Though I belong to the field of education, my interest travels round the international politics along with social and economic problems as they are intricately linked with the life of humans. And as a columnist all the incidents and happenings taking place around titillate me. My interest in these fields is coupled with the encouragement to go through the Lancet Series which accommodates the success stories of health situation of Bangladesh. I have found these series as valuable documents of the success stories in the health sector of Bangladesh. Without any doubt these series will enrich the people roaming in the area along with all the conscious and responsible professionals and citizens.
The rich and influential Lancet series of Mexico, China and South Africa inspired Dr Mushtaque Chowdhury, principal author of a Lancet Bangladesh Series paper, to publish the same sort of medical journal in Bangladesh. The series has advanced a roadmap for moving forward. The Call to Action has recommended a five-point agenda such as: develop a national human resource policy and action plan, establish a national insurance system, build an interoperable electronic health information system, invest to strengthen the capacity of Ministry of Health and Family Welfare and create a supra-ministerial council on health.
Some success stories and origins of their success have further been revealed through this series. The use of oral rehydration therapy (ORT) is an example of rigorous research developed at the International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B) and implemented by BRAC which took this discovery to every household through an innovative programme, Bangladesh has now the highest ORT use rate in the world. Important contributions of Bangladesh research shaping national programmes include projects on neonatal tetanus immunization, measles vaccination and child survival and DOTS delivery for the management of tuberculosis. Family planning is another important issue where the IDDDR,B has made substantial contribution. Development of innovative models adopted nationally made Bangladesh a successful example for family planning and control of population growth.
Research in Bangladesh has been limited to a few organizations. A search of articles published between January 2003 and August 2013, showed that six organizations - ICDDR,B (1,632 publications) BSMMU (194), BRAC (163), Bangladesh Institute of Research and Rehabilitation in Diabetes (BIRDEM 157), BRAC University (124) and University of Dhaka (118) - contributed 89 per cent of the publications.
Mushtaque Chowdhury has described the shift from the priority of managing infectious diseases to where we are now, and focuses on public health programs to mitigate the effect of natural disasters and the burgeoning of non-communicable diseases, especially in the country's urban areas.
The quality of both public and private health service is often poor. It is not uncommon to hear accounts of people being given inappropriate treatment such as antibiotics of diarrhea at great financial cost to the patient. It took Thailand 28 years but the results have been extraordinary and are a model for other countries in Asia.
BRAC has a central role in providing health, education and microfinance services to help alleviate poverty. In most villages of Bangladesh BRAC has more than 120,000 people and has trained 105,000 community health workers. "From the health perspective one of the highlights has been the role of community health workers in the jointly led government-BRAC DOTS programme for tuberculosis, and in the scale up of distribution of oral rehydration therapy across the country in the past two decades. Dr Chowdhury adds: "Without doubt BRAC will continue to have a role alongside the government on the road to UHC. In 2004, Chowdhury helped co-found BRAC University's James P Grant School of Public Health and as its Dean for five years he was instrumental in creating its Masters in Public Health porgramme and the students studying here will be able to make practical contribution to ongoing public health strategy. Outside of Bangladesh, Chowdhury has considerable expertise of the wider Asian health context, having previously worked for the Rockfeller Foundation as Senior Adviser in cross border disease surveillance projects in the Mekong countries of southwest Asia. And he's been involved with seminal global health initiatives, notably the UN Millenniums Project Taskforce.
In the Series, Sir Fazle Hasan Abed, the chairperson of BRAC, says, "My country, Bangladesh, has seen a health revolution in my lifetime. Maternal mortality has decreased by 75% since 1980, infant mortality has more than halved since 1990, and life expectancy has risen to 68.3 years, higher now than in neighbouring India and Pakistan. Such rapid changes in health have almost no historical precedent. Save perhaps for Japan's breakneck modernism following the 19th-centruey Meiji Restoration."
During the 1980s when BRAC began to implement this health solution on a national scale, it proved to be an enormous undertaking. BRAC turned to poor rural women to undertake the task and importantly we worked on their terms, many of the women, quite understandably, did not understand the concept of "a half litre of water, for home-made oral rehydration therapy, we developed a training programme that helped women to measure the correct solution by scratching marks on everyday household. Only 6% women used the knowledge of oral rehydration therapy, we retrained the trainers and discovered that 18% of women in the programme areas used oral rehydration therapy. BRAC continued the programme and by 1990 we had reached 70% of households in the country. Today nearly every Bangladeshi woman understands and uses oral rehydration therapy."
BRAC saw opportunity in every failure and learned that gender equality and women's rights could drive advances in health. BRAC now has perhaps the largest cadre of non-governmental organization-trained, front-line health workers in the world, with more than 100,000 self-employed community health workers who are incentivised to provide basic curative and preventative care to their families and neighbours.
In most countries health reforms begin with some kind of idealised policy framework. But the Bangladesh Government instead created an environment for pluralistic reform in which many participate in the health sector, including non-governmental organizations and the private sector, were allowed to flourish. This multiplicity of health sector could have produced confusion. But, as this Lancet Series shows, pluralism had positive effects. The government's willingness and flexibility to allow experimentation in service delivered to rapid health improvements. Writing earlier this year, as part of the series of country case studies on good health at low cost, Dina Balbanova and her colleagues concluded that 'Bangladesh has made enormous heath advances and now has the longest life expectancy, the lowest total fertility rate and the lowest infant and under-5 mortality rates in South Asia, despite spending less on heath care than several neighbouring countries.'
The success of our health sector can be attributed to the reasons mentioned here. The ICDDR,B pioneered important work in family panning, immunization, and treatment of diarrhea in an open culture of innovation. Importune investments were made in vaccination coverage, demographic health survey, maternal health and tuberculosis treatment. Impact evaluations were completed. Research provides reliable knowledge for health-system strengthening. Bangladesh's aptitude for innovation led to community-based approaches and partnerships that enable the country's locally produced research findings to be delivered at scale. Bangladesh has achieved many of its health gains not only because of the creativity and steadfast effort of its people, but also through the support of external partners. That culture still exists.
Mobilisation of communities, gender equity and a commitment of universal health coverage could make a big difference elsewhere. One example is tuberculosis treatment. By deploying community health workers, Bangladesh has achieved high treatment coverage and greater than 90% cure rates. South Africa has already copied this model for treatment of HIV as well as tuberculosis. Much of Bangladesh's success has centred on progress towards the Millennium Development Goals. Less successful have been improvements in maternal and child malnutrition and access to primary care. The future looms heavily in a small country with such a huge population creating deep poverty and inequality.
Dr Chowdhury hopes the policymakers will take the analysis and recommendations seriously and implement them in the greater interest of the nation. Health agenda finds its place at the bottom of priorities in the election manifesto of our political parities. Chowdhury hopes this series will sensitise to rethink the manifestos of our political parties as is a practice in Thailand for ensuring pro-people policies on health.
The writer is Program Manager: BRAC Education Program and Vice-president: Bangladesh English Language Teachers Association (BELTA). Email: [email protected]
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