Context

Bangladesh’s first 15 years after gaining independence from Pakistan in 1972 were marked by a series of military coups, countercoups, and political assassinations. These challenges were coupled with frequent natural disasters. Seasonal flooding and destructive cyclones regularly laid waste to large portions of the country. This undermined food security, poverty alleviation, and agricultural development efforts, and increased demand for health care while reducing the country’s ability to deliver it.

As Bangladesh’s political crises have become less frequent over the last two decades, and agricultural production has improved, the country has experienced improved economic growth. The agricultural sector still provides employment for a majority of Bangladeshis, but more than three million people – 80 percent of them women¹ – now work in the growing textile sector.² The country exports more than $30 billion worth of clothing a year. Annual GDP growth rates have been in excess of five percent since 2003. This economic growth has sparked a cultural, economic, and health transformation.³

Bangladesh is expected to become a middle-income country by 2021, though 24 percent of the population still lives below the international poverty line of less than $1.90 a day.⁴ With this economic growth, the country has seen a decline in infectious diseases and a rapid increase in non-communicable chronic diseases in an increasingly urban and aging population.⁵

Despite this economic growth, Bangladesh’s level of health expenditure remains low, just $90 per capita. That is the lowest in South Asia, less than half the South Asian average of $210 per capita, and close to the level found in much lower income countries such as Benin and Burkina Faso.⁶

Given the limited public sector expenditure on health care and openness to external partners, international funding has played a key role in the development of Bangladesh’s community health efforts. From 1995-2015, development assistance for health increased from roughly $2-3 per person to $7-8 per person. In 2015, Bangladesh’s development assistance for health was nearly double the South Asia average of $4 per person.⁶ Today, Bangladesh is the fifth highest recipient of total foreign development assistance for maternal, newborn, and child health (MNCH) programs, and the fourth largest recipient for tuberculosis (TB) programs in the world. The delivery of both MNCH care and TB treatment rely heavily on CHWs.⁷

There are a few characteristics of Bangladesh that make community health worker programming appropriate. These include the country’s extremely low health workforce (7.4 skilled health workers per 10,000 population in 2015 – a fraction of the WHO’s recommended minimum of 23 per 10,000) ⁸ and its rural character (an estimated 64 percent of Bangladesh’s 164 million citizens live in rural areas, far from health facilities).⁹

It is also worth noting that Bangladesh has an estimated 500,000 informal private sector health providers, the majority of whom are untrained and unregulated. Despite this, they provide a large portion of rural residents with health care. (More on these providers can be found in the Challenges section.)

Research and learning

The government of Bangladesh has benefited from one of the developing world’s most comprehensive, detailed, and longest-running longitudinal data resources maintained by icddr,b (founded as the International Centre for Diarrhoeal Disease Research, Bangladesh). In 1963, the organization established a field diarrhea hospital and surveillance system known as the Matlab Health and Demographic Surveillance System (HDSS), in Matlab, Chandpur (then, East Pakistan). Initially, the site evaluated cholera vaccines and oral rehydration therapy, and studied the epidemiology, prevention, and treatment of diarrheal diseases. The mission of the research program quickly expanded beyond diarrhea, and Matlab became a testing ground in which icddr,b and its many partners, tried innovative approaches to improving health care broadly, with an eye toward scaling across the country.

For more than 50 years, Matlab researchers have been collecting detailed demographic information. This includes visiting more than 200,000 households across 142 villages regularly to record data on births, deaths, illnesses, health care, education, marriages, and migration. This wealth of data on the health and health-seeking behavior of the local population, which icddr,b has shared with the government, other NGOs, and international researchers, has provided a clear understanding of health challenges and changes. It has profoundly informed and influenced Bangladesh’s CHW programs and policies.

icddr,b’s Matlab helped the government develop its initial CHW family planning program in the 1970s. And when Matlab’s research demonstrated that 63 percent of childhood deaths in Bangladesh were due to vaccine-preventable disease, the government launched immunization campaigns spearheaded by CHWs.¹⁰

Connecting the research community with practitioners and policy makers to disseminate evidence has been as important as establishing Matlab’s research infrastructure. The National Institute for Population Research and Training (NIPORT), established by the Ministry of Health and Family Welfare (MOHFW) in 1977, serves as a key linkage in this respect. NIPORT is an autonomous research institute which conducts public health surveys (e.g., demographic health surveys, maternal mortality survey, health facilities surveys, etc.) and implementation science studies, and then disseminates learning from these studies to a broad range of government and NGO stakeholders. The hope is that these leaders then use presented learnings to make changes to existing program or design new programs to address new gaps and challenges.

For example, data from the 2014 Demographic and Health Survey showed the total fertility rate was much higher in Sylhet and Chittagong than in other divisions. NIPORT shared this finding with the Directorate General of Family Planning through a series of national consultations. The ministry then advocated for additional NGO-contracted CHWs to work in these areas and provide information about and access to modern contraceptives.

NIPORT also ensures that information gained through research helps shape the country’s public health research agenda and is factored into the training of government health workers who provide family planning services, including FWAs. BRAC also has a robust Research and Evaluation Division (RED) that includes a multidisciplinary independent research unit. The division plays an important role in designing BRAC’s interventions, monitoring the progress of those interventions, and identifying gaps. BRAC, like icddr,b and other partners, has shared its research and data with government to ensure policies and programs are evidence-based and effective.

Supportive policy environment for NGOs

Compared to other countries in the region, such as India and Pakistan, public policy in Bangladesh has been unusually successful in balancing the need for official oversight on NGOs, with the need to provide NGOs with the operational autonomy necessary for experimentation and innovation.⁵

The absence of heavy-handed constraints on the NGO sector by the government of Bangladesh has been cited as a key reason why the sector has grown more rapidly in Bangladesh than in other countries.¹¹

Bangladesh’s government regulatory architecture is simple: the NGO Affairs Bureau, housed within the prime minister’s office,¹² regulates all NGO activity in Bangladesh. In many other countries, including neighboring India and Pakistan, NGOs must navigate multiple layers of government bureaucracy.¹¹

Bangladesh does not just take a laissez-faire attitude toward NGOs. It has also adopted policies that recognize a robust role for NGOs within the health system. This is made clear by the 1998 Essential Health Services Package (ESP) and the first Sector-Wide Approach which formally recognized that NGOs and the private sector were indispensable to delivering essential health services to the rural and urban poor.¹³ The fifth Five-Year Plan (1997–2002), the first Sector-Wide Approach (1998) and the National Health Policy (2000) also explicitly encouraged the private sector and NGOs to assist the government in health care delivery and more squarely put government in a policy-making and monitoring role.¹⁴ The first Sector-Wide Approach included the following statement:

This broad policy declaration prompted two key shifts in NGO-government partnerships in the late 1990s:

In this supportive policy environment, public-private partnerships thrived.

Robust NGO sector

While other countries may have comparably large NGO sectors, Bangladesh is remarkable in that it is home to multiple national indigenous NGOs which enjoy deep community engagement, diversity in service delivery, and institutional and research sophistication. Indeed, NGOs like BRAC and Grameen are similar to governments in terms of their reach and complexity. Their significant and nuanced understanding of the local context, and strong and deep partnerships with village organizations, increases both the appropriateness and acceptability of their current role as leaders of national community health systems.

The country is also home to offices from many of the world’s largest international NGOs. Between local and international organizations, very little of the country remains untouched by NGOs. One 2000 study found that more than 90 percent of rural communities had some NGO presence.¹⁶

The origins of Bangladesh’s robust NGO sector can be traced back to the liberation war in 1971 and famine shortly thereafter. Given the country’s immense health challenges at the time, the new government’s limitations, and the need for broad investment in the country’s development, government leaders implemented a supportive policy environment toward NGOs. They were eager to allow the establishment and rapid growth of local NGOs that could help them problem-solve and develop the country.

Furthermore, during the challenging early days of the country’s history, civil society leaders were often viewed by the government as important allies. Likewise, these civil society leaders saw their role as serving Bangladesh alongside the government. NGO leaders established friendships with top government officials and developed parallel service delivery mechanisms which have grown with the government’s help. These indigenous NGOs have consistently taken a consultative approach to working with the government and, recognizing government limitations, have helped drive significant experimentation and innovation, delivering services when and where the government cannot.