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Health Policy, Programmes and System in Bangladesh

Article in South Asian Survey · September 2008

DOI: 10.1177/097152310801500206

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 HEALTH POLICY, PROGRAMMES
AND SYSTEM IN BANGLADESH:
ACHIEVEMENTS AND CHALLENGES
Ferdous Arfina Osman

Despite being a resource poor country, Bangladesh has achieved impressive health gains which
make it an example for other developing countries. Over the last decades key health indicators
like life expectancy and coverage of immunisation have improved significantly while infant
mortality, maternal mortality and fertility rates have dropped considerably. But most of these
achievements are mainly quantitative while qualitative improvement is negligible. Poor access
to services, low quality of care, high rate of maternal mortality and poor status of child health
still remain as challenges of the health sector. This article reviews the health programmes
undertaken since independence and the system itself to see which aspects of the policy have
contributed to these achievements and challenges. The findings show that the healthcare
plans and policy have actually helped to expand services causing quantitative advances while
managerial weaknesses and governance problems are the main factors inhibiting qualitative
improvement. Finally, the article puts forward some suggestions to address these challenges.

Bangladesh, a country with a huge population (140 million) living in a small area
(144,000 sq. km.), low per capita income (US$ 460) and low literacy (52.8 per cent),
has achieved remarkable improvement in its health status. Bangladesh’s health sys-
tem is the outcome of many policy shifts and changes. At the time of independence,
Bangladesh had an urban-based, elite-biased and curative health system which was
extremely limited in terms of medical facilities and services. With the passage of time,
Bangladesh’s health system has been refined to a large extent by shifting the policy
focus from urban to rural and curative to preventive care. Such a policy shift has pro-
duced many tangible outputs which are considered by many as a lesson for other
developing countries. There is perhaps no country in the world that has made more
progress in achieving health for all with fewer resources during the past three decades

Acknowledgement: The author acknowledges the comments and suggestions received from an anony-
mous referee of South Asian Survey.

Ferdous Arfina Osman is Associate Professor, Public Administration, University of Dhaka, Dhaka,
Bangladesh.
South Asian Survey 15 : 2 (2008): 263–288
SAGE Publications Los Angeles/London/New Delhi/Singapore
DOI: 10.1177/097152310801500206
 264/Ferdous Arfina Osman

than Bangladesh (Perry 2002). Bangladesh’s Infant Mortality Rate (IMR) and Total
Fertility Rate (TFR) have dropped significantly while life expectancy and immunisation
coverage have increased considerably. A combination of efforts of external donors and
the Government of Bangladesh (GoB) has helped the country achieve this impressive
level of success.
Despite the achievements, there remain many challenges. Making health services
(both basic primary and curative care) accessible to the poor is still a challenge. On the
other hand, high rates of maternal mortality and child malnutrition indicate that issues
of quality have not been properly dealt with. Based on secondary literature (policy,
plan and programme documents, review reports and research reports), this article at-
tempts to analyse the existing health system and the policy changes contributing to
these achievements and the challenges. It also endeavours to put forward some policy
options to address the challenges.
The article is organised into four sections. Section one reviews the health policies and
programmes since independence, their main thrusts and strategies and their impact on
the system. Section two presents an overview of the health system as a by-product of the
policies and programmes. Section three analyses the impact of the health system in terms
of its achievements and section four highlights the major challenges in Bangladesh’s
health sector with an accompanying analysis of their causes and remedies.

I BANGLADESH HEALTH POLICY: GOALS AND STRATEGIES

The National Health Policy of Bangladesh was formally approved by Parliament in

2000. Prior to this, the healthcare system had been running under the guidance of the
long-term Five Year Plans. Two population policies were adopted in 1976 and 2004.
In addition to these policy documents there have been two sector strategies: Health
and Population Sector Programme (HPSP) and Health Nutrition and Population
Sector Programme (HNPSP). Broadly, the goals of all these policy documents are to
reduce population growth, ensure access to primary healthcare services and provide
maternal and child healthcare services to the poor and disadvantaged sections of the
population.
The health sector started its operation with an underlying emphasis on population
control. Along with reducing population growth, the goal of the health sector was to
provide ‘minimum’ healthcare to the entire population with particular emphasis on
the poor and disadvantaged. With this objective, the First Five Year Plan (1973–78)
adopted the strategy of establishing the health infrastructure along with capacity
building of health professionals. Accordingly, the construction of health centres at
the union level and health complexes (31 bedded hospitals) at the thana (sub-district)
level began. In the meantime, the first population policy was adopted in 1976 and
the successive Five Year Plans were closely influenced by this policy. The key strategy
of the population policy was to provide comprehensive health and family planning
services mainly through clinics and female field workers, with a strong emphasis on

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 Health Policy, Programmes and System in Bangladesh/265

doorstep services to rural women (Bangladesh Health Watch 2006). The policy also
encouraged private sector and non-governmental organisation (NGO) participation in
the programme. In 1977 the government felt the need for private sector participation
in health service delivery which was reflected in the interim Two Year Plan (1978–80)
and in the Second Five Year Plan (1980–85). The Plan encouraged the private sector
and NGOs to share some responsibilities for providing healthcare services to the bulk
of the population. As a result, private healthcare facilities started increasing rapidly after
1982 when government restrictions on private laboratories, clinics and hospitals were
relaxed (Khan 1996) and some vertical programmes started to be implemented through
public-private-NGO partnership. The Second Plan specified its focus on ‘primary
healthcare’ as a means of providing ‘minimum healthcare’ to all and continued emphasis
on the construction of health infrastructure to achieve this goal. The Third Five Year
Plan (1985–90) added a new dimension in health services by focusing on Maternal
and Child Health (MCH) as an effective means of population control. Accordingly,
some MCH programmes like Expanded Programme on Immunisation (EPI), Vitamin
‘A’ distribution and control of diarrhoea were intensified. The Fourth Five Year Plan
(1990–95) also emphasised MCH services along with a focus on primary healthcare.
The Fifth Five Year Plan (1997–2002) added certain new strategic issues under the
influence of the Health and Population Sector Strategy (HPSS) adopted in 1997.
HPSS gave the health sector a new direction towards efficiency and cost-effectiveness
by advocating certain institutional and governance reforms. HPSS fed into the Fifth
Five Year Plan (1997–2002) and the National Health Policy approved on 14 August
2000. As a result, these three documents are very similar in their strategies. In 1998
the operational plan of HPSS, called the Health and Population Sector Programme
(HPSP), was launched.
HPSP (1998–2003) emerged as a major reform programme, which gave four big
boosts to the health sector:

1. A transition from a projectised bifurcated approach to sector-wide approach

(SWAp) of management through which all the sectoral projects were planned
and managed in an integrated manner instead of running vertical projects.
2. Unification of the health and family planning wings of the Ministry of Health
and Family Welfare (MoHFW) to avoid duplication and overlapping of MCH
services and to provide health and family planning services in a package to en-
sure efficiency gains.
3. To achieve the greatest health and impact per Taka spent and to serve the most
vulnerable groups like women, children and poor, an Essential Service Pack-
age (ESP) containing five basic maternal, child and public health services was
introduced which was delivered from one single service point, called ‘one stop
shopping’. The objective of introducing this was to make access easier to multiple
health services for clients (for multiple family members, i.e., a mother and her
young child or children) during a single health facility visit. One-stop-services

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 266/Ferdous Arfina Osman

were provided in a three-tiered fixed facility, i.e., Upazila Health Complexes

(UHCs) at the upazila (sub-district) level, the Union Health and Family Welfare
Centres (UHFWCs) at the union level and community clinics at the village
level. Bangladesh is administratively divided into 6 divisions, 64 districts, 481
upazilas (designated as thana till 1982) and 4,498 unions.
4. Construction of community clinics for every 6,000 population, which was
an effort to take the healthcare service structure closer to the people at the
grassroots.

The National Health Policy approved in 2000, having been closely influenced by
the HPSS, pronounced the same strategies as those mentioned above to achieve the
following goals:

1. To reach basic health services to the people at all levels, particularly to the
poor.
2. To ensure the availability of primary healthcare services at the union and upazila
levels.
3. To improve maternal and child health and reproductive health services.
4. To strengthen family planning services.

Implementation of HPSP started before the National Health Policy was enunciated.
Thus, HPSS is one of the most influential health policy documents in Bangladesh.
HPSP ended in June 2003, producing little improvement in Bangladesh’s health
indicators. Although the programme had some successes in introducing certain funda-
mental changes in planning, management and the pattern of service delivery, the
outcome and impact of the programme was not up to expectation. Table 1 shows a
steady decline of Maternal Mortality Rate (MMR) and Infant Mortality Rate (IMR)
from the pre-HPSP (1996/97) to post HPSP (2003) period, while life expectancy and
the Total Fertility Rate (TFR) remained constant. On the other hand, immunisation
appears to have increased considerably and delivery care by trained personnel also im-
proved, but less dramatically. Perceptions of health improvement tell a different story.
According to the third Service Delivery Survey (SDS) in 2003, rates of satisfaction
and utilisation of services decreased significantly. The performance of HPSP was also
very poor in terms of general access to ESP services. Streatfield et al. (2003) report
that while in the pre-HPSP period the percentage of total population having access
to one or more ESP components was 13 per cent (at public facilities), it only slightly
increased to 14 per cent, although the target for 2003 was 80 per cent.
Despite good initiatives, HPSP failed to improve health indicators as desired
due to a lack of good governance and political commitment. Studies show that the
partial unification of health and family planning wings (only at the upazila level
and below), withdrawal of domiciliary services, managerial inefficiencies including

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Table 1
Improvement of Health Status in Bangladesh Over Nearly Four Decades of Independence

1970s 1980s 1990s 2000s

Indicators (1978–80) (1990) (1996–97) (2003) 2007
A B C K
Population growth rate (in %) 2.7 2.10 1.74 1.54 NA
Infant Mortality Rate (per 1,000 live births) 150A 110B 77C 66K 52H
Under-5 Mortality Rate (per 1,000 live births) 229A 110B 116C 94K 65H
Maternal Mortality Rate (per 1,000 live births) 10.00A 5.7C 4.1C 3K NA
Life expectancy at birth (in years) 47A 53B 58C 60K 65.4J
Total Fertility Rate (per woman aged 15–49 5.04A 4.3B 3.3C 3.3F 2.7H
years)
Delivery care by trained personnel (in %) 2A 5B 8C 12K 18H
Fully immunised children (12–23 months) 2A 75B 66C 73G 82 H
(in %)
Under-5 Underweight (in %) NA NA 56D 48E 46H
Note: NA: Not available.
A
Sources: Second Five Year Plan (1980–85); B Fourth Five Year Plan (1990–95); C Fifth Five Year Plan
(1997–2002); D Mitra et al. 1997; E NIPORT et al. 2001; F NIPORT et al. 2003; G NIPORT
et al. 2005; H NIPORT et al. 2007; J BBS 2006; K IMED 2003.

inadequate provision of drugs and supplies due to a complicated procurement system,

poor supervision, erratic staff availability and lack of political as well as institutional
commitment were the major impediments to achieve the expected results from HPSP
(IMED 2003; Normand et al. 2002; Osman 2005).

HNPSP (2003 –201 0)

With the expiry of HPSP, GoB has undertaken another gigantic programme called
the Health, Nutrition and Population Sector Programme (HNPSP) for the period
2003–2010. HNPSP is basically a continuation of HPSP with some modifications
and additions in its concepts and components. For instance, it has incorporated nu-
trition in its programme activities and proposed to continue with the earlier sector-
wide approach, the Essential Services Package (ESP) and the client-centred focus on
a service delivery system with some modifications (MoHFW 2003, 2005). Major
reforms under HNPSP include:

1. Strengthening public health sector management through pro-poor targeting

measures and sector-wide approach.
2. Health sector diversification implying a shift from the government’s role as a
‘provider’ of services towards a ‘purchaser’ of services, thus establishing formal
collaborations between the public and private sectors called Public Private Par-
tnership (PPP).
3. Stimulating informed demand for essential services by poor households through
demand-side financing options (DSF). DSF aims to increase utilisation of
health services by the poor by subsidising the cost of drugs, tests and transport

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 268/Ferdous Arfina Osman

to the health facility, since utilisation is greatly discouraged due to high out-
of pocket spending for these purposes. It includes introduction of voucher
schemes enabling poor pregnant women to access private for-profit facilities
for institutional deliveries.
4. The significant modifications have been a U-turn to the previous system of
bifurcated health and family planning wings of the Ministry and restoration
of domiciliary services.

HNPSP has a strong emphasis on improving access to and utilisation of essential

services particularly maternal health services by the poor. As Table 1 shows, HNPSP
has achieved impressive gains in reduction in IMR and the under-5 mortality rate
(U5MR). Bangladesh has even overtaken India in reducing childhood and infant
mortality (MTR 2008). This is most likely due to the expansion of comprehensive
coverage of health related interventions (like Vitamin A distribution, EPI coverage
and diarrhoea management) and other related developments like improved primary
education of girls, better water supply and increased access to sanitation. Table 1 shows
that the percentage of births attended to by skilled personnel improved from 12 per
cent in 2003 to 18 per cent in 2007, fertility rate slightly reduced from 3.3 in 2003 to
2.7 in 2007 and IMR declined from 65 per 1,000 live births in 2003 to 52 in 2007.
MMR also declined from 3 per 1,000 live births in 2003 to 2 in 2007.
HNPSP could have produced more positive results had it not suffered from slow
implementation in the initial years. The first Annual Programme Review of HNPSP
held many internal governance problems responsible for the slow implementation of
the programme. The programme received momentum only from 2007. Improved
governance and institutional commit ment are responsible for the advances seen in
the last year (MTR 2008). Despite significant achievement of HNPSP in improving
health indicators, inequity in access is still quite large. Progress in improving maternal
health is also slow as reflected in high rates of home delivery (85 per cent) managed
by unqualified providers. MTR (2008) has identified governance and institutional
weaknesses (a bifurcated structure of the MoHFW, inefficient management of human
resources, a lengthy procurement system and lack of monitoring and evaluation) as
the reasons for poor achievement of HNPSP in maternal health.
The sequencing of major policy and programmatic developments since independence
and their impact on the health system are given in Table 2. These policy changes and
innovations have shaped the present health system of Bangladesh.

II HEALTH SYSTEM IN BANGLADESH: AN OVERVIEW

The health system of a country defines how healthcare is provided, financed and
regulated. Roberts et al. (2004) have identified five ‘control knobs’ of a health
system—financing, payment, organisation, regulation and behaviour—which are the
significant causal determinants of health system performance. These are factors that

South Asian Survey 15, 2 (2008): 263–288

 Table 2
Major Policy and Programmatic Developments in Bangladesh since Independence
Year Policy/Programmes Major Actions or Innovations
1973–78 First Five Year Plan (1973–78) i) Priority to population control
ii) Provision of ‘minimum healthcare’ to the entire
population
iii) Develop and expand training facilities
1976 The Population Policy i) Targeted towards population control for achieving
the demographic goal of slowing population growth
ii) Comprehensive health and family planning services
through clinics and domiciliary workers
iii) Encouraged private sector and NGO participation
in family planning programme
1980–85 Second Five Year Plan (1980–85) i) ‘Health for all by the year 2000’ through Primary
Healthcare approach.
ii) Public-private partnership for health and family
planning services emphasised
1985–90 Third Five Year Plan (1985–90) Maternal and child health was emphasised as a strategy toIntensification of EPI, control of diarrhoeal disease,
provide PHC and population control services
Changes in the Health System
A separate administrative structure for family planning
(1975), health and family planning bifurcated
The strategy of establishing health infrastructure in all
rural thanas by establishing a Thana Health Complex
(presently known as upazila health complex) with 31
beds in all rural thanas/upazilas
Establishment of Medical Colleges and hospitals, training
institutes
Various social and legal measures and system of
incentives and disincentives were undertaken to reduce
population growth
A new cadre of female field workers was created to
provide domiciliary services, which increased easy access
to free-of-cost health, and family planning services
Public-private-NGO partnership developed in health and
family planning services
Target was fixed to construct THCs in each rural
thana and Union Health and Family Welfare Centres
(UHFWCs) in each union by 1985
Private health facilities started to grow rapidly and NGOs
became active partners in many health programmes
Vitamin ‘A’ distributionUHCs and UHFWCs were to
deliver both family planning and MCH services
(Table 2 continued )
(Table 2 continued )

Year Policy/Programmes Major Actions or Innovations Changes in the Health System

1990–95 Fourth Five Year Plan (1990–95)
19 August 1997 The Health and Population Sector
Strategy (HPSS), a policy document
MCH and PHC services were emphasised
i) Priority in the allocation of resources to an Essential
Service Package of public health, reproductive health
and limited curative care
Comprehensive health and family planning service
delivery was focussed on
Introduction of ESP to make health services cost effective

1997–2002 Fifth Five Year Plan
28 June 1998 Health and Population Sector
Programme (HPSP) (1998–2003)
(The operational plan of HPSS)
14 August 2000 Health Policy
ii) Unification of health and family planning wings
of the Ministry of Health
iii) Provision of a one-stop service delivery
iv) Transition from a project driven approach to a
sector-wide approach
Partial unification of health and family planning wings
at the thana level and below instead of top to bottom
unification
All the basic services under ESP are being delivered
through one-stop service centres at the upazila
(UHCs), Union (UHFWC) and partially at the village
(Community Clinics) level
In planning, the newly introduced SWAp enfolded all
the relevant programmes as a single entity rather than
having separate plans for individual projects. This led to
a drastic reduction in the number of line directors from
126 to only 29
In implementation, all sources of funding including
GoB, donors and households was considered as sectoral
resources as a whole
2003 Health, Nutrition and Population Sector i) Health sector diversification, through the
Programme (HNPSP) development of new delivery channels for publicly
and non-publicly financed services (PPP)
(2003–2010)
ii) Stimulating informed demand for essential services
through demand side financing (DSF)
iii) Continue sector-wide approaches
iv) In addition to the previous five components the ESP Scope of ESP has been broadened
has added nutritional aspect and control of emerging
communicable diseases such as dengue, arsenic
v) Back to the previous system of bifurcated health
and family planning wings of the Ministry of Health
vi) Continuation of doorstep delivery of services
Source: Author’s analysis.
Voucher scheme being implemented with provisions for
antenatal and birthing care at home and in public or
private sector facilities
Outsourcing of management of Union Health Centres
and Community Clinics to NGOs is at an early stage
DSF has been implemented in the form of a maternal
health voucher scheme that provides for transport and
maternity care in 33 poorest upazilas
SWAp continued
Health and family planning wings have again been
bifurcated
Domiciliary services have been reinstated
 272/Ferdous Arfina Osman

can be adjusted by government action. In this section, the health system in Bangladesh
is described and analysed in the light of these control knobs.

Financing

Roberts et al. (2004) note that healthcare financing is one of the important factors
determining the performance of the health system as it indicates how much money
is available, who is going to bear the financial burden and who controls the funds.
Health financing in Bangladesh is a combination of different methods, which include
households, government revenue, donors and community financing through NGOs.
Of these various sources, the chief source of financing is household out-of-pocket
expenditure. About 47.3 per cent of the health funds come from out-of-pocket,
26.6 per cent come from government revenue, 25.8 per cent from external donors
and the remaining 2 per cent from community financing through NGOs (MoHFW
1996).
A donor consortium led by the World Bank provides financial and technical assi-
stance to the health sector of Bangladesh. Of all the members of the consortium,
the United Nations Children’s Fund (UNICEF), the United Nations Population
Fund (UNFPA), the World Health Organisation (WHO), Asian Development Bank
(ADB) and the United States Agency for International Development (USAID) assist
Bangladesh’s health sector on a continuous basis. UNICEF supports child health,
immunisation and nutrition programmes, USAID and UNFPA support family
planning service delivery and population education, WHO is the main international
source of technical assistance in the field of health supporting primary healthcare and
maternal and health services and ADB provides support for health planning capacities
(Osman 2004).
In 2007–08, the GoB spending on health was 7 per cent of the national budget
(MTR 2008), which was 3.4 per cent of Gross Domestic Product (GDP) (NIPORT
et al. 2005). By comparison, India spends 4.8 per cent (WHO 2005) and Sri Lanka
3.5 per cent (WHO 2007) of their respective GDPs on health. Private and social
insurance systems are almost non-existent as the necessary economic and administrative
conditions are yet to be put in place. To make health services accessible to the poor,
the government provides free services at the upazila level and below.
Due to the policy emphasis on primary care, the health expenditure pattern had
a preventive bias for a long time. This has now changed its track. During the 1980s
and 1990s about half of the total expenditure was being spent on primary level care
(MoHFW 1995). This increased slightly during the HPSP period due to greater
emphasis on the funding of particular services rather than primary care more generally
(Ensor et al. 2002). Studies suggest that the ESP approach was successful in diverting
more resources (between 60 and 70 per cent of public spending) into primary levels
of care, in focusing attention on resource flows into vital essential services such as

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 Health Policy, Programmes and System in Bangladesh/273

maternal care and in shifting attention from hospitals to primary services most used
by the lower income groups (MoHFW 2001). The reverse has been happening in
the HNPSP period: MTR (2008) notes a declining share of budget for ESD services
and for rural facilities (upazila level and below) as expenditure for tertiary hospitals
has increased.

Payment

In health service, payment refers to the ways in which money is paid out. This could be
in the form of fees, capitation (the unit of payment is defined on a per-person basis) or
budgets (Roberts et al. 2004). These methods create incentives, which influence how
providers behave in determining the quantity and quality of services. In Bangladesh,
public expenditure accounts for 31 per cent while private out-of-pocket expenditure
accounts for 69 per cent of total expenditure on health (WHO 2006). The government
uses tax revenues to subsidise the cost of healthcare provided in public facilities. Another
widely used method of payment is salaries. Healthcare providers like doctors, nurses and
health workers are mostly employed by the government, which closely influences the
pattern of their services. They tend to be less responsive to the patients as the quality
of their services does not affect their income. Although public facilities are supposed
to provide most services free of charge, in reality they are not free for patients. Often
the patients are forced to purchase drugs and supplies. Moreover, various kinds of
unofficial and informal payments are widely practised. A study conducted by the
Ministry of Health found that informal fees are common at all levels of the health
system and they can amount to more than ten times the official charges (Killingsworth
et al. 1999). In the tertiary level hospitals, patients pay user-fees at a nominal rate
which is far from sufficient to pay for the needed care leading to low quality services.
Again, about 75 per cent of the government doctors are engaged in private practice,
wherein they are paid by the patient from out-of-pocket. In private practice, doctors
typically charge high fees, which lower income people cannot afford. Moreover, this
creates profound differences in access even to public services because public doctors
give favourable treatment to their private patients.

Organisation

This refers both to the overall structure of the health system, and to the individual
institutions that provide healthcare services. In Bangladesh, health services are provided
by a mix of public-private institutions and NGOs. The public sector provides all types
of care (both curative and preventive), the private sector mainly provides curative care
and NGOs provide mainly preventive and basic care. GoB has contracted some of
its services to NGOs which include immunisation, nutrition and tuberculosis (TB)
control. Despite these multiple providers, public sector services are considered as
the key source of care for a majority of the population. Government health services

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 274/Ferdous Arfina Osman

are provided through a four-tier system of government-owned and staffed facilities.

They are:

1. Union Health and Family Welfare Centres (UHFWC) at the union level covering
a population of about 30,000 each. There are 4,400 UHFWCs which provide
mainly Primary Healthcare (PHC) services including maternal and child health
services, family planning services, EPI, Behaviour Change Communications
(BCC) and limited curative care. At the ward level, there are community clinics
to serve 6,000 people.
2. At the upazila level, there are 417 Upazila Health Complexes (UHCs) with
31–50 beds providing both in-patient and out-patient care, PHC, family plan-
ning services and some referral services.
3. At the district level, there are 59 District Hospitals with bed capacities ranging
from 50 to 250 providing both primary and tertiary care and both in-patient
and out-patient care.
4. Medical College Hospitals at the regional level providing tertiary care accom-
panied by specialised laboratory facilities for the treatment of complicated cases
usually (but not always) referred to them by the lower level facilities. There are
14 public Medical College Hospitals with bed capacities of 250 to 1,400 and
with a total bed capacity of 8,000 (Rahman 2006).

In addition to these four levels of facilities, at the national level there are six post-
graduate institutions providing both in-patient and out-patient specialised care.
Of the above-mentioned facilities, UHFWCs and the UHCs are the key facilities
to provide services in rural areas. In addition to these facilities, at the ward levels,
there are government run satellite clinics for providing immunisation and family
planning services. Other than these government facilities, NGOs, private practitioners
including medical doctors as well as traditional healers also provide health services in
rural areas. In urban areas, private medical doctors are the main source of care for the
rich while the poor go to the public facilities. Private hospitals and clinics outnumber
public facilities in urban areas although in the rural areas public facilities are the main
sources of modern care.
Table 3 gives a description of the organisation of the health system in Bangladesh.
It shows that the public sector is much stronger than the private sector in terms of
physical infrastructure across the country, although private hospitals outnumber public
hospitals in urban areas.

Regulation

This refers to the use of coercion by the state to alter the behaviour of actors in the
health system including providers, insurance companies and patients. In Bangladesh,
the Ministry of Health regulates the activities of all the providers by framing policies,
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 Health Policy, Programmes and System in Bangladesh/275

Table 3
Organisation of Health Facilities in Bangladesh

Levels Types of Facilities Public Private NGO Total

Union (4,498) Union Health and Family Welfare Centres 4,400 – NA 4,498
Upazila (481) Upazila Health Complexes 417 – – 417
District (64) District Hospitals 59 – – 59
Regional Medical Colleges in cities and towns 14 20 – 34
(6 Divisions)
Other hospitals 676 1005 2 1,683
National Post-graduate institutions 6 – – 6
Source: BBS 2006.

rules and regulations. In addition to this, the Bangladesh Medical and Dental Council
(BMDC) regulates the medical profession by issuing licenses to medical personnel
for practicing medicine. The regulatory function of BMDC is limited only to the
issuance of licenses rather than monitoring the performance of doctors or punishing
their misdeeds. Due to the lack of a strong regulatory mechanism, private practice is
unregulated and many criminal activities take place in the private sector. On the other
hand, private clinics and hospitals are regulated by being registered with the Directorate
General of Health Services (DGHS) only. There is no system to monitor the quality
of private care, competence of providers and for ensuring the safety of patients.

Behaviour

This refers to individual behaviour affecting the performance of the health system.
Due to illiteracy, the behavioural aspect at the individual level still remains a barrier
to making Bangladesh free from malnutrition and high rate of maternal mortality.
The Information, Education, and Communication Unit (IEC) under the purview
of DGHS carries out the design, implementation and evaluation of programmes in-
tended to change individual behaviour with limited success. School health education
programmes and the electronic media play important roles in creating health awareness
among the people.

III ACHIEVEMENTS

Since independence, Bangladesh’s health sector has made considerable progress in

improving the health status of the population through expansionary programmes
targeted towards the poor, overall economic growth and improved rates of literacy.
The most remarkable achievement includes considerable reduction of IMR, which
is currently lower than in India, although Bangladesh has only half the per capita
income of India (World Bank 2005a). The total fertility rate has declined, average life
expectancy at birth has risen significantly and the maternal mortality rate has witnessed
some improvement, though slow (Table 1). Interestingly, with the lowest total health
expenditure (i.e., only 3.4 per cent of GDP) in South Asia, Bangladesh stands behind

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only Maldives and Sri Lanka in terms of the most important health indicators like
life expectancy and child and adult mortality (Hossain 2006). Bangladesh records
improved access to drinking water and sanitation, though this a bit lower than that
available in Sri Lanka.
There has been significant improvement in vaccination coverage in recent years.
The country has progressed well with respect to children’s immunisation programme
when compared to India, Pakistan and Indonesia (Quasem 2008). The percentage
of children (12–23 months of age) who are fully immunised increased over the last
two decades from less than 2 per cent to 82 per cent (NIPORT et al. 2007) and the
percentage of newborns protected through maternal immunisation increased from
less than 2 per cent to 86 per cent (MoHFW 1998; WHO 1995). The Bangladesh
Demographic and Health Survey (NIPORT et al. 2007) notes that between 2004
and 2007 only immunisation coverage increased by 9 percentage points (from 73 per
cent to 82 per cent).
Remarkable progress has also been achieved in reproductive health. The Total
Fertility Rate (TFR) has fallen from 4.3 births per woman of reproductive age in
1990 to 2.7 in 2007 (NIPORT et al. 2007) which is the same as India but lower than
Pakistan, Nepal, Cambodia and the Philippines. Since independence the percentage
of women of reproductive age using a modern method of contraception increased
from 5 per cent to 58.1 per cent in 2004, although it has since declined to 55.8 per
cent in 2007 (NIPORT et al. 2007).
A declining trend of child mortality also indicates impressive gains. A comparison
of mortality rates over the last five years shows that infant and child mortality declined
by 20 per cent and 42 per cent respectively (NIPORT et al. 2007).
The first decade of independence (1970s) witnessed the growth of hospital
beds reflecting high priority given to in-patient curative care while the rural health
infrastructure was not set up as expected. During this period quantitative expansion
of health services took place in terms of hospital beds (from 9,300 in 1971 to 15,485
in 1980) bed population ratio (from 1:6,000 in 1974 to 1:4,290 in 1981), doctor
patient ratio (from 1:10,000 in 1974 to 1:7,810 in 1981) and rural health centres
(from 151 in 1971 to 179 by 1977), though quality of service in terms of coverage of
the poor was quite low (30 per cent) (Osman 2004).
The second decade (1980s) achieved remarkable progress in both urban and rural
infrastructure and manpower development. Development of rural infrastructure and
a comprehensive approach of family planning with particular emphasis on MCH
services helped in the decline of IMR and MMR.
The third decade (1990s) emphasised improvement in managerial efficiency and
development of human resources. UHCs and UHFWCs were planned for strength-
ening delivery of both FP and MCH services. The health sector received funding
from donors in a more extensive manner which started to show impressive gains. Al-
though drastic reforms introduced by HPSP failed to show noticeable improvement
in health indicators during the programme period (1998–2003), the institutional

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 Health Policy, Programmes and System in Bangladesh/277

reforms introduced by the programme (SWAp and ESP provision through one-stop
services) carried forward to the subsequent programme HNPSP (2003–2010) did
show impressive gains due to political commitment.
The achievements indicate a favourable policy environment in the country that
includes institutional support through government policy, a well-established physical
infrastructure, provision of adequate resources (both internally and externally funded)
and government-NGO partnership in service delivery. Moreover, economic growth and
declining poverty levels, general improvements in the status of women in Bangladesh
society and improvements in the educational level of women, even though limited,
have been critical factors driving these gains (World Bank 2005b). Despite signs of
gradual improvement in the quantitative indicators of health over nearly four decades
of independence (Table 1), the overall health status remains poor due to low qualitative
improvement. It has remained a challenge for the health sector to improve and even
sustain the already attained successes.

IV CHALLENGES

Despite the above achievements, poor access to services, both primary and tertiary
care, low quality services, high rate of maternal mortality and child malnutrition are
the issues which present a disquieting picture of health services in Bangladesh. Child
malnutrition and maternal mortality rate still remain among the highest in the world.
About 15,000 mothers die annually at the time of delivery, with 3 maternal mortality
per 1,000 live births, and 7,000 infants die everyday (Nath 2008). NIPORT et al.
(2007) notes that about 70 per cent of pregnant mothers suffer from anaemia, 86 per
cent of deliveries take place at home, 36 per cent of children are stunted and 46 per
cent of babies are born with low weight. These data seriously overshadow the health
sector achievements discussed so far and give a cautionary signal about an uncertain
future if they are not tackled immediately.

Access

Despite many impressive gains in health indicators, inequity in access to health services
is widely prevalent. Although there has been a remarkable expansion in public facilities
targeting the poor, a large portion of them still remain excluded. At present, less than
40 per cent of the population has access to modern primary healthcare services beyond
immunisation and family planning (Abedin 1997). Access to health services varies
considerably by household income, gender and place of residence.
Public sector health service is the only source of modern care for the rural poor as
private service is not affordable. But there is growing evidence that vulnerable people
have poor access to publicly provided health services even though these services are free
or subsidised (MoHFW 2005). The poor are less likely to seek treatment for illness
mainly due to the cost burden involved. A recent review also reports that both the
poor and the rich are making increased use of health services, although the poor are
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 278/Ferdous Arfina Osman

still behind in coverage (MTR 2008). The rich-poor gap is quite large for attended
deliveries and antenatal care (ANC). NIPORT et al. (2007) data shows that only
4.5 per cent deliveries in the poorest quintile are attended by skilled personnel,
compared with 60.1 per cent in the richest quintile. The study also shows that ANC
coverage in the poorest quintile is only 28.3 per cent while in the richest quintile it is
91 per cent. The urban-rural differential in antenatal care coverage is also quite large;
71 per cent of urban mothers had antenatal care from medical personnel, compared
with only 46 per cent of rural mothers (NIPORT et al. 2007). This gap seems to be
widening over the years rather than narrowing.
Although Bangladesh credits itself for achieving near universal child immunisation,
access to this service also varies widely in rich-poor and rural-urban areas. The rich-poor
gap in immunisation coverage is also quite large: a study conducted in 2000 showed that
47.2 per cent of the poorest quintile had immunisation coverage compared to 66.7 per
cent in the richest quintile (Gwatkin et al. 2000). There also appears to be no sign of
improvement: in 2007, 64 per cent of the poorest quintile had immunisation coverage
compared to 89 per cent in the richest quintile (NIPORT et al. 2007). Immunisation
coverage of urban children aged 12–23 months is 81 per cent compared to 71 per cent
in the rural areas (NIPORT et al. 2005). In other areas also the rural-urban disparity
is quite clear (Table 4).

Table 4
Rural-urban Disparity in Health Indicators
Issues Urban Rural National
Life expectancy (in years) 68 64.6 65.4
Under-5 Child Mortality(per 1,000 live births) 2.8 3.9 3.7
Infant Mortality Rate (per 1,000 live births) 35 46 44
Crude Birth Rate (per 1,000 live births) 17.7 21.4 20.6
Source: BBS 2006.

Apart from primary healthcare services, the poor also lack access to high quality and
advanced healthcare, especially in tertiary healthcare services. Even though the public
sector provides free or subsidised care, the hidden costs (informal payments) associated
with seeking treatment are not affordable for the poor. The poor face difficulties even
in getting admission to the specialised and Medical College Hospitals which have
a good number of free beds. The affluent and influential have greater access to the
services of these hospitals, whether in the public or the private sector (Rahman 2006).
Even District Hospitals, which are public, are also not always accessible for patients
without money. Evidence also suggests that in District Hospitals government doctors
provide free out-patient services to the poor for a specified time (say, once in a week),
while for the rest of the week they see patients privately within the hospital premises.
This practice severely restricts access of poor to the available services.

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 Health Policy, Programmes and System in Bangladesh/279

WHY POOR ACCESS?

There are four probable causes of poor access: (i) inefficient management of existing
facilities, (ii) underutilisation of available facilities, (iii) inadequate facilities, and
(iv) urban biased health expenditure.
Despite the existence of a sound health infrastructure, inaccessibility has been a
serious concern due to its inefficient management. Managerial inefficiency involves
issues like maldistribution of available resources in both the public and private sectors,
between urban and rural areas and between districts (with only 16 per cent qualified
doctors practising in rural areas); vacancies (41 per cent positions for doctors in
rural areas are left vacant); absenteeism (the percentage is high in rural areas); lack
of accountability to the community or to the institution; and lack of monitoring of
performance of providers.
Poor access to health services has been exacerbated by the underutilisation of existing
facilities. Unavailability of doctors, drugs and supplies, caused by the aforementioned
managerial problems, discourage people from utilising the existing services. Besides,
the lack of a poor-friendly attitude among healthcare providers also discourages po-
tential clients from making fuller use of services at government hospitals and clinics
(CPD 2003).
Another important reason for the underutilisation of existing facilities is the lack
of demand caused by the cost involved in seeking care (e.g., drugs, transport and
laboratory tests). Illiteracy and lack of awareness among the rural poor is another cause
of low demand for service utilisation.
Many studies show that the use of facilities is primarily based on location. Ensor
et al. (2001) note that most facilities, even a majority of the medical colleges other
than the Dhaka Medical College Hospital, are utilised by people who live within
5 miles of the facility. Another survey to monitor HPSP also confirms that location
remains one of the most important reasons for accessing services (Cockcroft et al.
2001). Unavailability of the required facilities also indicates the existence of physical
inaccessibility of services.
There are also expenditure differentials, which directly or indirectly restrict accessi-
bility to health services. Contrary to the policy pledge of ensuring access to health
services for the poor and disadvantaged, public health expenditure favours the rich
and urban people. Allocations of the Ministry of Health expenditure to the upazila
level and below—the services mostly used by the poor—declined from 51 per cent
in 2003–04 to 42 per cent in 2005–06 while money for tertiary hospitals and the
administration of the Ministry increased (MTR 2008).
HOW TO IMPROVE ACCESS?

To address managerial problems, issues of maldistribution of human resources

should be given serious attention. To prevent absenteeism, a mechanism should be

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 280/Ferdous Arfina Osman

established to monitor and evaluate the performance of doctors and health workers.
Such monitoring can be done by the community or by the local government, since
the departmental monitoring mechanism has proved to be a failure. Upazila health
committees can be empowered to take local level decisions in terms of planning, man-
agement, resource generation and monitoring. Although recently the policy focus
has shifted from target to client demand, the clients or service users are not given
adequate scope of participation in planning, reviewing and monitoring the services
locally to make the health service truly responsive and accountable to the community.
Even the community health workers are not given an opportunity to participate in
the Union Parishad meetings. The community needs to be empowered with resource
management and decision-making powers. There should be a patient’s Bill of Rights,
so the deprived may have recourse to law.
To address the cost barrier leading to a lack of demand for service, a ‘voucher scheme’
for maternal health services under the demand-side-financing mechanism of HNPSP
is underway. Demand for maternal health services is expected to rise significantly in
the coming years once it is mainstreamed in the whole country. Demand generation
can also be effectively done through strengthening the health education programme
and BCC. With this objective the efficiency of the service providers, particularly the
community health workers, needs to be improved through adequate training.
To remove physical inaccessibility, as per policy commitments, although the
government is supposed to establish one UHC in each upazila and one health centre
in each union, till today 64 upazilas and 98 unions do not have any health facilities.
This issue needs to be addressed urgently.
Measures should also be taken to reduce the rural-urban and rich-poor disparities
in expenditure allocation. While the budget for rural hospitals should be increased,
corruption and theft within the system need to be eradicated at the same time for
the increased allocation to have much effect. Appropriate mechanisms to audit these
expenditures should be devised to ensure transparency and accountability in the practise
of financial autonomy in public hospitals.

Poor Quality Services

The overall quality of health services, both in the public and private sectors, is poor.
In particular, government hospitals in rural areas are in a dismal condition and the
nature of care that these hospitals provide is substandard. The underlying factors
leading to low quality service in public facilities include (i ) unavailability of doctors
and other providers, (ii) negative attitude of service providers towards the poor,
(iii ) unavailability of drugs and supplies and logistics, and (iv) lack of regulatory
mechanisms for controlling the service providers.
The availability of doctors is a major determinant of service quality, which is one
of the major problems in rural facilities. There are two reasons for the unavailability
of doctors: (i ) sanctioned posts of doctors are not filled and (ii) doctors posted in

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rural facilities remain absent or give less time to official service provision than they
are required to. A study showed that 39 per cent of upazila health complexes lacked
a residential medical officer (head of upazila indoor service facilities) and nearly
60 per cent of union sub-centres lacked a doctor in 2003–04 (FMRP 2006). Even
while in-post and present in the facility, studies agree that doctors devote less time
to their patients than they are supposed to (Akter and Islam 2006; FMRP 2006).
Most of the doctors are busy in private practice, or spend short weeks in rural areas to
spend more time in big cities where demand for their services is greater. Absenteeism
of doctors was studied by the World Bank in 2003, which showed that absenteeism
among doctors is 41 per cent for upazila health complexes and 44 per cent for union
facilities (Chaudhury and Hammer 2003).
It is frequently alleged that public health facilities fail to provide quality services
due to inadequacy of their supplies. Most hospitals either lack the required medical
equipment or trained technicians to operate the equipment. An obvious implication
is that supplies are subject to leakage or corruption (Hossain and Osman 2007). Many
studies have revealed that costly medicines and equipment are sold by corrupt officials
and staff (Akter and Islam 2006; FMRP 2007). Often it is also the case that the available
machinery and equipment are left idle due to negligence of the authority.
Absence of strong regulatory mechanisms is an underlying cause of poor quality
service of public health facilities. Absenteeism or loss of service time of doctors reflects
the absence of any meaningful regulatory mechanism. It is estimated that 80 per cent
of all government doctors also maintain a private practice, not surreptiously but legally
(Gruen et al. 2002). Although doctors typically report that their private practice is
conducted in the afternoons and off facility premises, there is strong evidence that
private and public service provision tend to be provided on the same premises and
during office hours (Osman 2004: 305). No effective mechanism exists to regulate
this practice. Due to the lack of effective regulatory mechanisms, quality of services in
the private sector also cannot be ensured. The private sector provides services almost
in an unregulated manner.
HOW TO IMPROVE THE QUALITY OF SERVICES?

There is no magic bullet to improve the quality of health services but there is no
denying the fact that efficient management of the vast workforce would lead to much
more improved health services. A regulatory framework needs to be prepared that
would ensure the availability of doctors in their work places as well as accountability to
their patients and supervisors. There should be serious punishments for absenteeism,
negligence in diagnosis and treatment. There should also be a code of conduct for
healthcare professionals that clearly states expected levels of performance as well as
the provisions of punishment in case of violation.
Along with introducing regulatory mechanisms, another practical issue needs serious
attention. One of the main reasons for absenteeism of doctors in rural areas is because

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‘career and family imperatives draw this group of educated middle class professionals
to the larger cities where post graduate and professional training schools and other
amenities are available’ (Hossain and Osman 2007). In order to improve the quality
of services, availability of drugs, equipment and other logistics should also be ensured
when needed. Policy makers need to pay serious attention to these issues.

High Rate of MMR

Maternal mortality is one of the biggest challenges in Bangladesh’s health sector because
the country has one of the highest maternal mortality rates in the world. High maternal
mortality rates are underpinned by the fact that about 85 per cent deliveries take place
at home and most of which are attended to by untrained providers. Although the
government has established physical facilities at upazila and lower levels and arranged
BCC and training of doctors, nurses and field staff to provide emergency obstetric care
(EMOC) at these facilities, the utilisation of these services is still quite low.
WHY IS MMR SO HIGH?

The underlying causes of the high rate of maternal mortality are (i) inefficient man-
agement of the facilities leading to poor quality of maternity services coupled with
inadequate equipment and drugs and lack of training of providers; (ii) low utilisation
of services due to a variety of socio-cultural factors constraining care seeking behaviour,
and (iii) lack of awareness.
One of the major causes of the high rate of maternal mortality is that the existing
facilities are failing to provide adequate services due to inefficient management of
human resources. A Mid Term Review (MTR 2008) of HNPSP notes that only
about 75 EMOC facilities are operational compared to the target of 132, and that
the upgraded EMOC facilities cater to only about 25 per cent of the complications
occurring in their catchment areas. Moreover, training of field workers is also
inadequate as it does not include midwifery skills. MTR (2008) further notes that
only about 3,000 field workers have been trained compared to the target of 13,000,
leading to unavailability of trained staff for 24-hour maternity services. Similarly, at
the facilities at the upazila, district and tertiary levels, midwifery trained nurses are
also inadequate. Even if training is imparted, the trained providers are not duly placed
in the designated posts.
The most significant cause of maternal mortality is the high incidence of teenage
marriages, which should be discouraged. In Bangladesh, maternal mortality is closely
associated with pregnancy and childbirth rather than medical practices. Sometimes,
cultural ties deter women from delivering in health facilities or with medically
trained attendants because women in their families have given birth ‘naturally’ for
generations.
Underutilisation of the existing facilities is also an important barrier in improving
maternal health. Women are not brought to the facilities when they need care due to

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the distance of the facility, cost involvement or lack of awareness or realisation about
the complicacy of the condition. The Bangladesh Maternal Mortality Survey (BMMS
2001) found that there were delays in recognition of emergencies, in reaching the facility
and further delays in deciding what treatment should be sought. One anthropological
study also suggested that lack of information is often a cause of the inability to access
good emergency obstetric care (Blanchet and Zaman 1999).
HOW TO IMPROVE THE STATUS OF MATERNAL HEALTH?

To improve maternity services these managerial weaknesses need to be addressed. The

facilities in rural areas should well-equipped to provide EMOC services. Doctors as well
as field workers should be imparted adequate obstetric training. MTR (2008) reports
that as long as the support and governance systems remain weak and nonperforming,
maternal health cannot improve.
Effective reduction of MMR can take place by looking closely at the social dimen-
sions. As a result, social factors affecting pregnancy and childbirth, like enhancing
the social position of women through better access to education, better economic
conditions and greater possibilities for deciding their own future, would help reduce
maternal mortality in a more effective way.
To improve the utilisation of maternal health services, as has already been mentioned,
the government has introduced a maternal health voucher scheme on a limited scale.
A nationwide introduction of the voucher scheme could improve the maternal health
status by dealing with the cost factor as a barrier to access. BCC should be intensified
to increase awareness among women and sufficient education on reproductive health
should be introduced in schools and colleges.

Poor Status of Child Health

Although the prevalence of malnutrition in Bangladesh has declined in recent decades,

it is still greater than levels found even in Sub-Saharan Africa (HKI and IPHN 2006).
A recent study reveals that around 900 children die of malnutrition in Bangladesh every
day, mainly due to a poor dietary intake in the earliest months of their lives (Daily Star
2008). The study also estimated that Bangladesh ranks in the fourth position in the
list of children suffering from malnutrition. The status of child malnutrition has been
improving at a slow pace. At present, 46 per cent of the children are underweight, a
slight drop from 48 per cent in 2004 (NIPORT et al. 2007). Another recent estimate
(Mondal 2006) presents more distressing information: it suggests that the proportion
of underweight children in Bangladesh is 16 per cent higher than in 16 other Asian
countries at similar levels of per capita GDP.
HOW TO IMPROVE THE STATUS OF CHILD HEALTH?

Though poverty is the key, basic cause of malnutrition, stunting is also prevalent among
the rich. In fact, socio-cultural factors such as access to cultivable land, medical services

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 284/Ferdous Arfina Osman

and factors related to hygiene are associated with stunting. Increasing access to food
should be given priority for reducing the burden of malnutrition.
The health sector programme itself is not sufficient to improve the status of child
health. This problem requires inter-sectoral coordination. Child health mainly depends
on adequate nutrition, safe drinking water, sanitation, a clean environment and primary
education, all of which are interconnected. Studies reveal a strong correlation between
the status of a child’s health and the level of his/her mother’s education. NIPORT et al.
(2007) shows that children of mothers with no education are more than twice as likely
to be stunted (51 per cent) as children of mothers who have completed secondary and
higher education (22 per cent). It also shows that children of more educated mothers
are more likely than other children to be fully vaccinated. Therefore, mother’s education
must be a major policy focus in order to improve the child health status.
Lack of awareness among the rural poor is one of the reasons for poor child health.
To meet this challenge, health education and behaviour change communication
should be intensified particularly in low performing and hard to reach areas. More
intensified school health education programmes can play an effective role in improving
the nutritional status of children. Besides, involvement of women’s groups, local gov-
ernment, NGOs and the electronic media can reach programme information to the
unserved and underserved population.

V CONCLUSION

Due to the expansionary nature of its health policy, plans and programmes, the
health sector in Bangladesh has achieved remarkable successes in terms of quantitative
indicators. However, the qualitative improvement is negligible. Managerial and gov-
ernance weaknesses are the main causes of this deficiency. Before the 1990s, managerial
issues were emphasised less in policy documents. However, since the late 1990s
issues like managerial efficiency and cost effectiveness have come to the forefront of
Bangladesh’s health policy discourse, but with limited impact on the system so far.
Without an improvement in governance and efficient management, the problems
facing Bangladesh’s health sector are unlikely to be addressed.

ACRONYMS

ANC Antenatal Care

BBS Bangladesh Bureau of Statistics
BCC Behaviour Change Communication
DGHS Directorate General of Health Services
EPI Expanded Programme of Immunisation
ESP Essential Service Package
GOB Government of Bangladesh
HPSS Health and Population Sector Strategy

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 Health Policy, Programmes and System in Bangladesh/285

HPSP Health and Population Sector Programme

HNPSP Health, Nutrition and Population Sector Programme
IEC Information Education and Communication
IMED Implementation Monitoring and Evaluation Division
IMR Infant Mortality Rate
MMR Maternal Mortality Rate
MCH Maternal and Child Health
MTR Mid Term Review
NGO Non-Governmental Organisation
SWAp Sector Wide Approach
TFR Total Fertility Rate
U5MR Under-5 Mortality Rate
UHFWC Union Health and Family Welfare Centre
UHC Upazila Health Complex

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