Bangladesh: Improving Capacity to Meet Growing Needs

Challenges – Progress, but still short of demand

Bangladesh has made impressive progress in achieving health-related Millennium Development Goals.

The country has improved coverage and access to basic services and shown gains in maternal and child health related indicators, such as child and maternal mortality. The total fertility rate in Bangladesh has declined to almost replacement level, while immunization coverage with all basic vaccinations is above 80 percent.

While improving, the proportion of Bangladesh’s stunting children remains high at 36 percent (2014); the number of children needing attention for stunting, wasting and underweight cases hovers at 5.5, 2.2, and 3.8 million children, respectively. The number of overweight and obese women and children is increasing causing a double burden of nutritional problems.

With one of the lowest tax-to-gross domestic product (or GDP) ratios in the world, the Government of Bangladesh is constrained in what it can spend on health.  Currently, Bangladesh spends just 0.8 percent of its GDP (or less than $10 per person per year) on health, well below the already-low South Asia regional average of 1.3 percent.  The share of Bangladesh’s national budget allocated to health (5.13 percent in 2014) falls far behind regional and global standards.  Sixty-three percent of total health expenditures are borne by the patient out of his or her pocket, driving an estimated 3.5 percent of the population into poverty.

Bangladesh has a reasonably good network of health care facilities – most recently expanding the network of community based clinics. But it still suffers from a shortage and distribution of qualified health workers.  Moreover, the health sector is overly centralized with weak accountability mechanisms and regulatory frameworks for working with the large private and non-profit sectors.

There are strong disparities between rich and poor and for girls and women regarding health outcomes and health care utilization.  While Bangladesh’s health system attempts to meet the increasing demand for more and better quality health services, it struggles to meet the changing health needs -- a rising tide of non-communicable diseases, rapid urbanization and climate change. 

For example, the problem of saline intrusion into drinking water held back maternal health progress and is likely to be further exacerbated by climate change. In the last 35 years, salinity in the country’s drinking water has increased by 26 percent, putting the 40 million people who live in coastal Bangladesh in danger.

Solutions – Investments to achieve universal health coverage

The Government of Bangladesh has a Health, Nutrition and Population (HNP) Sector Development Program, which laid out the countrywide health strategy for 2011 to 2016. The World Bank finances a portion of the $7.7 billion program, along with eight international development partners, with nearly $889 million in a sector-wide approach (or SWAp) – one of the largest health operations in the world.  

The Government has prepared a new HNP Sector Development Program for the period 2017 to 2021, which it sees as fundamental for achieving the Sustainable Development Goal of universal health coverage (UHC) by 2030.  The World Bank and development partners are preparing to support its implementation through a Program for Results (PforR) focused on verified progress in service delivery to the most vulnerable, systems strengthening and laying the foundation for new challenges.   This operation is expected to be approved by the World Bank Board in February 2017 with financing from IDA ($300 million to $500 million), the Global Financing Facility ($30 million) and development partners ($200 million).

The Bank is also implementing a program of Advisory Services and Analytical work, which aims to inform Bangladesh’s efforts to achieve UHC. Focus has been on meeting the challenges related to health workforce, non-communicable diseases, mobilizing fiscal space for health and work related to health in urban areas. 

Results – Solid, encouraging gains.

Bangladesh has recorded:

• A 40 percent reduction in maternal mortality, down to 194 deaths per 100,000 live births in 2010 from 320 deaths in 2000.
• A 29 percent reduction in under-five child mortality, down to 46 deaths per 1,000 live births in 2014 from 65 deaths in 2007.
• 42 percent of births attended by medically trained professionals in 2014, up from 21 percent in 2007.
• 84 percent of children under 23 months received basic vaccination in 2014
• 2.3 total fertility rate (children per woman) in 2014 after a long plateau in the 1990s around 3.3 children per woman.
• 62 percent contraceptive prevalence rate in 2014, up from 55 percent in 2007.
• 13,006 Community Clinics made functional in the last six years.
• 64 percent of pregnant women receiving ante-natal care from a medically trained provider in 2014, up from 53 percent in 2007.
• 33 percent children underweight in 2014, down from 41 percent in 2007