- Bangladesh has benefitted from a rise in access to family planning and declining fertility rates, along with women's empowerment initiatives such as the Female Secondary School Stipend Project and microcredit lending programs.
- In-country research organizations have generated statistical evidence to inform decision-making, while other professional bodies have played a key role in developing interventions.
- Improvements in the economy and in the transportation and road system have further enabled improvements in under-five health.
Geography and History
Bangladesh is a predominantly low-lying riverine country in the Ganges River delta on the Bay of Bengal. Bordered by India to the north, west, and east, it also shares a border with Myanmar to the southeast.
Within these borders is one of the most densely populated countries on Earth, with 1,070 people per square kilometer. Somewhat counter intuitively, Bangladesh is also categorized as a highly rural country, in the sense that a large proportion of its people (77 percent) live outside its cities.1,2,3
The population has grown rapidly over time, more than doubling from 70 million in 1975 to 156 million in 2015 – more people than live in Russia or Japan, which is astonishing when one realizes that Bangladesh occupies a physical area slightly smaller than its regional neighbor Nepal, which has only about one-fifth of Bangladesh’s population.35
Bengalis are overwhelmingly the main ethnic group in Bangladesh, accounting for more than 98 percent of the national population.4 About nine in ten Bangladeshis are Muslim, with Hindus constituting almost all of the remainder.5 The country has two official languages – Bangla/Bengali and English – though nearly 40 others are spoken in various parts of the country, including Sylheti, Rangpuri, Chittagonian, and Chakma.6
In 1947, British rule in the subcontinent came to an end, and India was partitioned to create a new independent country, Pakistan. At the time, the country consisted of two Muslim-majority areas. One bordered India to the northwest (West Pakistan), the other to the northeast (East Pakistan).
The geographical and cultural distances between Pakistan’s two halves made their union untenable. In the spring of 1971, East Pakistan and West Pakistan went to war. By the end of that year, a victorious East Pakistan declared its independence and its new name – Bangladesh.
Within a mere three years, the fledgling country suffered one of the most devastating famines in modern history. The 1974 crisis, variously attributed to flooding, grain mismanagement, and the aftereffects of war, killed an estimated 1.5 million people.7
Bangladesh also had to contend with regional strife. In the southeastern Chittagong Hill Tracts, the Chakma and Jumma ethnic groups had suffered displacement as a result of ongoing government projects within their area.
Between 1977 and 1997, the United People’s Party of the Chittagong Hill Tracts and its armed wing Shanti Bahini waged war on the government of Bangladesh.8 During the case study period, ongoing political unrest occasionally affected efforts to reduce mortality among children under age five (under-five mortality or U5M).
Beginning soon after independence, Bangladesh introduced socialist economic policies that involved the nationalization of much of its manufacturing and agricultural sector. These policies resulted in economic hardships within the country and by the mid-1970s, a new regime began moving away from socialist policies. These reform measures resulted in economic growth throughout the 1990s and were enacted with support from the International Monetary Fund and the World Bank.9,10
Bangladesh’s gross domestic product (GDP) per capita maintained an upward trend from $1,642 in 2000 to $3,524 in 2017 (PPP, 2011 Constant International $).11 Despite these increases, Bangladesh’s GDP per capita remained below the South Asian average, as well as below those of its regional neighbors India and Myanmar.11
Bangladesh's GDP per capita, compared to its neighbors
The Human Development Index in Bangladesh showed gradual improvements, from 0.468 in 2000 to 0.505 in 2005 and 0.592 in 2015.12 The proportion of the population living below the national poverty line fell by half, from 48.9 percent in 2000 to 24.3 percent in 2016. The proportion of Bangladeshis living in extreme poverty (less than $1.90 per day) also fell, from 34.3 percent in 2000 to 14.8 percent in 2016.13,14
Poverty headcount ratio at $1.90 a day (2011 PPP) in Bangladesh and other South Asian countries
Throughout the 2000–2015 study period, Bangladesh’s economy was predominantly driven by its agricultural sector, with rice and jute (a fibrous plant commonly used in sacks and matting) as the primary crops. The manufacturing sector, particularly of ready-made garments, experienced significant growth, and by 2015 accounted for 80 percent of Bangladesh’s total exports.3,15,16
Another major source of national income was remittances from Bangladeshis living abroad. This amount grew from US$1.97 billion (4 percent of GDP) in 2000 to US$15.30 billion (8 percent of GDP) in 2015.17
An increasingly important factor in Bangladesh’s social and economic development is climate change, which has both a direct and indirect impact on efforts to reduce U5M. In 2007, a cyclone killed more than 3,000 people and is attributed at least in part to climate change.18,19 A 2019 UNICEF report observed that 19 million Bangladeshi children are vulnerable to the floods, cyclones, and droughts that are made likelier by the impacts of climate change .20
These events can have tragic effects in terms of children’s lives lost, but they also have significant indirect effects resulting from families’ increased vulnerability to property loss, dislocation, and disease.
Contextual Factors Contributing to Success
Several contextual factors at the national, subnational, and community levels, and among implementing partners, have contributed to Bangladesh’s successes in reducing U5M. Some of the most significant factors are addressed in the sections that follow.
Reproductive Health and Declining Fertility Rates
The rise in access to family planning and decline in fertility rates were important elements of a broader theme in Bangladesh’s efforts to reduce U5M – a greater empowerment of women in a traditionally conservative society. This theme of empowerment manifested itself across several areas, including increased availability of microcredit financing and heightened school enrollment levels.
Long before the study period (in the 1960s and 1970s), Bangladesh identified its rapid population growth as a major challenge to its development, and began implementing several initiatives to increase access to family planning services, decrease fertility rates, and delay marriage of adolescent girls.
These initiatives included the establishment of the Directorate General of Family Planning (DGFP) at the Ministry of Health and Family Welfare (MOHFW) in 1975, and the drafting of Bangladesh’s Population Policy in 1976 (although this latter policy was only formally introduced in 2004).
Another major component of Bangladesh’s family planning initiatives was the 1976 introduction of the family welfare assistants, CHWs who visited couples to distribute contraceptives and provide guidance on family planning. This marked the launch of Bangladesh’s CHW program. These efforts helped Bangladesh reduce its fertility rate from the highest to among the lowest in South Asia.
One informant described such family planning measures as the “number-one contributor” to the country’s progress to reduce U5M over the course of the study period.
These and related policies, along with strong economic growth and improved education, have helped curb Bangladesh’s population growth. Bangladesh’s total fertility rate dropped from six births per woman in 1975 to two in 2014, while demand for modern methods of family planning increased from 55 percent in 1993 to 73 percent in 2014.21,22
In addition to its family planning and fertility reduction policies, Bangladesh embraced other measures that narrowed the equity gap between women and men. These measures helped establish social conditions more favorable to women’s health, and in turn improved the health and well-being of the country’s children.
The country’s improvements in educational equity took a major step forward in 1994 with the Female Secondary School Stipend Project, which aimed to improve girls’ secondary school enrollment and retention. It provided girls in rural areas with stipends for attending school at least 75 percent of the time, maintaining passing grades, and delaying marriage until the completion of secondary school or their 18th birthday.
The literacy rate for women in Bangladesh increased from only 26 percent in 1991 to 40.8 percent in 2001, jumping to 62 percent by 2015,23 slightly higher than the South Asia average of 61.2 percent, and not far behind the men’s literacy rate of 68 percent. In addition, the proportion of women in the workforce increased from 26 percent in 2003 to 36 percent in 2016.23,24,25
Another major component of Bangladesh’s female-empowerment initiative was the introduction of microcredit lending programs in the 1980s. As noted in the section on CHWs, BRAC (originally the Bangladesh Rehabilitation Assistance Committee, now known only by its initials) had incorporated its community health programs into its microfinance work, a blend that made it possible for more village women to learn about their financial options.26 Studies have demonstrated that community health education campaigns can have a higher impact when carried out in tandem with microfinance programs.27
By virtue of their engagement with such programs, women secured additional assets and enhanced their roles as decision makers within their families, which in turn put them in a stronger position to act on health information provided by CHWs.
A 2003 study found that the introduction of microcredit programs had increased Bangladeshi women’s roles in household decision making as a result of their improved access to financial and economic resources and corresponding increases in mobility and social connections.28
According to the World Economic Forum’s Global Gender Gap Report 2016,29,30 which assessed women’s parity with men in economic opportunity, educational attainment, and political empowerment, Bangladesh ranked 72 out of 144 in gender equity.
Capacity of In-country Research Organizations and Professional Bodies
In addition to its support from international donors and partners – and separate from its own diverse array of nongovernmental organizations (NGOs) – Bangladesh benefited greatly from its in-country research institutes and professional organizations.
The International Centre for Diarrhoeal Disease Research (ICDDR,B) provided research leadership for several programs and – along with other in-country organizations – generated statistical evidence that proved crucial to the advancement of data-driven initiatives to reduce U5M.
Professional bodies including the Obstetrical and Gynaecological Society of Bangladesh, Bangladesh Neonatal Forum, and Bangladesh Pediatrics Association provided guidance on which interventions to deploy and when and how to deploy them. They also were essential to the development of numerous interventions, including facility-based Integrated Management of Childhood Illness (FB-IMCI).
A Skilled NGO Sector With Accountability and Autonomy
Compared with other countries in the region, such as India and Pakistan, public policy in Bangladesh has been successful in balancing the need for official oversight of NGOs with a respect for the operational autonomy necessary for experimentation and innovation.31
An NGO Affairs Bureau housed within the Prime Minister’s office32 regulates all NGO activity in Bangladesh. In many other countries, including neighboring India and Pakistan, NGOs must negotiate with multiple layers of government bureaucracy.33
The absence of heavy-handed constraints on the NGO sector has been cited as a primary reason why the sector has grown more rapidly in Bangladesh than in other countries.33
In addition to the research contributions that Bangladeshi NGOs made toward the national effort to curb child mortality, in-country organizations also played a critical role in the ultimate implementation of evidence-based interventions. This reflected the country’s highly empowered and capable NGO sector, as noted in the How Did Bangladesh Implement? article.
For example, NGOs like BRAC implemented crucial interventions to reduce malaria and diarrhea, and Proshika and Thengamara Mohila Sabuj Sangha implemented the Bangladesh Integrated Nutrition Project.
Economic Development and Infrastructure Improvements
Bangladesh experienced significant improvements in its economy during the study period, with GDP per capita (as measured in purchasing power parity adjusted 2011 constant international $) improving from $1,642 in 2000 to $3,319 in 2016.11 Also, 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 2016.34
Bangladesh's economic development over time, 2000 - 2017
Research conducted in 2015 noted that improvements in the transportation and road system in Bangladesh were a major facilitator of improvements in child health in the country (including U5M), because the roads facilitated improved access to health services for rural communities. As of 1991, the number of paved roads in Bangladesh was 9,704; by 2007, this figure increased to 17,321. Another infrastructural development that facilitated the drop in U5M was increased access to telecommunications; the proportion of households using mobile phones increased from 35 percent in 2007 to 78 percent in 2010.25
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