Look into any news that concerns the health sector in Bangladesh and what do you expect to find? Epidemics, pandemics, challenges, and gridlock in systems? Yes, those may be there, but that should not overshadow the fact that Bangladesh has worked a minor miracle in achieving better health planning and service delivery through a shift in how it delivers services and measures results. And, for the country as a whole, this has meant better access to services that, as evidence shows, are what the citizens of Bangladesh really need.
First, some background: In 1998, the Ministry of Health and Family Welfare reasoned that it could improve upon the vertical health systems that focus on specific health sectors, such as family planning, nutrition, and population. Instead, it adopted a sector-wide approach that included all three.
Since then, there have been three rounds of health, nutrition, and population (HNP) development programs, each covering five to seven years. The overarching objective has been to improve access to and utilisation of an essential package of health, population, and nutrition services, particularly among vulnerable population groups. According to a recent article published by Measure Evaluation and icddr,b, while challenges exist, the sector-wide approach has resulted in significant progress in these ways:
Better program management and financing
The sector-wide approach replaced 128 discrete projects and marked a shift towards a more integrated, better-planned delivery of HNP services. As a whole, the management capacity of the health and family welfare ministry has improved, as measured in a 2008 mid-term review. In terms of financing, the total budget available for HNP service delivery increased at a higher rate under the sector approach (24% increase per annum during 1998–2013 compared with 16% during 1992–1998). Better management and increased funds available bode well for better health services for people.
Policy formulation and planning
Under the first sector-wide health program, the focus of health service delivery was realigned from home-based to a community clinic-based service delivery and the expansion of emergency obstetric care from health facilities.
Each successive strategic plan outlined specific health interventions tied to resources available and within operational plans, which helped ensure that intended services were actually delivered. This has meant that the health service expectations of citizens are more often realised.
Reform initiatives
The sector-wide approach also has focused on improving health sector efficiency through innovation, and policy and institutional reforms. Notable institutional reforms in health sector include improving financial management and procurement systems through a centralised information system; the establishment of the Program Management and Monitoring Unit (PMMU) and the Procurement and Logistics Monitoring Cell (PLMC), to strengthen critical aspects of management/monitoring and procurement, respectively; and the outsourcing of some services and setting up a contracting system with NGOs.
Aside from these management reforms, the years 1998 through 2013 also saw the revitalisation of community clinics, a voucher program to enable poor pregnant women to procure maternal health services, and mainstreaming of nutrition services through existing health service delivery arrangements.
Provision of health services
Of most interest to Bangladeshi citizens, studies of selected health facility statistics between 1997 and 2011 indicate that service provision improved in both primary and secondary level facilities; the availability of physicians, nurses, and functional equipment improved, resulting in a substantial increase in outpatient consultations and admissions in government health facilities.
And, during 1997 to 2010, available beds in public hospitals increased by 51%: In 1981, there was one bed for every 5,350 people; in 1997, that had improved to one bed for every 4,293 people, and in 2010, there was a bed available for every 3,435 people.
Health service utilisation
In early 1990, in the family planning and maternal health sector, access to services markedly improved. For example, in 1991, 40% of married women were using contraceptives and in 2011, the use rate reached 61%. Births attended by a medically-trained provider increased from 10% of births to 32% between 1992 to 2011, largely because of facility deliveries, increasing from fewer than 4% to 29%.
Apart from overall coverage, equity in service utilisation also improved considerably. For instance, during the same period, the gap between the richest 20% and the poorest 20% of the population, the sections for facility delivery decreased substantially.
Health outcomes
Over the past two decades, the total fertility rate in Bangladesh decreased in rural areas, from 3.5 children per woman to 2.3 children per woman, and is approaching population replacement-level fertility.
In another indicator for health outcomes, the maternal mortality ratio (MMR, maternal deaths per 100,000 live births), also significantly declined during 1999 to 2008 from 322 deaths to 194 deaths per 100,000 live births. Bangladesh is also on track to achieveing the Millennium Development Goals (MDGs) related to reducing malnutrition and deaths among children.
These and other available data demonstrate that the health sector program in Bangladesh has evolved as the government has learned from its implementation and refined the program over the years. Despite some challenges, the sector-wide approach has been successful in achieving the majority of national and global health goals and these results are worth being shared more broadly as an example of the successful adaptation of a sector-wide approach in a developing country with a complex administrative structure.