Bangladesh: 50 Years of Advances in Health and Challenges Ahead

INTRODUCTION

A colleague said many years ago, “Bangladesh is to development as Paris is to fashions.” One could also say that Bangladesh is a positive deviant—in a class by itself compared to other low-income countries in the achievements it has made in health and development since its independence in 1971. At that time, it was the second-poorest country in the world (after Upper Volta, now Burkina Faso). Now, Bangladesh is a lower-middle-income country,¹ and the government believes that in 20 years, it will become a high-income country.

The reasons for this remarkable progress—from, as Henry Kissinger infamously called it in the early 1970s, “an international basket case,” to a country bustling with empowerment, optimism, and a “basket of innovations”—are complex. But among the important contributors is Bangladesh’s extraordinary achievement in improving the health of its people. This is the subject of a recently published book, 50 Years of Bangladesh: Advances in Health.² Convened by the Bangladesh Health Watch, an independent citizens’ oversight group,³ this book is a most fitting sequel to another book written by one of us (HBP) in 2000.⁴ The other of us (AMRC) is the principal editor of the recent book.

As one reflects on Bangladesh’s gains of the past half-century and anticipates the challenges and opportunities of the next half-century, now is an opportune moment to remember the 3 million Bangladeshis who lost their lives in the struggle for independence, the millions whose lives were cut short by death from readily preventable or treatable conditions, and the hundreds of millions who suffered from stigma, discrimination, and subhuman poverty. This is also an opportune moment to remember with gratitude those who provided fearless and inspired leadership in overcoming what to many would have been insurmountable odds. Many of these people are no longer with us today. Among the many hundreds if not thousands of people that one might mention, a special remembrance is owed to Bangladesh’s founder, Bangabandhu Sheikh Mujibur Rahman; the founder of BRAC, Sir F. H. Abed; the founder of Grameen Bank and Nobel Peace Prize laureate, Professor Muhammad Yunus; the freedom fighter, war surgeon, and founder of one of Bangladesh’s leading nongovernmental organizations (NGOs), Gonoshasthya Kendra; and the champion of Bangladesh’s renowned drug policy, Dr. Zafrullah Chowdhury.

After reading all 370 pages of this book, one could not, perhaps, help but stand in awe at the collective action required to produce this book—103 authors and co-authors working together to produce 20 chapters. And one cannot help but also stand once again in awe at the extraordinary achievements described in this book. Collectively, they are the product of so many individuals, programs, organizations, and institutions that dedicated themselves to improving the health and well-being of the 170 million people who now live in Bangladesh.

HEALTH ACHIEVEMENTS IN BANGLADESH OF NOTE

In their 2013 series of articles in The Lancet, Mushtaque Chowdhury and colleagues referred to the “the Bangladesh paradox: exceptional health achievement despite economic poverty” that was achieved with gender- and equity-oriented, highly focused nationwide interventions.⁵ Among the many noteworthy achievements, at least a few that are well known to many are important to recall.

• The improvement in life expectancy at birth from 50 years in 1971 to 72 years in 2021⁶

• The reduction in mortality of children younger than 5 years of age from 251 in 1971 to 31 deaths per 1,000 live births in 2021^7,8

• The reduction in the total fertility rate from 6.6 in 1975 to 2.0 births per woman in 2021^9,10

• The expansion in coverage of childhood immunizations from 2% in 1978 to nearly 100% in 2021 as well as the elimination of polio^10,11

• The discovery in Bangladesh of oral rehydration therapy as an effective treatment for dehydration produced by diarrhea and the implementation by BRAC of its national Oral Therapy Extension Program, setting the foundation for the highest usage rate (87%) in the world of oral rehydration therapy for childhood diarrhea¹² and contributing to the decline in the percentage of deaths in children younger than 5 years from diarrhea from 25% in 1970 to 2% in 2000 and since¹¹

• The detection of more than 70% of cases of pulmonary-active TB and the completion of treatment in 90% of detected cases¹³

• The reduction in the rate of open defecation from 34% to less than 1% between 2000 and 2015¹²

• The development of strategies that have mitigated the mortality and consequent sufferings associated with cyclones and floods through early warning systems, construction of shelters and housing that provide a safe haven, and pre-planning for rapid response when disaster strikes¹⁴

Routine home visits by women community health workers (CHWs) were responsible, to a considerable degree, for the remarkable progress in child and reproductive health. Female CHWs visited all homes to promote family planning at a time when women could not leave their homes or immediate neighborhoods. These workers visited all homes to mobilize mothers to take their children to special sites for immunizations on days when a government mobile team would arrive in their community. They visited more than 12 million homes specifically to teach them how to prepare and administer oral rehydration fluid to prevent fatal dehydration from diarrhea. These actions were all the result of community engagement and the empowerment of women as CHWs. As the book states¹⁵:

The adeptness of NGOs to successfully transform ordinary, less educated rural women into confident and self-dependent individuals and inspiring such women to participate in social reforms has been a fundamental element in Bangladesh’s progress.

The book concludes by declaring that¹⁶:

[c]reating a cadre of female health workers …, demystifying health care and making it more understandable for the general public have been found to be critical factors for success of Bangladesh’s health sector.

All of these achievements were aided and abetted by the benefits of broad socioeconomic development, of course. Bangladesh’s progress in women’s empowerment, elimination of illiteracy, raising the level of education (especially for girls), formation of women’s groups and microcredit programs, other poverty alleviation programs, and expansion of agricultural output, as well as improvements in roads, communications, and other infrastructure, have all helped to make these health achievements possible.

Bangladesh now stands at a critical moment in its history. It has a proud heritage of achievement in health, social development, and poverty alleviation. The achievements of the past 50 years have given Bangladesh a momentum that will propel it into ever-increasing economic prosperity. The unanswered question now is, “Will that economic prosperity also produce ‘Health for All’?” Will the poor enjoy the benefits now available to people who live in high-income countries, similar to the better-off Bangladeshis?

THE WAY FORWARD

There are several key priorities for the next 50 years that arise from this book.

CONCLUSIONS

Throughout the world, good health is routinely put at the top of the list of individuals’ priorities for their own well-being. Health, like education, is among the basic capabilities that give value to human life and that create human capital, one of society’s basic building blocks.²⁶ The value that people place on health is also evidenced in many other ways, not the least of which is the vast sums spent in highly developed countries on health care. In the United States in 2020, for example, per capita spending on the health sector was 20% of the national GDP and amounted to US$12,530 per capita.²⁷ One can anticipate that Bangladesh will follow a similar path as its economy grows. The overarching question is whether the money spent in Bangladesh over the next 50 years will be used in a way that will bring the greatest benefits possible to the health of the population and particularly to the poorest and most vulnerable members of its society.

The Universal Declaration of Human Rights, which is the United Nations’ moral charter and whose 75th anniversary is being celebrated in 2023, resoundingly affirms that “Everyone has the right to life, liberty and security of person,” that “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, … including medical care,” and “Motherhood and childhood are entitled to special care and assistance.”²⁸ The “right to life” includes the universal right to accessible basic health care services that are effective for preventing and treating serious conditions.

The 1978 Declaration of Alma-Ata called for the achievement of “Health for All” by the year 2000—a level of health that will permit people to lead a socially and economically productive life.²⁹ It also affirmed that “[p]rimary health care is the key to attaining this target as part of development in the spirit of social justice.”²⁹ The Declaration of Alma-Alta also reminds us that “[t]he people have the right and duty to participate individually and collectively in the planning and implementation of their health care.”²⁹ CEA Winslow in 1920 offered his now-classic definition of public health as³⁰:

the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through organized community efforts … which will ensure to every individual in the community a standard of living adequate for the maintenance of health.

Bangladesh has inspired the rest of the world over the past 50 years because of its effective implementation of the science and art of public health—saving lives and overcoming poverty through organized community efforts, thereby bringing dignity and hope to millions of people. The closing remark in this newly released book proclaims that³¹:

The government must play a bold role and lend a hand towards the transformation of the health system. That is, the government needs to have courage and full commitment.

Only through this, but within a pluralistic health system that incorporates the full spirit and participation of citizens and local communities, will such efforts succeed in providing “Health for All.” CHWs reaching every household on a regular basis are the core legacy of Bangladesh’s health advances for the past 50 years. Maintaining and building on this will enable Bangladesh to reach “Health for All” sooner rather than later.