Tackling the Baby-Killers
It is in the startling achievements in public health that the Bangladesh paradox is at its most contrary: how did such a legendarily poorly equipped, badly governed, understaffed, over-crowded health system defy 'the expert view that improvement of population health is a straightforward function of reducing poverty and increasing resources for health' (Adams etal. 2013, 2109), confounding 'any simple association between health system effectiveness and human development outcomes' (Ahmed etal. 2013, 1747)? In themes that will by now be familiar, the answer lies in: a close focus on reaching women and the rural poor; a pragmatic mix of public and private provision and aid- supported partnerships; and experimentation and learning.10
A shining success has been reduced infant and child mortality rates, achieved to a significant degree by tackling the main childhood diseases through high immunization coverage and improving diarrhoeal disease management. Infant and child mortality were closely implicated in high fertility and sensitive indicators of human wellbeing in the mid-1970s. An early assessment of the situation noted that not only could almost half of infant and child deaths be easily prevented through basic vaccines and better diarrhoea management, but '[m]ost of the technologies required are already developed, available at low cost, and readily applicable'. The challenge was political, financial, and organizational: the need to 'generate the political commitment, mobilize the necessary resources, and organize the health care providers and local communities to deliver the services' (Chen et al. 1980, 32).
Bangladesh has done well on saving children from preventable deaths, but as Figure 7.3 shows, it has not done noticeably better on this (and other related indicators) than its regional comparators. What does make it stand out is its 'positive deviance': its gains have come at relatively low cost, low GDP, and high poverty levels (Chowdhury etal. 2013; Koehlmoos etal. 2011). This reflects the fact that Bangladesh suffers from a chronic shortage of health professionals, with only 0.58 per 1,000 people—well below the World Health Organization's cut-off point for a 'serious shortage of human resources for health', which is 2.28 (El Arifeen etal. 2013, 2014). The success is partly explained by the involvement of community-based health workers, often women, on a national scale in delivering services and communicating public health messages, including fertility control. A range of models for deploying 'achievements' in this respect are not all that remarkable. It is mainly when viewed from the perspective of the Malthusian preoccupations of aid donors of the early 1970s that Bangladesh's transition appears so dramatic. Many thanks to Andrew Fischer for pointing this out.
10 For this section, I have mainly drawn on the 2013 special issue of The Lancet which analyses Bangladesh's health achievements and challenges. See Chowdhury etal. (2013) for an overview.
Figure 7.3. Under-5 mortality rate in South Asia (probability of dying per 1,000 live births under 5 years)
Source: World Development Indicators. Accessed 3 January 2016. http://databank.worldbank.org/ data/reports.aspx?source=world-development-indicators.
these workers have been trialled with varying success by state and non-state providers. Although they deliver few care services, community health workers play a significant role in health promotion and prevention by virtue of being able to reach and communicate with rural women in particular. Of the around 200,000 community healthworkers, a quarter are government and the rest NGO workers, at least half of whom are employed by BRAC (El Arifeen et al. 2013). To some extent, then, the success of the Bangladesh model enables those so inclined to point out that public health advances need not depend on expanding public health bureaucracies: the private (albeit substantially nonprofit) sector can do some of the heavy lifting.
It seems to be true that effective government-NGO partnerships and a generally pluralist approach to provision has helped in this 'whatever works' context. Amartya Sen notes that the devotion to ideological purity over private or public provision common in other health systems has been absent here, replaced by a pragmatic approach to getting all hands on deck in what was, in the 1970s at least, an emergency situation (Sen 2013). The government of Bangladesh has created space for independent NGO action but also partnered with them in a range of ways, explicitly and otherwise, including on major public health efforts such as the successful tuberculosis treatment (Directly Observed Treatment Short course—DOTS) campaign (May et al. 2011), as well as in the Expanded Programme on Immunization (EPI) since 1980—widely termed 'a near miracle' because of the pace at which coverage was achieved (Huq 1991)—and more recently on water and sanitation. It certainly had miraculous effects: between 1987 and 1997 alone, an estimated 1.2 million child deaths were prevented by immunization. This pluralism brings problems—a weakly governed health system with apparently little incentive to increase the numbers of doctors and nurses, or to spread them beyond urban centres, among others (Ahmed etal. 2013). These will pose significant challenges to the next generation of health provision (Adams et al. 2013). But for this first generation of substantially preventive and promotive public health programmes, pluralism enabled an under-resourced and informal system to benefit from the advantages of different providers—outreach, cost, public authority, scale, monitoring, innovation, and so on.
Their reproductive roles, including nourishment and caring for infants and the sick, put women at the centre of gains in health. Attention to women and gender inequality closely guided the design and delivery of many successful programmes, and women health workers were a key part of the strategy. Assumptions about what women could and could not do were thrown out, no doubt reflecting the recognition that times had changed and so had gender relations (see also Chen 1983). Early on, the NGO BRAC took an explicit learning approach to its initiatives, testing models out before scaling them up (not only in the health sector) (Korten 1980; Smillie 2009). In the process it learned about what parts of gender relations could—and could not—change to accommodate an approach to infant and child health that depended directly on mothers' knowledge and capacity to act. The public backing of the government for programmes like the EPI lent it public authority, in a context in which the population have relatively high levels of trust in their state. At the same time, NGOs were able to build a network that spread across villages and into homes, working directly with rural women who had rarely been in contact with outsiders or officials before.
The successes have also been marked by the rapid uptake of innovations— several, such as oral rehydration therapy (ORT) for the treatment of diarrhoea, home-grown in the aid lab itself, designed specifically for the conditions of rural Bangladesh. The NGO BRAC pioneered this, but at different times with the involvement of the government and the ICDDR,B (or Cholera Hospital, as it was once called). The development and adoption of the saline solution (an easily prepared and orally administered mix of salt, molasses, and water) is believed to have saved millions of young lives over the decades, as diarrhoea was the single greatest killer of children by the 1980s. The ORT programme was particularly striking for its combination of lab-like conditions and private sector incentives. The approach was carefully designed, with different options costed and tested, and a process of learning built into the programme. A careful system of monitoring was developed and healthworkers were 'incen- tivized' to ensure they taught mothers correctly through small performance- based payments based on retention of the knowledge of how to prepare the solution (Chowdhury 2001; Chowdhury and Cash 1996).
One achievement in health that cannot go unmentioned is the Essential Drugs Policy, passed in 1982, which restricted the activities of transnational pharmaceutical companies to encourage production of essential drugs and help grow the local pharmaceutical industry. This is a remarkable tale of a battle between Big Pharma and a military dictator-backed group of medical professionals and activists in which, for once, the little guy won (Chowdhury 1995; Chowdhury 1996). The Bangladeshi pharmaceuticals industry now exports drugs to 107 countries and produces 97 per cent of locally used drugs (Dhaka Tribune 2015), and the policy continues to be credited with having brought good-quality medicines in reach of the masses.