A. Mushtaque R. Chowdhury

The Bangladesh paradox: exceptional health achievement despite economic poverty

Bangladesh, the eighth most populous country in the world with about 153 million people, has recently been applauded as an exceptional health performer. In the first paper in this Series, we present evidence to show that Bangladesh has achieved substantial health advances, but the countrys success cannot be captured simplistically because health in Bangladesh has the paradox of steep and sustained reductions in birth rate and mortality alongside continued burdens of morbidity. Exceptional performance might be attributed to a pluralistic health system that has many stakeholders pursuing women-centred, gender-equity-oriented, highly focused health programmes in family planning, immunisation, oral rehydration therapy, maternal and child health, tuberculosis, vitamin A supplementation, and other activities, through the work of widely deployed community health workers reaching all households. Government and non-governmental organisations have pioneered many innovations that have been scaled up nationally. However, these remarkable achievements in equity and coverage are counterbalanced by the persistence of child and maternal malnutrition and the low use of maternity-related services. The Bangladesh paradox shows the net outcome of successful direct health action in both positive and negative social determinants of health--ie, positives such as womens 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. Bangladesh offers lessons such as how gender equity can improve health outcomes, how health innovations can be scaled up, and how direct health interventions can partly overcome socioeconomic constraints.

Control of tuberculosis by community health workers in Bangladesh

BACKGROUND Tuberculosis remains a major public-health problem in Bangladesh, despite national efforts to improve case identification and treatment compliance. In 1984, BRAC (formerly the Bangladesh Rural Advancement Committee), a national, non-governmental organisation, began an experimental tuberculosis-control programme in one thana (subdistrict). Community health workers screened villagers for chronic cough and collected sputum samples for acid-fast bacillus (AFB) microscopy (phase one). Positive patients received 12 months of directly observed therapy. Phase two (1992-94) included another nine thanas and, in phase three (1995), eight more thanas were included. From 1995, the treatment was an 8-month oral regimen. METHODS In 1995-96, we analysed all programme data from 1992 to 1995. First we analysed phases two (12-month therapy) and three (8-month therapy) separately for proportion cured, died, treatment, failed, defaulted, migrated, and referred. Second, we did a cross-sectional survey of tuberculosis cases in more than 9000 randomly selected households in two phase-two thanas and one non-programme thana, and analysed the follow-up of all patients treated in the programme thanas. FINDINGS In the phase-two analysis, 3497 (90%) of 3886 cases identified had accepted 12-month treatment. In phase three, all of 1741 identified cases accepted the 8-month regimen. 2833 (81.0%) and 1496 (85.9%) in phases two and three, respectively, were cured; 336 (9.6%) and 133 (7.6%) died. The relapse rate 2 or more years after treatment was discontinued was higher than the early relapse rate. The drop-out rate was 3.1%. In the cross-sectional survey, the prevalence of tuberculosis in the two programme thanas was half of that in the comparison thana, where only government services were available (0.07 vs 0.15 per 100 [corrected]). INTERPRETATION The BRAC tuberculosis-control programme has successfully achieved high rates of case detection and treatment compliance, with a cure rate of at least 85% and a drop-out rate of 3.1%. The prevalence survey suggested that at least half of all existing cases had been detected by the programme.

All for universal health coverage

As the USA engages in what promises to be a vibrant debate over how the world’s most costly health-care system can effi ciently and equitably provide access to quality health services to all American people, controversies about universal health coverage are brought into high relief, not only in the USA, but also worldwide. Since the mid-20th century, most nations have signed many accords, establishing that provision of health is a fundamental human right; health for all should be not only an aspirational target but also an essential framework for the United Nations system; international donor mechanisms should include support for essential health systems and health-workforce development; poor population health contributes to social and economic instability and undermines development eff orts; and specifi c targets for country achievements in health should be set, and funded, through international instruments. The world community is at a crucial juncture in implementation of all these understandings and agreements, each of which underscores the need for, and utterly depends upon, extending universal health coverage. The nearly US

Importance of health research in South Asia

25 billion yearly enterprise that is global health features a long list of bold, targeted programmes, from child vaccination eff orts to appropriate treatment of tens of millions of people now living with HIV/AIDS. Yet, the full bill for health spending in the world may already surpass

Enrolment at primary level: gender difference disappears in Bangladesh

6 trillion or 10% of the global gross domestic product (GDP), and the fi nancing challenges in low-income and middle-income countries will increasingly be domestic, just as they are in high-income countries. There is increasing appreciation of the links between disease and population health and nations’ security, foreign policy, economic, and general social wellbeing. Amid the unfolding H1N1A infl uenza pandemic, political leaders everywhere are appreciating the strong link between health systems in low-income and middle-income countries, and the ability of the global scientifi c community to acquire real-time assessments of epidemic spread and clinical eff ect. And new threats to health arising from climate disruption suggest the need for vast infrastructures of adaptation to population-scale health disasters resulting from rising global carbon dioxide concentrations: catastrophic weather events, drought, heatstroke and dehydration, new infectious diseases emergence, food and malnutrition crises, and human migrations. On an immediate basis, the global campaign to provide antiretroviral drugs to people with HIV living in low-income countries, coupled with the worldwide increase in cancer, cardiovascular disease, diabetes, and other long-term management ailments, have prompted a shift in thinking about global health. For decades, global health referred mainly to prevention of infectious diseases and epidemic control. Campaigns nowadays increasingly address lifelong interventions that need permanent systems of medical assessment and treatment in addition to population approaches to health promotion. In the 20th century global health world, vaccination was a dominant approach, often administered in one-off campaigns. The 21st century exigencies for global health dawned in Durban, South Africa, at the International AIDS Conference, amid demand for universal access to antiretroviral drugs, and the lifelong disease management required to sustain the life-sparing eff ects of the drugs. As WHO Director-General Margaret Chan has correctly pointed out, “I think we can now let a long-standing and divisive debate die down. This is the debate that pits single-disease initiatives against the agenda for strengthening health systems.” Chan continued in her address in June, 2009, “As I have stated since taking offi ce, the two approaches are not mutually exclusive. They are not in confl ict. They do not represent a set of either-or options. It is the opposite. They can and should be mutually reinforcing. We need both.” Debate has emerged, pitting—we believe, incorrectly— health-systems support against targeted health campaigns. In truth, development of systems capable of delivering health, generally, or specifi cally targeted campaigns and health initiatives, all rely on the existence of health fi nancing mechanisms that off er universal access to health. The specifi c nature of such fi nancing schemes and service delivery models will vary, dependent on nations’ economic and cultural norms. To assume that universal health coverage necessarily requires a single-payer government mechanism would be a mistake, and adherents to that position doom the people of the poorest nations to generations of medical defi ciency. In classic terms, debates may be framed as the Bismarck model versus the Beveridge model, but this dichotomy is increasingly viewed as being as false as that which seeks to pit vertical schemes of health against horizontal. Whether a nation chooses a mixed economy model of coverage, single-payer mode, donor-issued voucher mechanism, or other innovative models of universal fi nancing is not the issue; provision of universal health coverage is the issue facing the entire global health construct. Sadly, for most of the world’s populations universal health coverage remains a mirage, blurred further out of focus by the present world fi nancial crisis. In the USA, for example, where spending on health topped

Development knowledge and experience: from Bangladesh to Afghanistan and beyond

2·4 trillion in 2008, or 17% of GDP, an estimated 47 million citizens have no health coverage whatsoever, and another 25–45 million are covered by insurance that is so inadequate that major medical events may cause family bankruptcy (panel). Studies in the USA show that at least half of all bankruptcies fi led by American families Lancet 2009; 374: 1294–99

Without Sex Education: Exploring the social and sexual vulnerabilities of rural Bangladeshi girls and boys

South Asian countries face similar health problems and would benefit from collaboration in health research Research is essential to guide improvements in health systems and develop new initiatives.1 South Asia has a quarter of the worlds population, weak public sector health care, and a staggering disease burden, and thus research is particularly important. Although investment has increased in infrastructure for health research over the past decade, gaps remain in evidence to guide reduction of important problems such as communicable diseases, maternal and perinatal conditions, childhood diseases, and nutritional deficiencies.2 Furthermore, even when technical knowledge is available, political commitment, managerial competencies, and incentives for changing behaviour within health systems are often lacking.3–5 Despite diversity in their geographical, linguistic, and political structures, Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka face common health challenges. Most bear a triple burden of persisting infectious diseases, increasing chronic conditions, and a growing recognition of injuries and violence. Incomplete demographic transitions, HIV and AIDS, massive unplanned urbanisation, and a host of social determinants of health compound these problems.6 Another common characteristic is that national estimates of health mask large variations within countries (fig 1).7 8 Fig 1 Life expectancy and healthy life expectancy by gross domestic product per capita9 Health systems across the region also have to confront challenges such as a lack of evidence based policies and limited social accountability. With no or limited national health insurance schemes and the large role of the private sector, individuals face high out of pocket payments on top of other economic and social consequences of ill health (fig 2).10 In many countries, the devolution of financial responsibility for health services has outpaced capacity and decision making authority, contributing to fragmentation of policies and services.11 Striking …

Urban–Rural and Socioeconomic Variations in the Knowledge of STIs and AIDS Among Bangladeshi Adolescents

Abstract In the recent past, there have been a number of new initiatives to improve the access to primary education in many developing countries. Such initiatives, which came from the public, private and non-governmental (NGO) sectors, have resulted in improved performance in various efficiency indicators. This paper reports results from a nationwide study in Bangladesh on the levels and changes in enrolment pattern of children at the primary level. The gross enrolment ratio has reached 107% and the net enrolment rate 77%. Gender gap has disappeared; in fact girls have surpassed boys! However, the increase in enrolment taking place is not at the desired speed; it is less than one percentage point per year. The government is still the major provider of primary education with two-thirds of all enrolments, but non-formal schools run by NGOs also have important contributions to the positive changes that are taking place in Bangladesh.

Home-based treatment: teaching matters

PROBLEM In Afghanistan the challenges of development are daunting, mainly as a result of many years of conflict. The formation of a new government in 2001 paved the way for new initiatives from within and outside the country. BRAC (formerly Bangladesh Rural Advancement Committee), a Bangladeshi nongovernmental organization with a long history of successful work, extended its development model to Afghanistan in 2002. LOCAL SETTING Provincial Afghanistan. APPROACH BRAC has implemented programmes in Afghanistan in the areas of health, education, microfinance, womens empowerment, agriculture, capacity development and local government strengthening, and has taken many of these programmes to scale. RELEVANT CHANGES With a total staff of over 3000 (94% Afghan and the rest Bangladeshis), BRAC now works in 21 of the countrys 34 provinces. BRAC runs 629 non-formal primary schools with 18 155 students, mostly girls. In health, BRAC has trained 3589 community workers who work at the village level in preventive and curative care. BRAC runs the largest microfinance programme in the country with 97 130 borrowers who cumulatively borrowed over US

Producing effective knowledge agents in a pluralistic environment: What future for community health workers?

28 million with a repayment rate of 98%. LESSONS LEARNED Initial research indicates significant improvement in access to health care. Over three years, much has been achieved and learned. This paper summarizes these experiences and concludes that collaboration between developing countries can work, with fine-tuning to suit local contexts and traditions.