Challenges

Key Points

• Even with its impressive advances in reducing its under-five mortality rate, Bangladesh still faces significant challenges as it seeks to bring that rate down further.
• Remaining high levels of poverty, coupled with insufficient or unsustainable health care funding, could create financial barriers limiting peoples' access to care. In addition, the lack of trained health care personnel, especially in rural areas, is a further barrier to access
• Inconsistent quality of care in public health facilities has led to distrust and low uptake of public health facility-based services.
• Other remaining challenges include entrenched gender inequities in some regions, challenges in reducing neonatal mortality, and gaps in coverage, oversight, and personnel of community health worker programs.

Continued High Levels of Poverty

Bangladesh’s economy grew impressively during the study period, and the proportion of the population living below the national poverty line declined from 48.9 percent in 2000 to 40 percent in 2005, 31.5 percent in 2010 and 24.3 percent in 2016.¹ Yet the fact that nearly a quarter of the country’s people remain impoverished will likely exert a drag on progress to reduce U5M for some time to come.

This is evident in the lingering challenge of malnutrition. Even with the improvements that have resulted from large-scale nutrition interventions, rates of malnutrition have remained high. As of 2014, the rate of stunting among children under five was 36 percent, the rate of wasting was 14 percent, and 33 percent were underweight.

Research conducted in 2018 attributed these high rates to ongoing challenges with food insecurity in Bangladesh, where 35 percent of the population was found to be food insecure.² One informant noted that the diets of many Bangladeshi children are insufficiently varied or nutrient-rich, and they rely excessively on carbohydrates.

As of 2018, the country still had not implemented Community-Based Management of Severe Acute Malnutrition (CMAM), which it had begun planning for in 2011.³

Lack of Trained Health Care Personnel, Especially in Rural Areas

Bangladesh’s health system (public and private) faced challenges throughout the study period with the number and distribution of qualified health care personnel. The number of physicians and nurses/midwives remained well below the World Health Organization (WHO) target of 4.45 doctors, nurses, and midwives per 1,000 people, with an estimated 0.3 physicians and 0.1 nurses and midwives per 1,000 people as of 2011 .^{4 16} 

Much of the country’s higher-skilled health personnel is concentrated in urban areas such as Dhaka, even though more than 70 percent of the national population lives in rural areas. This geographic gap persists despite the establishment of regionally-dispersed divisional medical colleges and nursing schools, and the expansion of the country’s private health sector.

The lack of trained health care professionals in rural Bangladesh has resulted in widespread reliance upon “village doctors” – traditional healers in rural areas far removed from formal health facilities. In 2005, Bangladesh conducted two-day trainings on the community-based Integrated Management of Childhood Illness (CB-IMCI) protocol for 144 village doctors, followed by a two-year period in which they were monitored for their implementation of the protocol.

This study found that village doctors could adequately implement the CB-IMCI protocol, as demonstrated by their understanding of the proper methods for assessing and managing pneumonia and diarrhea up to two years after training. For example, their knowledge of the correct management of severe pneumonia and diarrhea increased from 62 percent and 65 percent, respectively, to 84 percent and 82 percent after the training, and remained relatively high through the end of the two-year interval.⁵

Despite these positive findings, the absence of standardized criteria for becoming a village doctor – and the inability to ensure consistent competency among village doctors in the country – resulted in a government decision to limit their CB-IMCI role to one of counseling and referral.

A 2007 study found that only 4 percent of these healers had any government training.⁶ Another 2007 study of village doctors in Chakaria found that many of them engaged in inappropriate and harmful practices.⁷

[For more information on the assessment of village doctors’ readiness to carry out community-level care, see the What Did Bangladesh Do? chapter in this narrative.]

Limitations of Community Health Worker Programs

While Bangladesh’s community health workers (CHWs) have been vital to the country’s successes in reducing U5M, CHW programs suffer from important limitations, including position vacancies, absenteeism, inconsistent supervision, and gaps in coverage.

In some cases, the reported coverage of initiatives remained lower than expected due to the unavailability or inadequate preparedness of CHWs. This was the impetus for expanding skilled birth attendance, which was undermined by inadequate supervision and overburdening of CHWs.

One overarching problem affecting the CHW program is slow and bureaucratic decision making. Establishing a new CHW post requires approval from six ministries and institutional entities and can take as long as three years.⁸ Moreover, key components of CHW programming, like recruitment, retention, and management, fall under the purview of several ministries.

At the same time, significant gaps remain in the government oversight of nongovernmental CHW programming. For example, no minimum standards or training guidelines exist for nongovernmental CHW cadres. Save the Children, UNICEF, USAID, and others are teaming up with the government to develop those standards and guidelines.

Retention of CHWs is also a concern. Approximately 15 percent of government CHW positions are vacant at any given time, and anecdotal evidence suggests absenteeism rates are exceedingly high.⁹ This is part of the reason why nongovernmental CHWs have been responsible for carrying out many interventions.

[For more information on the limitations of the CHW program, see the Exemplar narrative on CHWs in Bangladesh (Exemplars in Global Health: Community Health Workers in Bangladesh).]

Inconsistent Quality of Care

According to key informants, quality of care in public health facilities remained a significant challenge to U5M reduction efforts in Bangladesh. This has contributed to distrust and low uptake of public health facility-based services, and increased use of private facilities in Bangladesh.

Underlying causes included gaps in monitoring and supervision, and the national leadership’s delay in making quality of care a leading priority. By 2009, key informants noted that implementing partners and donors began to prioritize and advocate for quality improvement as a means to improve the effectiveness of U5M reduction efforts in Bangladesh.

Bangladesh adopted the WHO Pocket Book of Hospital Care for Children for inpatient pediatric care in 2010, and a variety of international aid organizations began providing capacity-building support to the quality improvement unit of the Directorate General of Health Services (DGHS).¹⁰

Bangladesh also introduced a National Quality Improvement Strategic Plan in 2015. By 2018, after the study period ended, implementing partners and donors such as the US Agency for International Development (USAID) and the United Nations Children’s Fund (UNICEF) were supporting the establishment of divisional and district-level quality improvement units.

Uneven Progress in Women’s Empowerment

Several informants mentioned that regional differences in implementation and outcomes was an important factor in advancing efforts to reduce U5M in some parts of Bangladesh, and hindering them in others. For example, entrenched gender inequities slowed progress in some regions, such as northeastern Sylhet.

One informant said that part of the country was characterized by “low empowerment of women,” while another informant said equity outcomes there had lagged “because Sylhet people are more conservative,” as opposed to areas like Khulna where “ladies speak out in family matters.”

Another region with relatively high U5M rates – the hill tracts of Chittagong – may be “a hard-to-reach area,” said the informant, “but they are different because they are quite happy to take up [U5M interventions], while there is resistance in Sylhet for receiving care.”

Ongoing Challenges in Reducing Neonatal Mortality

Although neonatal mortality rates decreased, this progress lagged behind improvements overall in reducing U5M. Among Bangladesh’s challenges is reducing mortality among low birth weight and premature infants. In addition, rates of facility-based delivery remain low, and quality of antenatal and neonatal care is uneven.

Bangladesh has experienced a concerning increase in delivery by Cesarean section, reaching 23 percent of deliveries in 2014 – higher than the WHO’s recommended range of 10 to 15 percent.¹¹ The high rates of Cesarean sections are associated with an increasing proportion of deliveries in private-sector facilities, where government oversight is more limited.

Inconsistencies in Data Availability and Quality

Bangladesh’s history of strengthening data systems has been a notable factor in its efforts to reduce U5M. The country has continued to experience problems, however, related to the collection, availability, and quality of data.

As noted in the How did Bangladesh Implement? article, the country has struggled with low levels of data availability. A 2016 study assessed availability of electronic maternal, newborn, and child health information, and gave Bangladesh a score of 1 (compared with an average of 8.65) out of 15 possible points – the lowest score of all 22 countries assessed.¹²

In addition, the various government and NGO CHW programs each collect different data, from different sources, on different schedules. They store and manage that data in unique ways, creating a patchwork of systems incapable of providing the clear and actionable information that policy makers need. Until recently, CHW data has not been shared – even between government agencies, let alone between the government and NGOs.

To address these inconsistencies, Bangladesh and its partners have worked to establish a culture of clear data collection standards. In 2014, Bangladesh introduced an electronic Health Information System (e-HIS) to synthesize public facility-level data, and it set up a Health Management Information System (HMIS) unit within the DGHS.

Insufficient or Unsustainable Health Care Funding

During the study period, Bangladesh’s total health expenditure per capita increased from $43 in 2000 to $96 in 2015 (2018 PPP International $).¹³ Yet government expenditures as a percentage of overall health spending declined from an already low 26 percent in 2000 to 19 percent by 2015 .¹³ Total health expenditure was only 2.8 percent of the gross domestic product (GDP) in 2015, one of the lowest in the world.¹⁴

The government has stepped in to fill some important spending gaps – such as with the continuation of FB-IMCI funding after donors pulled back from the program, and with the shouldering of higher percentages of immunization funding as donors have reduced their outlays.

However, informants noted that this spending picture represented a threat to the sustainability of programs required to ensure continued U5M reduction. Some of them also observed that Bangladesh’s ongoing dependence on donor funding for much of its work toward reducing U5M presented sustainability challenges of its own.

Long-term sustainability is especially a concern given that donor support for Bangladesh’s health sector has been steadily declining. The proportion of all-cause development assistance for health, as a percentage of overall health expenditure, fell from 11 percent in 2000 to 6 percent by 2015.¹³

In contrast to donor and government funding, the percentage of overall health expenditures covered by all-cause, out-of-pocket spending was high – and continued to rise. It was 60 percent in 2000, and 72 percent in 2015.¹³ 

Higher out-of-pocket spending was driven in part by an increasing reliance on private-sector health systems. The national government sought to slow or reverse this trend through a variety of means, including subsidization of outpatient visits, free provision of certain medications, and free hospitalizations for selected conditions.

While such programs helped lower-income Bangladeshis gain access to services they could not have afforded otherwise, a 2015 study found that it was still not uncommon for citizens to purchase items such as syringes, plaster for casts, and intravenous fluids on their own when supplies were unavailable at public health facilities.¹⁵

In 2012, Bangladesh committed to achieving universal health coverage by 2032.⁸ Small-scale testing of a new financing strategy for such coverage was planned for 2012–2016, but implementation was delayed until 2017, after the study period ended.⁸