Present status of the Health Sector in Bangladesh
Bangladesh is the most densely populated country in the world with a population of 139 million people, 40 percent of whom are living in poverty (HIES 2005). The Bangladesh National Strategy for Accelerated Poverty Reduction (NSAPR 2005) considers in particular the human dimensions of poverty (deprivation of health, education, nutrition, gender gaps) and commits the MoHFW to reach the poor and vulnerable, especially women and children. The Health and Population Sector Strategy (HPSS), which commenced in 1998, sets the stage to develop the SWAp and for the development of the Health and Population Sector Programme (HPSP) which was to include reforms such as improved and more efficient service delivery by unifying the two wings, health and family planning (FP), under the MoHFW.
The current Health, Nutrition and Population Sector Program (HNPSP) outlines activities from 2003-2010, with objectives to improve health outcomes, reduce health inequities, enhance quality of care, modernize the GoB health sector, and attain the health related MDGs. This document has tried to incorporate the MDG (4, 5 and 6) targets, while offering slightly different targets for HNPSP. The Revised Programme Implementation Plan (RPIP) of Health, Nutrition and Population Sector Programme (HNPSP) 2003-2010, proposed budget for the whole sector by dividing it into four sub-sectors: Health Programme (HP), Nutrition Programme, Population Programme (PP) and Ministry Level Sector Development. Major Reproductive Health (RH) components are under HP and PP.
There are mainly four levels of health facilities in Bangladesh which are primary health care (UHC, UHFWC, USC & CCs), secondary healthcare (District Hospitals), tertiary health care (Medical College Hospitals), and super specialized care (specialized institutions). Under HPSP, about 13,500 new community clinics, each for 6000 population, were supposed to be constructed. Currently 6708 CCs are functioning with DGHS Health Assistant (HA) and DGFP Family Welfare Assistant (FWA) and another 7156 CCs are handed over to NGOs (HEU 2007). The HA and FWA are performing home visits and working from CCs (if operational) and providing family planning services, maternal and child health care, including immunization, communicable disease control, symptomatic curative care for common complaints, and upward referrals (HNPSP 2005).
At Union level there are 3622 Union Health and Family Welfare Centre (UHFWC) under DGFP and upgraded UHFWC (formerly called Union Sub-centres, USC) under DGHS. UHFWC has one Sub-Assistant Community Medical Officer (SACMO), one Family Welfare Visitor (FWV), one Pharmacist, one Aya and one MLSS. In the Unions, where no UHFWC has been constructed, there is a post of FWV only (HNPSP 2005). The training of FWVs in FWV Training Institutes managed by NIPORT started in 1970’s, but unfortunately stopped since 1997. The termination of the training of FWVs is expected to have adverse effect on maternal and child health in Bangladesh as FWVs provide services to mainly rural women (BHW 2007). Each of the 1275 upgraded UHFWCs has the posts of a Medical Officer, a Medical Assistant and a Pharmacist (HNPSP 2005).
There are 431 Upazila Health Complexes (UHCs) with 31-50 beds in each facility and 60 Rural Health Centre’s (RHCs) with 10-20 beds in each facility, and providing both outpatient and inpatient care, in Upazila level. On the health side there are nine doctors including one dental surgeon, nursing supervisor and senior staff nurses, two Medical Assistants, Medical technologists (pharmacy, radiology, dental) and an EPI technician along with other support staff in each of the UHCs. The UHCs also have the posts of Upazila Family Planning Officer (UFPO), Medical Officer (MCH), Assistant Family Planning Officer, Senior FWV and two FWVs on the family planning side (HNPSP 2005).
There are 61 District Hospitals (DHs) which constitute the third layer on the health side in the country. DHs are larger facilities in comparison with UHC, with an average bed size of 133 (range 48 to 375). The districts also have Maternal and Child Welfare Centres (MCWCs) based in the district town which offer Comprehensive Emergency Obstetric Care (C-EmOC) and clinical contraception run by the DGFP. The fourth layer of the public health system includes Medical College Hospitals (MCHs) and Post Graduate Institutes and Hospitals. There are 15 Government Medical College Hospitals (MCHs), 1 Dental College, 1 Homeopathic Medical College and Hospital, and 1 Ayurvedic Degree College and Hospital (HEU 2007). Currently these MCHs produce around 1200 doctors per year (BHW 2007). In Bangladesh there are also
21 Specialized hospitals (mental, leprosy, infectious disease, chest diseases etc.).
The scarcity of skilled health personnel, specially nurses, is one of the main challenges in the health sector of Bangladesh as there are around five physicians and two nurses per 10,000 population (BHW 2007). The density of qualified providers, including doctors, dentists and nurses, in the country is 7.7 per 10,000 populations. The distribution of qualified providers is highly urban biased. There are 18.2physicians, 5.8 nurses and 0.8 dentists per 10,000 populations in urban area while the corresponding figures in rural area are 1.1, 0.8, and 0.08 respectively. The data also show that the number of male physician per 10,000 populations is five times higher than the number of female physician per 10,000 populations (Table 1).
Table 1: Distribution of physician, nurse, dentist per 10,000 population and nurse per physician ratio by gender and area
There are also high regional disparities in the distribution of physician, nurse and dentist in the country. The highest number of physician is concentrated in Dhaka division (10.8 per 10000 population) followed by Chittagong division (4.8 per 10000 population). The availability of qualified provider is lowest in Barisal followed by Sylhet and Rajshahi (Table 2).
Table 2: Distribution of physician, nurse, dentist per 10,000 population and nurse per physician ratio by division
There are 65 nursing institutes, 45 run by the Government and 19 by private entrepreneurs, in the country offering three years Diploma in General Nursing and one year Diploma in Midwifery/Orthopedic. There is one College of Nursing affiliated to the University of Dhaka offering two years Bachelor of Science Degree (BSc) in Nursing and Public Health Nursing (BHW 2007). Another Nursing College will be constructed soon.
The country spends 3.2 percent of GDP on health and the per capita health expenditure is US$ 12 (NHA 2000). Detail analysis of health expenditure show that 46 percent spending is on drug retail outlets, 30 percent on curative care, and 11 percent on public health services. There is inequity in healthcare expenditure in Bangladesh. People belonging to the poorest income decile spend only 8 percent of health expenditure while the people from the richest income decile spend more than 15 percent (NHA 2000). There are also regional disparities in MOHFW spending. The per capita spending is highest in Barisal division (Taka 160) and lowest in Dhaka division (Taka 113) (PER 2007).
The Government of Bangladesh has also committed to the MDGs and working to align its national and sectoral strategies with the MDGs. The country is half way through the path and needs to rethink about its position regarding achievement of the MDGs and also about the current policy planning process both at national and sub national level. In the process of doing so the first step is to look at the trends of MDG targets in Bangladesh and identifying the most essential interventions needed to achieve the targets by2015. This report focuses on the efficiency of the health sector of Bangladesh and covers the health related MDGs and targets.
Three of the eight MDGs directly focus on health. The health related MDGs; and targets and indicators of the goals are presented in the following table.
Table 3: MDG goals, targets and indicators
2. The trends of MDG 4,5, and 6 targets in Bangladesh
This section discusses the trends of MDG indicators and analyses the variations in the indicators by gender, location of the household and division.
2.1 MDG 4 Reduce child mortality
MDG 4 is reducing child mortality. It has one target and three indicators, which are under five mortality rate, infant mortality rate and immunization against measles.
2.1.1 Under-five mortality rate
Bangladesh has achieved remarkable progresses in reducing under five mortality rate and infant mortality rate in the last two decades. The under five mortality decreased significantly from 133 to 94 per 1000 live births between 1989 and 1999 (BDHS 2007). The most common diseases among children under five were common cold/URI (19 percent), influenza (14 percent), diarrhea (13 percent), acute cough/bronchitis (10 percent) and fever (9 percent). A total of five percent of the children also suffered from immunizable diseases like measles, whooping cough, tuberculosis, poliomyelitis and tetanus (BBS 1999). The reduction in under five mortality rate from 2000 to 2003, compared to the earlier period, was not satisfactory (Figure 1). In these years the major causes of deaths among the children under five were possible serious infections1 (31 percent), ARI (21 percent), birth asphysia (12 percent), diarrhea (7 percent) and prematurity/LBW (7 percent) (BDHS 2004).
During 2003-2006 the under five mortality rate reduced from 88 to 65 at a momentous rate of 4.3 percent per year. Given this situation, the under five mortality rate will have to reduce at the rate of only 2.6 percent per year to attain the MDG target level, which is 50 per 1000 live births2, in 2015. Therefore, Bangladesh is on track towards meeting the under five mortality MDG target.
Table 4 shows that for the period of 1986-1996 and 1993-2003 on average male under five mortality rate is higher than female under five mortality rate as male infants are naturally more vulnerable than female infants. However, during 1989-1993 and 1995-2000 the average under five mortality rate was higher for girls than for boys possibly showing the relative nutritional and medical neglect of female children (BDHS).
The disaggregated data shows that under five mortality rate is considerably higher in rural areas than in urban areas. This might be due to poor access to health services in rural areas compared to the urban areas. The rural urban variation was highest during 1989-1993 and gradually reduced afterwards (Table 4).
There is also regional disparity in the under five mortality rate. Sylhet division has experienced highest under five mortality rate followed by Chittagong in all the survey periods apart from BDHS 1999-2000. Khulna division has the lowest under five mortality rate in all the reference periods (Table 5).
Under five mortality rate is also associated with some high risk fertility behaviour like, mother’s age, birth spacing and number of children in a family. Evidences show that under five children have a higher probability of dying if they are born to mothers who are too young or too old, if they are born after a short birth interval, or if they are born to mothers with high parity (BDHS 2004).
A significant proportion of children in Bangladesh is still severely malnourished. This is an important determinant of under five mortality. Among all children under five 43 percent of children were stunted and 16 percent severely stunted according to BDHS 2007. Evidences also show that 17 percent of children was wasted and 3 percent severely wasted. Weight for age results illustrate that 41 percent of the children were under weight, with 12 percent severely under weight (BDHS 2007).
2.1.2 Infant mortality rate
Infant mortality rate in Bangladesh, like under five mortality rate, also has decreased impressively from 1990 to 2006. Data on infant mortality is available from two sources, BDHS and SVRS. The infant mortality rate was 87 per 1000 live births in BDHS 1993-94 and it reduced to 66 in BDHS 1999-2003 (Figure 2).
The general diseases among the infants were common cold (22 percent), diarrhea (16 percent), fever (12 percent), and influenza (11 percent). About 7 percent of the infants were suffering from
immunizable diseases and more than 5 percent has had measles (BBS 1999). During 1995-2003 the infant mortality rate almost remained constant. The major causes of death among the infants in this period were acute respiratory infection (ARI), diarrhea, birth asphyxia, and premature
birth/LBW. A significant number of infants also died because of congenital abnormality and neonatal tetanus (BDHS 2004). Similar to the trend of under five mortality rate in Bangladesh, the infant mortality improved considerably in the period of 2002-2006. Data from SVRS 2006 show that the infant mortality rate was 45 per thousandlive births in 2006, indicating that the trend of infant mortality rate is well on track in achieving MDG target, 31 per 1000 thousand live births3, in 2015 (Table A1).
The data disaggregated by gender shows that, as expected, male children are more likely to die in infancy than female children. In the all reference periods infant mortality was higher for boys than for girls (Table 6).
The rural urban variation in infant mortality rate is also evident from the analysis. The differences in infant mortality rate by division are large. The Khulna division has the lowest levels of infant mortality rates while the Sylhet division has the highest levels of infant mortality rates in all years. However the gap between the highest and lowest infant mortality decreased from 63 per 1000 live births in 1992-1996 to 44 per 1000 live births in 1999-2003 (Table 7).
Infant mortality rate is also highly correlated to mother’s age, birth spacing and number of children in a family like the under five mortality rate, Infant mortality is likely to be higher if the mothers are less than 18 years of age or over 34 years of age at the time of delivery. Birth spacing is negatively related to infant mortality rate and birth order is positively associated with infant mortality rate (BDHS 2004).
2.1.3. Child immunization against measles
Bangladesh has improved significantly in childhood vaccination coverage, which is crucial for reducing infant and child morbidity and mortality. Under the government’s Expanded Programme for Immunization (EPI), children under one year of age should receive immunization for six vaccine-preventable diseases (tuberculosis; diphtheria, pertussis, and tetanus (DPT); poliomyelitis; and measles). Recently a Hepatitis B vaccine is also recommended as part of the immunization schedule in Bangladesh. This programme has been highly successful in increasing the immunization coverage from less than 1 percent in 1981 to 84 percent in 2006 (MICS 2006).
The data shows increasing trend of childhood vaccination coverage in the country from 1990 to 2006 except for the period 1992-96. The decline in the percentage of children age 12-23 months who received all vaccinations between BDHS1993-94 to BDHS 1996-97 was due to drop in the polio vaccination from 67 in 1993-94 to 62 percent in 1996-97. Eighty two percent of Bangladeshi children age 12-23 months were fully immunized during 2002-2006. Most of them by 12 months as recommended while 2 percent received no vaccination (Table A2).
There are also significant regional variations in proportion of childhood immunization. In Barisal and Khulna division around 90 percent of the children received all vaccine while in Sylhet only 71 percent children were immunized in 2002-2006 (Table A3).
According to MDG indicator 15, all children should be immunized against measles by 2015. Evidences show that there has been significant improvement in immunization against measles in recent years. Proportion of children vaccinated to protect against measles increased from 76 percent during 1999-2003 to 83 percent during 2002-2006 (Figure 3).
Evidences show that proportion of children immunization against measles is higher in urban areas than in rural areas for all the years from 1989 to 2006 but this urban-rural disparity is improving over time (Table 8).
Data disaggregated by divisions show that Barisal (90 percent) experienced the highest rate of childhood immunization against measles followed by Khulna (89.6 percent). On the other hand only 73 percent of the children received immunization against measles in Sylhet division (Table 9).
2.2 MDG 5 Improve maternal health
MDG 5 is to improve maternal health. This goal has one target and two indicators, maternal mortality ratio and births attended by skilled health personnel.
2.2.1 Maternal Mortality Ratio
The government of Bangladesh has attached utmost emphasis to rapidly improve maternal health by way of drastically increasing use of modern health care among all segments of the population and has been successful in progressing some of the indicators. According to MDG 5, the maternal mortality ratio should be reduced by three-quarters between 1990 and 2015. In Bangladesh Maternal mortality ratio has reduced from 574 per 100,000 live births in 1991 to 320 per 100,000 live births in 2001 (Figure 4).
In 2006 the estimated maternal mortality ratio was 290 per 100,000 live births (UNFPA). However, currently the maternal mortality ratio is expected to be higher than 290 because of the recent flood and cyclone. This rate also does not include the abortion related deaths. Yet the trend in the maternal mortality ratio shows that the country more or less is on the way to meet the
target, which is 143 per 100000 live births, by 2015.The decrease in maternal mortality ratio between 1990 and 2006 might be due to increase in the rate of receiving antenatal care and tetanus toxoid vaccine by the pregnant mothers from 1990 to 2006, as it reduces the risks for the mother and child during pregnancy and at delivery (Table A4). The proportion of pregnant mother who received at least one ANC and who received it from medically trained providers (doctor/nurse, trained midwife) almost doubled (28% in 1989-92 to 49% in 2002-06) in this period. The mothers, who received two or more tetanus toxoid vaccines during pregnancy increased from 49% in 1990-93 to 64% in 2002-06 (Table A4).
2.2.2 Births attended by skilled health personnel
Still 85 percent of delivery take place at home in Bangladesh. The proportion of birth delivered at health facility increased from 4 percent in 1989-93 to 15 percent in 2002-2006. The institutional deliveries in Bangladesh increased significantly in the last three years compared to the progress in earlier years. However, there are high rural-urban variations and regional disparities in institutional deliveries. According to BDHS 2007 the birth delivered at facilities was three times higher in urban area than that in rural area. The proportion of institutional deliveries was highest in Khulna followed by Dhaka and Chittagong (Table A5 and Table A6).
Proportion of assistance during delivery by medically trained providers was only 5 percent in 1990 and it increased to 18 percent in the period 2002-2006, at an annual average rate of 16.25 percent. It is yet considerably lower than the MDG target, which is 50 percent, in 2015 (Figure 5).
If the proportion of deliveries attended by skilled health personnel increase at the current rate then the country will not be able to achieve the MDG target and the required annual average growth rate is equal to 19.75 percent. Moreover, in addition to qualified doctors, the medically trained providers include trained nurse, midwife, paramedic, family welfare visitor (FWV), and CSBA; who are not trained enough to prevent many of the obstetric complications. In Bangladesh steps should be taken to significantly increase Institutional deliveries in order to improve maternal health to a satisfactory level. The statistics show that the proportion of delivery assisted by skilled health personnel is considerably higher in urban areas than that in rural areas. Thirty five percent of the deliveries were attended by medically trained providers in urban area and only 7 percent in rural area during 1991 to 1993. In the period of 2002-2006 the corresponding figures were 37 percent and 13 percent respectively. This trend illustrates that the rate of improvement in terms of increase in number of deliveries attended by skilled health personnel is higher in rural area compared to urban area (Table 10).
Table 11 shows the trends in percentage of delivery assisted by medically trained personnel by division. The regional disparity is very high in terms of assistance during delivery. The proportion of births attended by skilled health personnel in Khulna (26.6 percent) is about 2.5 times higher than that in Sylhet (10.9 percent). Only 13.4 percent deliveries in Barisal and 15.4 percent in Rajshahi are assisted by medically trained providers.
MDG 6 is to combat malaria and other diseases. It has two targets and seven indicators, which are discussed below.
2.3.1 Prevalence and prevention of Malaria
Malaria is one of the major public health problems in Bangladesh and 13 districts, out of total 64 districts, belong to the high-risk malaria zone. Over 98 percent of all malaria cases in the country are concentrated in these districts. In 2007 there was 50634 reported cases of malaria and 239 deaths due to malaria. The case fatality ratio was 472 per 100000 in the same year (Table 12).
The trend of the malaria cases per 100,000 shows that the disease’s prevalence increased from 43 in 2000 to 47 in 2002, which is the highest prevalence in the period of 2000 and 2005. After 2000 it reduced to 42 and remained almost same in 2003 and 2004. Then the prevalence of malaria reduced drastically in 2005 to 34 cases per 100,000 populations (Figure 8).
Figure 8: Notified cases of malaria per 100,000 population
Changes in the malaria death rate per 100,000 population shows similar trend as the trend in reported cases of malaria. Malaria mortality rate was highest (0.44) in 2002. It declined sharply after 2002 and in 2005 the malaria mortality rate was 0.34 per 100,000 population. The total number of deaths due to malaria was 1282 in 2002 and 537 in 2007 (Figure 9).
The statistics indicate that Bangladesh has achieved success in halting and reversing the spread of malaria to some extent after 2002. Between the period of 2002 and 2005 the malaria prevalence decreased at average annual rate of 9.22 percent and malaria mortality rate also reduced by 7.58 percent. If the country maintains the rates of reduction consistently than it will be on track to achieve the MDG targets by 2015. The status and trends of prevention of malaria cannot be analyzed due to limitation of the available data.
2.3.2 Prevalence and prevention of Tuberculosis
In the course of time the country has made significant progress in halting and reversing the spread of tuberculosis (TB) during the last two decades. In Bangladesh TB services were mainly curative and based in TB clinics and TB hospitals before the Second Health Population Plan (1980-86). During this plan TB services was expanded to 124 UHCs and were operationally integrated with leprosy during the Third health and Population Plan (1986-91). The National Tuberculosis Control Program (NTP) adopted the DOTS Strategy during the Fourth Population and Health Plan (1992-1998) and was integrated into Essential Service Package under the Health and Population Sector Programme (HPSP) in 1998. Under the current Health, Nutrition and Population Sector Program (HNPSP) TB control is also recognized as a priority and at the end of 2006 the entire country was covered under the DOTS strategy (NTCP 2007).
The TB prevalence rate has reduced from 406 per 100,000 per year in 2006 to 391 in 2007. TB mortality rate also reduced in this period from 47 to 45 per 10,000 per year (NTCP and WHO, Bangladesh). The data on MDG indicator 24a, which is TB detection rate under DOTS, show that the country has been highly successful in identifying the TB cases from 21% in 1994 to 71% in 2006 and well on track towards 100% detection rate by the year 2015. the most significant improvements in identifying TB patients under DOTS were between 2002 (34 percent) and 2006 (71 percent) , the detection rate almost doubled in this period (Figure 10 and Table A7).
The country has made good progress in Tuberculosis treatment under DOTS as well. The tuberculosis treatment success rate under DOTS gradually and consistently increased from 73 percent in 1994 to 92 percent in 2006. Given this phenomenon Bangladesh is well on track towards achieving the MDG target which is 100 percent treatment success rate (Figure 11 and Table A8).
Though Bangladesh has considerably succeeded in achieving most of the MDG targets challenges still remain in improving some indicators. These are
1. The nutritional status of children and women in Bangladesh is very poor and needs special attention in order to improve the overall health status of the population. Despite various interventions designed under National Nutrition Project (NNP) low birth weight and malnutrition continue to be important causes of infant and under five mortality. A significant proportion of pregnant women is also iodine deficient and develops night blindness during pregnancy.
2. Improvement in births attended by skilled health personnel is not satisfactory. Only on average 480 CSBA are produced annually by the Obstetrical and Gynaecological Society of Bangladesh (OGSB) and a total of 3000 have been trained so far compared to the target 13,000 (MTR 2008). Rapid training of skilled health personnel, increase in infrastructure and cautious monitoring is needed if the country wants to reach the target by 2015.
3. The availability of comprehensive Em OC services in public facilities, specially at district level and below, is also not up to the target level. One important intervention of the Maternal Health Strategy 2001 was to train medical officers in obstetrics or anaesthesia (1 year diploma level or 4 months Em OC training) and place them in functional teams at District and Upazila facilities. So far 206 obstetrics and 118 anaesthesia have been trained. Moreover, only 57 percent of the obstetrics and 69 percent of the anaesthesia are appointed in designated positions with frequent failure to retain both the obstetric and the anaesthesia to perform caesarian sections in a facility due to variety of reasons (MTR 2008). The Government should take steps to overcome this problem with giving special emphasis on reducing absenteeism in rural areas.
4. Limitation of the data on HIV/AIDS prevalence is a major obstacle in tracking the MDG targets. The gender and regional disparities in awareness and knowledge about prevention of AIDS among the citizens should be reduced.
5. In Bangladesh still now there is very little knowledge about the MDGs in the grassroots level. Until and unless the concept is well understood by the mass people, the achievement of the MDGs might be hampered.
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