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
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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
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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
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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
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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
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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.