Richard Smith: Why has Bangladesh done so well?

How has Bangladesh been so successful in achieving MDGs and good health outcomes? Richard Smith discusses.

richard_smith_2014Since the end of the War of Liberation in 1971 when millions died, and despite the famine of 1974 when probably more than a million died, Bangladesh has made remarkable progress. It’s one of the few low income countries to achieve the Millennium Development Goals. Life expectancy has increased from around 50 to over 70, and women now live longer than men, whereas Bangladesh was one of just three countries where men lived longer than women. Child deaths under 5 years have dropped from 25% to 4%, and maternal mortality has fallen from 700 per 100 000 to 150. Almost all children go to school, and the literacy rate of around two thirds is equal among males and females.

Why has Bangladesh done so well, and are there lessons for other countries? Attempts were made to answer these questions at a meeting earlier this week at the Institute of Development Studies in Sussex and an accompanying meeting with the All Party Group on Bangladesh in the Houses of Parliament. The Lancet has also had a special series addressing the question.

One reason for Bangladesh’s success is that despite political turbulence, the governments in Bangladesh have remained committed to human development, food security, reducing poverty, and promoting gender equality. Professor Nizam Ahmed from Chittagong University pointed out, however, that all the important developments have happened since Bangladesh became a functioning democracy in 1991. Economic development does not necessarily, however, deepen democracy, and the opposition did not contest the last election.

Bangladesh has also been blessed with two major organisations that together have been important in development: BRAC, the world’s largest non-governmental organisation, and icddr,b [formerly the International Centre for Diarrhoeal Disease Research, Bangladesh]. In broad terms icddr,b has made important discoveries that BRAC has scaled up. The classic example is oral rehydration treatment (ORT), the standard treatment for childhood diarrhoea, which was developed at icddr,b and scaled up across Bangladesh by BRAC.

Mushtaque Chowdhury, the vice-chair of BRAC, explained how research was important not just in the development of ORT but also in its scaling up. Initially, ORT was available only in hospitals, but BRAC trained 15 million women in their own homes on how to make ORT with “one pinch of salt, two spoonfuls of sugar, and half a litre of water.” But research showed that mothers would often get mixed up and add two pinches of salt and one spoonful of sugar. So the formula was changed to “one pinch of salt and one fistful of sugar.” The next problem was that mothers were told to use “safe water,” but it often wasn’t available. Research showed that any water was better than no water.

Further research exposed a “know-do” gap in that the mothers knew about ORT but gave it only 10% of cases of childhood diarrhoea. One problem was that because men had been not been educated on the use of ORT they would veto its use—and so men were educated. Research then showed that women recognised four different sorts of diarrhoea (each with a different name in Bengali) and treated only the most severe form with ORT. They were then trained to use it for all types of diarrhoea. Finally, the main source of medical advice to women were the 800 000 “village doctors” who are not medically trained. They were against the use of ORT, but BRAC worked with them to not oppose its use.

Four fifths of cases of childhood diarrhoea in Bangladesh are now treated with ORT, which is the highest rate in the world. BRAC works in 10 other African and Asian countries and has spread its use—but, as the Bangladesh story shows, social science research is crucial for scaling up ORT and will be needed in each country.

The Lancet and most of those who spoke at the meetings identified research itself as one of the important factors in Bangladesh’s success. Research in family planning has been crucial in reducing the fertility rate from 7 to 2.2, probably the fastest fall anywhere. Importantly, children who aren’t born can’t die prematurely, and fewer episodes of labour reduce a woman’s chances of dying in childbirth. Research on “assisted menstruation” has also been crucial in halving the number of illegal abortions: a woman who has missed her period can present for “menstrual regulation” and be treated so long as she is not given a pregnancy test. (Termination of pregnancy is illegal in Bangladesh.)

Research on vaccines has also been important in Bangladesh. High levels of child immunisation have been achieved, and vaccination for cholera, which is endemic in Bangladesh, is close. Much of the research in Bangladesh has been funded by international donors from Britain, Canada, Sweden, the US, and other countries as well as bodies like the Gates Foundation and the Wellcome Trust. Saul Walker from the Department for International Development pointed out that aid accounts for only 1.3% of Bangladesh’s Gross National Income but thought that aid had been important in Bangladesh’s success story and that “investing in local institutions long term” was the key.

The empowerment of women has been important in Bangladesh’s progress. Many have been educated, and they are the ones who have administered the ORT, embraced family planning, and made sure their children were vaccinated. Microfinance schemes have been important for alleviating poverty, and 80% of loans are made to women, who are much more reliable than men in paying back the loans. And as men have migrated to cities and overseas for work, women have taken on the running of farms and homes. Now women too are migrating for work.

But empowerment of women has a way to go. Only around 30% of women participate in the workforce, which is lower than in other South Asian countries. Child marriage remains common with 60% of women marrying under 16, and intimate partner violence is rife. Researchers are also seeing an increase in the number of women veiled, and there is a “conservative backlash.” And although maternal mortality has come down to 150 per 100 000, it is still way above the 30 per 100 000 achieved in Sri Lanka.

Bangladesh, which is expected to become a middle income country within 10 years, still faces formidable problems. Top of the list and threatening to undo achievements is climate change, said Rushanara Ali, the Labour Member of Parliament for Bethnal Green and Bow who was born in Bangladesh. Some 20-30 million people may be forced to move as much of the country disappears under water. And because of the success of previous programmes, non-communicable disease now accounts for about three quarters of death, and responding to it will be more complicated than treating childhood diarrhoea. Security is also a major problem currently in Bangladesh, and restoration of full democracy would help future development.

Richard Smith was the editor of The BMJ until 2004.

Competing interest: RS is the unpaid chair of the Board of Trustees of icddr,b.