Attaining MDGs: Government-NGO collaboration

In the bureaucracy and high-level jobs, which entail visibility and exercise of authority, women's presence is negligible. The ground realities must conform to and reflect the spirit of gender equality and non-discrimination as enshrined in the Constitution. Addressing underlying socio-cultural factors that make women vulnerable is a challenge that requires immediate attention and long-term commitment.
Parliament has passed a number of laws against child marriage, acid-throwing, dowry, cruelty and violence against women and children with provision of speedy and summary trials and exemplary punishment. Nevertheless, the effective implementation of these laws and policies remains a major challenge.
Strengthening the capacity of the national statistical system and the ministries in generating and reporting data, especially data disaggregated by gender is identified as a major challenge confronting the government.
MDG 4, 5 & 6: Bangladesh has already met the target of reducing under-five mortality rate. Against the target of achieving 48 per 1,000 live births in 2015, it has already achieved 44 per 1,000 live births in 2011. The target of reducing the infant mortality rate is also on track. The maternal mortality ratio in 1990 was 574 per 100,000 live births in Bangladesh. However, according to the Bangladesh Maternal Mortality Survey (BMMS), maternal mortality declined from 322 in 2001 to 194 in 2010, a 40 per cent decline in nine years. The average rate of decline from the base year has been about 3.3 per cent per year, compared to the average annual rate of reduction of 3.0 per cent required for achieving the MDGs in 2015. The BMMS 2001 and 2010 show that overall mortality among women in the reproductive ages has consistently declined during these nine years.
Bangladesh has performed well in halting communicable diseases under this goal. Available data show that the prevalence of HIV/AIDS in Bangladesh currently is less than 0.1 per cent and thus is still below an epidemic level. There was a significant improvement in the reduction of malarial deaths in the country over the years. Bangladesh has already achieved the MDG targets of TB case detection and cure rates.  

A fundamental factor in better health outcomes in Bangladesh has been political continuity. This political commitment has transcended party politics and, despite changes in the political landscape and in key actors, many policies have been sustained for a significant period of time. Another factor in Bangladesh's success has been the government's ability to collaborate with non-governmental actors. The government views NGOs (non-governmental organisations) as a way of extending their reach, particularly in the implementation of national strategies and policies. NGOs have developed strong capacity and innovative delivery models that have prompted a two-way learning exchange between government and non-governmental entities.
Policies that have been pivotal in improving the population's health include the Population Policy (1976), which pioneered a community-based intervention that brought family planning services, including contraceptives and education, directly to individual households. The Drug Policy (1982), which included categorising and procuring essential medicines and the establishment of the Essential Drugs Company Limited. This led to domestic production of drugs appropriate to local needs, saving the country approximately US$ 600,000 million.
Finally, the Sector Wide Approach (SWAp) (1998) has reduced duplication and financial waste in the health sector and has simplified the process of programme development and implementation.

LOW-COST INTERVENTIONS: Bangladesh is a global leader in developing low-cost interventions such as the use of zinc in the treatment of childhood diarrhoea, oral rehydration solution, delivery kits, tetanus vaccinations for pregnant women, and iodised salt. These interventions have been rolled out locally, scaled up and even used in other developing countries. Bangladesh's strong emphasis on childhood immunisation has resulted in almost universal access.
Finally, non-health, poverty reduction initiatives have played an important factor in Bangladesh's progress. Participation in microcredit programmes has been connected to better child survival and the expansion of electricity coverage, and road infrastructure has assisted the roll out of immunisation programmes to rural areas. An increase in net primary education enrolment has resulted in improved literacy rates. The economic and social position of women has improved in line with education, income-generating activities, access to microfinance and employment in the garment industry.
Bangladesh's disaster preparedness has shown the world that it has the ability to plan, coordinate and implement crisis action. This demonstrates the improving governance structures across public sectors.
With regard to HIV/AIDS, Bangladesh followed a systematic process to face the challenge. The National AIDS Committee was formed in 1985. The National HIV/AIDS Programme was started in 1998. The National HIV/AIDS Policy was adopted in 2000, the National HIV/AIDS related BCC strategy developed in 2001, the National AIDS and STD Control and Prevention Program initiated in 2002 and the National Strategic Planning 2004 to 2010 adopted in 2005.
Control of AIDS was included as a strategy in the Poverty Reduction Strategy Paper (PRSP) document in 2005 and a training manual was developed for all categories of staff related with AIDS services.
According to the 2013 UN MDGs report, worldwide, the mortality rate for children under-five dropped by 41 per cent (from 87 deaths per 1,000 live births in 1990 to 51 in 2011). Despite this enormous accomplishment, more rapid progress is needed to meet the 2015 target of a two-thirds reduction in child deaths. South Asia has achieved reductions of 39. With regard to Maternal Mortality Ratio, globally, the MMR declined by 47 per cent over the past two decades, from 400 maternal deaths per 100,000 live births in 1990 to 210 in 2010 (South Asia 64 per cent).
ADVANCES ON HEALTH INDICATORS: Bangladesh has made enormous advances with basic population and health indicators, which are now at par with, or better than, its neighbours who have higher per capita income. Bangladesh's health gains have been made with relatively low total health expenditure when compared regionally, 3.4 per cent of GDP (gross domestic product) or US$ 12 per capita in 2007. Compared with other countries in the region, Bangladesh has among the longest life expectancy for men and women, the lowest total fertility rate and the lowest infant, under-5, and maternal mortality rates. Between 1994 and 2011, life expectancy increased from 58 years to 69 years. There has been a dramatic decrease in total fertility among women aged 15-49 years. The international comparison of Bangladesh with respect to health issue among its neighbouring countries is shown in Table 5 and 6.
The series of inter-linking factors that have made Bangladesh's health system successful in realising better health for its population can be expressed by four words all beginning with C - referred to as the 4 Cs. They are Capacity (the individuals and institutions necessary to design and implement reform), Continuity (the stability that is required for reforms to succeed), Catalysts (the ability to seize windows of opportunity) and Context (the ability to take context into account in order to develop appropriate and relevant policies).
Lack of quality services is the major bottleneck in facility-based child and newborn healthcare. Quality service is frequently inadequate in health facilities because of insufficient number of skilled or trained personnel. Moreover, a lack of routine supportive supervision and monitoring is a major cause of poor quality of services. Reducing the neonatal mortality remains a challenge and which may also impact on infant and under-5 mortality. Thus high evidence based intervention for newborn services need to be scaled up rapidly across the country.
Adequate availability of essential drugs is a major impediment to providing relevant services. The achievements of universal health coverage, the removal of rural-urban, rich-poor and other form of equities and the provision of essential services for the vast majority of the population are the key concerns for which effective strategies are to be adopted. Human resource capacities remain a major obstacle to quality health service delivery. Key challenges include acute shortage of manpower of all categories, insufficient skills-mix and insufficient numbers of health workers especially in the rural areas.
Despite expansion of physical facilities, use of public health facilities by the poor remains low due to supply-side barriers such as lack of human resource capacities, inadequate drug supplies and logistics, and management inadequacies. Underlying socio-cultural factors contribute to the lack of knowledge about maternal health complications among women and families. Social marginalisation, low socio-economic status of women and lack of control over their personal lives make it difficult for many women to seek reproductive health care. Other contributing factors include early marriage and child bearing, poor male involvement in reproductive health issues and poor community participation in issues relating to maternal health.
MDG 7:    At present there is only 13.20 per cent of land in Bangladesh having tree cover with density of 30 percent and above and the area having tree cover is much lower than the target set for 2015. Since 1991, there has been a steady increase in CO2 emission in Bangladesh because of increasing development interventions and activities. In 2012, the emission was 0.32 tonne per capita. At present the proportion of terrestrial and marine areas protected is 1.83 percent which is much less than the target of 5 percent. Data show that without considering the issue of arsenic contamination, 97.9 percent of the population of Bangladesh is using improved drinking water source; 55.9 percent of population is using improved sanitation in 2012-2013. However, access to safe water for all is a challenge, as arsenic and salinity intrusion as a consequence of climate change fall out will exacerbate availability of safe water especially for the poor.   
 Prof. Shamsul Alam is Member, General Economics Division (GED), Bangladesh Planning Commission.
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