Elsevier

The Lancet

Volume 382, Issue 9906, 23–29 November 2013, Pages 1734-1745
The Lancet

Series
The Bangladesh paradox: exceptional health achievement despite economic poverty

https://doi.org/10.1016/S0140-6736(13)62148-0Get rights and content

Summary

Bangladesh, the eighth most populous country in the world with about 153 million people, has recently been applauded as an exceptional health performer. In the first paper in this Series, we present evidence to show that Bangladesh has achieved substantial health advances, but the country's success cannot be captured simplistically because health in Bangladesh has the paradox of steep and sustained reductions in birth rate and mortality alongside continued burdens of morbidity. Exceptional performance might be attributed to a pluralistic health system that has many stakeholders pursuing women-centred, gender-equity-oriented, highly focused health programmes in family planning, immunisation, oral rehydration therapy, maternal and child health, tuberculosis, vitamin A supplementation, and other activities, through the work of widely deployed community health workers reaching all households. Government and non-governmental organisations have pioneered many innovations that have been scaled up nationally. However, these remarkable achievements in equity and coverage are counterbalanced by the persistence of child and maternal malnutrition and the low use of maternity-related services. The Bangladesh paradox shows the net outcome of successful direct health action in both positive and negative social determinants of health—ie, positives such as women's empowerment, widespread education, and mitigation of the effect of natural disasters; and negatives such as low gross domestic product, pervasive poverty, and the persistence of income inequality. Bangladesh offers lessons such as how gender equity can improve health outcomes, how health innovations can be scaled up, and how direct health interventions can partly overcome socioeconomic constraints.

Introduction

Bangladesh has a population of about 153 million, and is the eighth most populous country in the world, and third most populous Muslim-majority country after Indonesia and Pakistan.1 At the time of independence after the Bangladesh War of Liberation in 1971, the country was desperately poor, and densely populated, with an agrarian economy subject to frequent natural disasters. Henry Kissinger labelled Bangladesh as a country without hope.2 However, four decades later, Bangladesh has had exceptional health achievements. In 2010, the UN recognised the country for its exemplary progress towards Millennium Development Goal (MDG) 4 in child mortality,3, 4 and for being on-track to achieve the maternal mortality reduction goals of MDG5.5 More recently, Bangladesh was praised as an example of “good health at low cost”.6 Neither extreme of previous hopeless desperation, nor recent unqualified applause, captures the subtlety or complexity of Bangladesh's health story. The country presents a puzzling paradox of substantial mortality reductions alongside uneven health burdens due to the mixed effects of direct health actions and many social determinants of health.

The 1971 war had an important role in starting national development processes, which were characterised by social mobilisation, institutional pluralism, and civil dynamism, creating space for many stakeholders, government, non-governmental organisations (NGOs), informal providers, international donors, and commercial enterprises. In health-service delivery, all these stakeholders combined to pursue a pro-equity strategy, concentrating direct action on high-priority health issues such as family planning, immunisation, oral rehydration therapy, tuberculosis, vitamin A supplementation, and others. Noteworthy is that these health actions emphasised women's empowerment and gender equity to a degree that Bangladesh, despite its low gross domestic product (GDP), was able to enter the medium range of the UNDP Human Development Index category in 2003.7, 8 In the health sector, pioneering innovations for new policies, products, and processes were developed that were rapidly adopted and widely disseminated.9 Health actions were scaled-up to the entire country through the massive and unprecedented deployment of diverse cadres of mostly female frontline health workers reaching every household.10, 11

Key messages

  • Bangladesh is an exceptional health performer, but it presents the paradox of pronounced reductions in mortality accompanied by persistent malnutrition and low use of some basic health services

  • Bangladesh's success might be attributed to a pluralistic health system with many stakeholders, including government and non-governmental organisations, who pursue women-focused, equity-oriented, nationally targeted programmes, such as those in family planning, immunisation, oral rehydration therapy, maternal and child health, tuberculosis, vitamin A supplementation, and others

  • Especially noteworthy is Bangladesh's approach to equity, and its widespread deployment of (mostly female) community health workers to bring high-priority services to every household in the country

  • The Bangladesh paradox shows successful direct health action in the context of positive and negative social determinants of health—positives such as women's empowerment, widespread education, and mitigation of the effect of natural disasters, and negatives such as low gross domestic product, pervasive poverty, and the persistence of income inequality

  • Bangladesh offers many lessons, including how gender equity can improve health outcomes, how health innovations can be scaled up, and how direct health interventions can partly overcome socioeconomic constraints

However, impressive health progress has been imbalanced. Despite progress in human survival, other health indicators have lagged behind. Health service indicators show insufficient access to and use of maternity services.12, 13 Noteworthy is the persistence of a high prevalence of child and maternal malnutrition, even as the early signs of a rise in obesity have begun to emerge.14 Bangladesh's pattern of health improvements is imbalanced because of the effects of crucial social determinants of health. Pro-health social determinants include gender equity, widespread education of girls, and mitigation of the effects of frequent natural disasters. Social determinants reducing health advances include low national GDP, high level of poverty, and persistent income inequality. In the first paper in this Series, we present the story of Bangladesh, starting with the history and culture, followed by evidence to substantiate arguments about Bangladesh's remarkable health performance.

Section snippets

Historical overview

Geography and history are important aspects to understand Bangladesh's path of development. Located in south Asia, the country is surrounded on three sides by India (with a narrow border with Burma in the southeast of the country), and with the Bay of Bengal in the south (figure 1). The main language is Bangla (or Bengali). Compared with other countries in the region, the landmass that constitutes Bangladesh is fairly new. It is part of a delta created by silt flowing from the Himalayas and

The paradox

The Economist has recently applauded Bangladesh because of the country's spectacular gains in some of its social indicators.2 Analysis of data from various sources (panel 2), reveals that, compared with the country's Asian neighbours, Bangladesh shows exceptional health achievement, but not without qualifications (table 1, figure 1). In addition to neighbouring countries in south Asia and southeast Asia, we have compared Bangladesh with the Indian state of West Bengal, which was separated from

The picture of health in Bangladesh

To classify Bangladesh as a country of good health at low cost might oversimplify the subtle and complex picture. In the context of Bangladesh, good health resulted in improved survival rates, but less impressive reductions in morbidity burden. Low cost is deceptive in that it does not distinguish between low national GDP, high prevalence of poverty, or actual investments in the health sector. Nor does the phrase give details of why and how Bangladesh has achieved its distinctive successes.

Into the future

In the future, Bangladesh is likely to continue to face the complex pushes and pulls of many social determinants. Despite an annual economic growth of nearly 6%, because of improvements in agriculture, exports (especially of apparels), and human resources, poverty and its persistence will continue to hold back Bangladesh's health progress. Even after much policy priority and financial investments, more than 30% of people in Bangladesh are still classified as extremely poor and income inequality

References (83)

  • Human Development Report 2003: Millenium Development Goals: A Compact among Nations to end Human Poverty

    (2003)
  • Human Development Report 2011

    (2011)
  • S El Arifeen et al.

    Community-based approached and partnerships: innovations in health-service delivery in Bangladesh

    Lancet

    (2013)
  • The state of health in Bangladesh: health workforce in Bangladesh: who constitutes the health care systems: James P Grant School of Public Health

    (2008)
  • Bangladesh demographic and health survey 2011

    (2013)
  • World health statistics 2011

    (2011)
  • State of food security and nutrition in Bangladesh 2010

    (2010)
  • RA Cash et al.

    Reducing the health effect of natural hazards in Bangladesh

    Lancet

    (2013)
  • D Lewis

    Bangladesh: politics, economy and civil society

    (2011)
  • Economics and governance of nongovernmental organizations in Bangladesh

    (2006)
  • AT Schurmann et al.

    Civil society, health, and social exclusion in Bangladesh

    J Health Popul Nutr

    (2009)
  • SM Ahmed et al.

    Harnessing pluralism for better health in Bangladesh

    Lancet

    (2013)
  • N Kabeer et al.

    NGOs' strategies and the challenge of development and democracy in Bangladesh. IDS working paper, 343

    (2010)
  • D Lewis

    On the difficulty of studying “civil society”: NGOs, state and democracy in Bangladesh

    Contrib Indian Sociol

    (2004)
  • RH Chaudhury et al.

    Maternal mortality in rural Bangladesh: lessons learned from Gonoshasthaya Kendra programme villages

    Asia Pacific Population Journal

    (2008)
  • Bangladesh Demographic and Health Survey 2007

    (2009)
  • Bangladesh Demographic and Health Survey 1999–2000

    (2001)
  • Bangladesh Demographic and Health Survey 2004

    (2005)
  • Census Report

  • Household income and expenditure survey 2010

    (2011)
  • Matlab demographic workbook

    (2012)
  • MK Mridha et al.

    Assessment of maternal, neonatal and child health and family planning facilities in Bangladesh

    (2011)
  • UN data: a world of information

  • World development indicators and global development finance

  • Country statistics: Bangladesh. United Nations International Children's Emergency Fund

  • Global Health Observatory: country statistics

  • Steps towards change: national strategy for accelerated poverty reduction II; FY 2009 – 11

    (2009)
  • Central Intelligence Agency: the world factbook

  • HRD data sheet 2011

  • Sixth five year plan, FY 2011–2015. Accelerating growth and reducing poverty. Part 1: strategic directions and policy framework

    (2011)
  • Sixth five year plan, FY 2011–2015. Accelerating growth and reducing poverty. Part 2: sectoral strategies, programs and policies

    (2011)
  • Cited by (276)

    View all citing articles on Scopus
    View full text