however, remained constant during the last five years around 55. The survey found that the average household size had dropped from 4.5 in 2012 to 4.3 in 2016 and that Bangladeshi women were still dominated by men. This feature has been reflected in a high male household headship rate of 87.2 per cent in 2016, against 85.5 in 2012, showing a moderate increase over the last five years. The adult literacy rate of the population aged 15+ has shown an increase of about 19 per cent over the last five years, reaching to 72.3 per cent in 2016 from 60.7 per cent in 2012. The increase in the adult literacy rate was more pronounced (22.8%) among females than among males (16.0%) over this period.
Life expectancy in Bangladesh has gone up by 2.2 years during the past five years, attaining an average of 71.6 years in 2016 from 69.4 years in 2012. A similar decline was noted in the infant mortality rate, from 33 per 1,000 live births in 2012 to 28 in 2016 (BSVS 2016).
Given the current status of economy, such an increase of population will have several adverse implications for our socio-economic development. Any delay in achieving its demographic goal means a heavy time-penalty and serious implications for Bangladeshs socio-economic development. Due to population increase, the number of landless people in absolute number will increase tremendously further aggravating the poverty situation. The total arable land space will be attenuated further. This will have an obvious adverse impact on per capita food production and food availability of the growing population. Thus, 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.
The activities involved in the implementation of family planning programs are much more complex and require a deliberate input from management concerned into the programs with emphasis on actual achievement of results. Identified crucial elements related to problems of management pertain to the level of policies and others to program execution.
Apart from policy issue mentioned above, there should be good governance in health administration, both in the private and the public sector, for which political commitment should be transparent and all allocations should be demand based and balanced ones. There could be arrangements where civil society organizations and human right agencies can interact to ensure accountability and transparency in procurement, supply chain management, logistics so that well-functioning services can be provided through access of quality medical products and technologies. A strong health financing structure is also important, which can ensure populations protection from health related financial crises. In addition to these aspects, a well-functioning information system is also vital, which would disseminate information timely on critical health outcomes. There should be also participation of health watch groups with regular inflow of information. Existing human resource development (HRD) plans need to be reconstructed to have long-term objective to improve the quality of healthcare services (clinical and managerial skills), and to address emerging health problems of Bangladesh. Funding on training is very much crucial for informal health providers, as wellas funding for community systems that mobilize demand for services. In addition to that tailor made programmes need to be provided in line with local needs, so as delivering services too hard to reach, atrisk and vulnerable populations. There should be strategies for community engagement/involvement to increase awareness of, access to, and utilization of health services, and provision of appropriate services at the community level. Moreover, strong leadership (political, donor, and government) support public accountability are essential to strengthen a sense of commitment accountability of Bangladesh health care systems, especially in times when the government is exploring means of reform.
Based on the failures in the state run health care system identified by the Bangladesh Health Watch report there will no doubt be a significant thrust to allow more private sector or non-governmental involvement in healthcare services. The report suggests that the potential benefits of harnessing the ubiquity and the influence of the informal healthcare providers could be massive, with training and monitoring. Bangladesh needs to improve quality of nursing to develop health sector. More doctors, nurses and informal health care providers are also need to be recruited. This could be explored as a public-private partnership and can greatly reduce the existing pressure on the medical infrastructure run by the government.
Despite these positive strides, many challenges remain. Given the momentum of the high rate of population growth in the past, family planning and maternal and child health services need to be strengthened further to meet the demands of the increasing numbers of men and women entering their reproductive years. The contraceptive prevalence rate needs to increase from 62 to 72 percent if the country is to achieve the national fertility goal of 1.8 children per woman. The contraceptive method mix is currently heavily reliant on short-acting methods, even though the average woman achieves her desired fertility by her late twenties. The level of unmet need is 12 percent. In addition, use of maternal healthcare services continues to be low, with only 31 percent of pregnant women receiving the recommended four or more antenatal checkups and less than half of all births (42 percent) being assisted by skilled birth attendants according to the 2014 Bangladesh Demographic and Health Survey (BDHS 2014). This national report further show that chronic and acute malnutrition are rampant and 41 percent of children under age five are stunted and 16 percent are wasted with 36 percent of children overall being undernourished. Large rural-urban disparities persist in use of maternal and child healthcare.
Low levels of knowledge or awareness is one of the main deterrents to healthcare use. Access is another problem, particularly in rural areas where the public sector is the primary provider and service delivery points are more dispersed than in urban areas. Although the country has done well in health and family planning over the last three decades, certain geographical regions of the country continue to lag behind. For example, the contraceptive prevalence rate is around 48 percent in Sylhet, 55 percent in Chittagong, and 70 percent in Rangpur, compared with the national average of 62 percent (NIPORT, et al., 2016).
The private sector plays a vital role in health service delivery and is usually the first point of contact for primary curative care, including among the poor. In Bangladesh, healthcare is offered either through government-run hospitals or through privately-run clinics. Bangladesh is still lagging in health care services for the poor as well as the affluent. In recent years, our neighbours, India and Thailand have forged ahead in respect of expertise and experience of doctors, advancement of healthcare technologies and high quality hospitals and health management organisations. To achieve this in our country, technological collaboration with technologically advanced hospitals are needed and follow health management organisations in the developed countries of Asia and the advanced nations of the West.
After twenty years of existence, health policy and systems research is now recognised as an important multiple disciplinary fields that are essential for strengthening health systems globally and nationally. This write-up shows how the field has evolved. It still needs to be more widely embraced by the broader health research community and national policy-makers. It still needs a critical mass of support from the research community. There are still many challenges ahead, as described here, which will require changing mindsets and opening of boundaries to policy-relevant research supporting health systems. The field is ready, with innovative science and new multidisciplinary partnerships, for the next leap forward towards achieving the Sustainable Development Goals. At a minimum, this will require a paradigm shift in the use of HPSR to guide policy and programmes and a phase shift in the quantity and quality of HPSR produced.
As country develop and improve universal health coverage schemes globally, there is increasing recognition that health policymaking and health system strengthening need to be informed by robust research evidence. In Bangladesh, complex health challenges require actionable and context-sensitive evidence to improve the responsiveness of health systems. This movement towards evidence-informed policymaking also calls for research that addresses key priorities identified by policymakers and stakeholders in the country. To stimulate this type of research the World Health Organization (WHO) developed Changing Mindsets, a strategy on health policy and systems research that advocates for thoroughly embedding research into health system decision-making. Recognising the importance of early and active engagement of policymakers, the World Health Report 2013 focused specifically on research for universal health coverage and called for more demand-driven research globally. Furthermore, there is a growing interest in the co-development of research and the engagement of policymakers in various empirical endeavours worldwide.
Considerable challenges remain in the forefronts in the efforts to improve the health status of the population, reduce health inequalities, improve the quality of care and public satisfaction with healthcare, and to increase the efficiency and sustainability of service-delivery agencies. These challenges point to the growing need for appropriate and applied research to enhance the knowledge about factors affecting the governance, provision, organisation, financing and use of healthcare and health services as well as at the role of key multispectral players within the healthcare system. Where resources are scare, it is vital that health system be strengthened so that every decision is the best decision. Health systems research can support that decision-making.
Good governance is important in ensuring effective health care delivery, and that returns to investments in health are low, where governance issues are not addressed. Strengthening the health system through better management and organisation and effective use of resources can improve health conditions and enhance the quality of health care delivery in Bangladesh. Furthermore, more research is needed on health system reforms.
For the health, the time has come to address health inequality and social determinants of health. National health inequality monitoring needs considerably more investment to realise equity-oriented health improvements in countries, including advancement towards the Sustainable Development Goals. Following an overview of national health inequality monitoring and the associated resource requirements, we highlight challenges that countries may encounter when setting up, expanding or strengthening national health inequality monitoring systems, and discuss opportunities and key initiatives that aim to address these challenges.
Establishing and strengthening national health inequality monitoring systems is an essential investment as country move forward to ensure that policies, programmes and practices are equity-oriented and effective. Bangladesh, however, face common types of bottlenecks that restrict the extent to which health inequality monitoring can be done, and impede the ability to implement changes. These barriers emerge from limitations associated with health information systems, but also from political, financial, social and cultural influences. Key opportunities that country should move forward on include: building robust data collection infrastructure, supported by national institutions; building knowledge and technical capacity for equity analysis and communication; and determining effective ways to use the results of health inequality monitoring for better resource allocation and programme implementation, including identifying and addressing barriers to action.
Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Our health is determined, in part, by access to social and economic opportunities; the resources and supports available in our homes, neighbourhoods, and communities; the quality of our schooling; the safety of our workplaces; the cleanliness of our water, food, and air; and the nature of our social interactions and relationships. Social determinants are often a strong predictor of health disparitiesso its important to recognise the impact that social determinants have on health outcomes of specific populations.
Individual-level factors such as access to health care, health behaviours, and genetics have an influence on health, but they do not fully explain patterns of health and illness within communities and across populations. It is the job of public health professionals to step back and look at these larger patterns and their causes. Across cities, towns, regions, and countries, disadvantaged populations consistently have poorer health than populations advantaged by greater economic and social resources.
Social determinants of health are the conditions in which people are born, live, work, and age that affect their health. Understanding the importance of social determinants of health is central to the history and practice of public health. For example, the links between health and housing have been clear since the earliest days of the Bangladesh public health system. In the 20th century, outbreaks of infectious diseases such as cholera, typhoid, and tuberculosis swept through crowded urban slums. Inquiries into the causes of these epidemics pointed to filthy and substandard living conditions, revealing an urgent need for effective public health administration.
More recently, the World Health Organizations (WHOs) Commission on Social Determinants of Health noted that the social and physical circumstances in which people find themselves affect the way they live and their risk of illness and premature death. Healthy People 2020 stress the importance of social determinants of health by highlighting them as 1 of the 4 overarching goals for the decade: Create social and physical environments that promote good health for all.
In the past decade, Bangladeshi society has been experiencing accelerating change, especially in the area of technology and communication. This is having an adverse impact on the health of Bangladeshi due to reduction in exercise and increase in sedentary lifestyles and associated consumption. Bangladeshi born during this period is expected to have unique thoughts and behaviours when compared to previous generations.
New health indicators of Bangladeshi Generations are needed in health policy formulation because health indicators are in prospective. Bangladeshi society consists of people of multiple generations. Each generation differs not only by age, but also in their way of thinking. The different attitudes and behaviours of each generation are shaped by the different social, economic and cultural contexts in which they grew up.
Currently, there are four main generations worldwide categorized by their year of birth. The Silent Generation, the Baby-boomer generation. Generation X and Generation Y. According to theory of Generations, members of the Silent Generation are generally described as risk-averse and prefer predictable patterns. Baby boomers are generally described as hardworking while members of Generations X and Y prefer independence in their work lives and are innately more familiar with modern technology.
The generation profile is shaped by each generations experience during various stages of their life cycle. Most members of the Silent Generation came of age during the World War and global depression. Baby Boomers grew up in the post-World War era and the economy was recovering.
Information technology (IT) and on-line society is changing the lifestyles of all the generations, but in different ways. Baby Boomers mostly use modern technology to follow the news and read books and magazines on-line. Gen X uses IT for work, while more Gen Y sees IT as a source of entertainment, social connection, and chatting live.
As birth rates dropped, there will need to be shift to promote quality birth among the dwindling numbers of youth. Thus, Bangladesh will need to intensify its investment in creating a positive environment, promote solidarity of the family, and invest in human capital starting at the pre-school level throughout childhood and adolescence with the hopes of creating quality citizens that will be productive members of the society in the future.
Childhood experience is an important determinant of the way people think show they view the world, and their values, attitudes towards society, and life style. Thus, persons of the same generation tend to share similar traits across these generations.
The Theory of Generations helps explain differences among large demographic cohorts and are usually defined by their year of birth. In this write-up the focus on four main generations: Silent, Baby Boomers, X, and Y. At present, Gen Y is the largest of the global population (39%) and Gen X is the second largest (27%0. Higher-income countries have a smaller proportion of Gen Y populations than middle- and lower-income countries.
Fully 3 out of 4 Gen Y are innately comfortable with using the range of features of technology; Baby Boomers are willing to learn new technology to meet certain needs. Modern technology is influencing the lives of all generations. Gen Y and subsequent generations are able to keep pace with the rapidly advancing information technology (IT) and more likely to make full use of new innovations than older generations.
The accelerating advancements in technology and Bangladeshs openness to absorb these into the local market have led to ubiquitous adoption of such conveniences as cell phone use and Internet access. Smart phones are now considered necessities by the newer generations as they allow 24-hour access to the Internet and an endless supply of applications.
It is clear that members of Gen Y were born in the age of global communications and high-speed Internet. Thus, they are very comfortable with modern IT and seem to effortlessly learn how to use new innovations and applications. By contrast, less than one in ten Baby Boomers have ever used a laptop or desktop computer, smart phone or tablet.
For most categories, Gen Y is more likely than other generations to use modern IT and the Internet for everyday transactions and conveniences such as on-line banking or e-books. This familiarity with technology positions Gen Y as most likely to benefit from and adapt new applications to enhance their daily life than their peers.
Bangladeshi Gen Y spends an average of one-third of their day on-line. Internet speed and wireless access in Bangladesh is expanding rapidly. Increasing portions of each generation are connected and have more mobile lifestyle, but this is most pronounced for the younger cohorts.
At present, access to the Internet can be done almost anywhere and anytime by mobile access through smart phones and tablet computers. On-line behaviour differs by generation, which can be a reflection of different ages. Many Gen X are now in the peak employment years and, thus, much of their on-line activity is work-related such as exchanging e-mail, selling/purchasing goods, and doing business on-line. By contrast, Gen Y use the Internet more for entertainment and social networking, while Baby Boomers, many of whom are in or approaching retirement, use the Internet to access news and information in their areas of interest, especially in the health sector and e-books.
Each day, Gen Y spend just over one hour in physical activity, the least in comparison to other generations. Gen Y in the West is typically characterised as health conscious, a trait that is not yet fully portrayed among Bangladeshi Gen Y.
One indicator of a threat to health is the age at first health risk behaviour. Using this indicator, youth in the largest generation show a younger age at first health risk behaviour compared to earlier generations. Having adequate physical activity is one important health- promoting factor. However, many Bangladeshis are not getting adequate activity, and the younger generation may be at greater risk of this than earlier cohorts. However, by age group, the Gen Y members had the lowest proportion that practiced adequate physical activity in their daily life among generations. Gen Y also spent the least amount of time per day in physical activity among generations.
There can be little doubt that one of the most pressing problems for the developing countries of the world today is that of curtailing population growth. Bangladesh is now firmly committed to a policy of population control. There is a need for Bangladesh to recognise the population problem for what it is. At the national level this is a problem which saps national resources, and leads to the maintenance of poverty and the persistence of illiteracy, with all its attendant ills. What is being advocated is not a reduction of national numbers and consequent power or prestige, but a balancing of the development of the human numbers with national resources and national capabilities, so that the people of Bangladesh would be able to attain their full genetic and social potential and contribute fully to the country and the world. The attainment this goal is being thwarted in Bangladesh by wrong approaches to development and by a rapid increase in the numbers of the people; hence the need for balanced, integrated and comprehensive health/population and people-oriented development programs.
The writer is former Head, Department of Medical Sociology, Institute of Epidemiology, Disease Control Research (IEDCR), Dhaka, Bangladesh, Cell phone: 01711616268, E-mail: [email protected]
