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Health and Poverty in Bangladesh Binayak Sen & Shambhu Acharya

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Health and Poverty in Bangladesh Binayak Sen & Shambhu Acharya 28 World Health • SOth Year, No. 5, September-October 1997 Health and poverty in Bangladesh Binayak Sen & Shambhu Acharya Sociology of health care period. Much of the progress at the The existence of a very aggregate level was propelled by the number of key health indica­ rapid growth of the immunization numerous underclass of tors in Bangladesh reflect programme, which covered less than Aimprovement during recent 3% of all children in the late 1970s extremely poor people is years. Infant and child mortality and over 80% in the mid-1990s. something which national rates have declined in rural as well Access to safe drinking-water is as urban areas, and there has been a another indicator which registered policies must come to terms dramatic reduction in the infant considerable progress in the 1980s; with, whether they are mortality rate from 116 per 1000 even in rural areas the access rate is births in 1988 to 75 in 1995. This currently estimated at 78% com­ designed to improve health has been accompanied by an in­ pared with only 50% in the early crease in life expectancy at birth - 1980s. The progress on the health or reduce poverty, or both. from 55 to 59 years in the same front was, however, mainly restricted to the sphere of preventive health care, with little sign of im­ provement in the area of essential curative health. Of course, there are stiJI signifi­ cant deficiencies in the field of preventive and primary health care. In particular, mothers' health is still a neglected area as evidenced by the high maternal mortality rate; com­ municable diseases that are mostly preventable account for the major portion of morbidity and mortality; and access to sanitary toilets is ]jmited to only 15% of rural house­ holds. The poor quality of health services and overall health and hygiene conditions, including the quality of drinking-water, are persis­ tent concerns. Furthermore, progress at the aggregate level masks serious di sparities between population groups. Thus, the infant mortality rate is more than twice as high for the households of landless people (90 to 95 per 1000 births) as it is for those of landowners (40 per 1000 births). The disparity between slum­ dwellers and other communities within the urban area is similar (129 per 1OOO compared to 63 per I OOO), while the overaJI rural-urban dispar­ ity is also revealing (I 03 per 1000 compared to 81 per 1000). Gender Preventive care in an outreach community. There is a definite cause-and-effect link between eco­ differences are prominent in the case nomic conditions and health status. Photo Still Pictures/M. Edwards© of most of the health indicators for World Health • SOth Yeor, No. 5, September--October 1997 29 which data are available. Child death long-term poverty (however it is policies is often greatly reduced by rates are higher for girls in the age defined and measured) over the last the lack of an adequate insurance group of 1-4 years, and women have 25 years, but the rate at which it has mechanism against health-related a lower life expectancy than men. declined has slowed down consider­ risks. Curative health care for mothers, ably since the mid-l 980s. A large In order to forge a closer link particularly essential obstetric care, contingent of the extremely poor between health and anti-poverty and services for injuries and acci­ have remained outside the trickle­ programmes what is needed is an dents for the poor in both rural and down process, and economic im­ effective combination of health urban areas, remain inadequate. This provements such as the expansion of action and micro-credit schemes is an issue not only of quality but roads, electricity, irrigation or new (along with education) specifically quantity. In urban areas there is no technology in agriculture, have not for the extremely poor. Meanwhile public health infrastructure and in helped them. Even micro-credit institutional arrangements for the rural areas it is shrinkjng. In 1984, programmes which target landless public health services leave much to only about 20% of the treatment in and land-poor groups have largely be desired; for instance, there is an rural areas for acute illness was bypassed the extremely poor. The endemic problem of absenteeism carried out in the public sector and in search for other ways of promoting among the doctors at rural health 1994 the proportion had fallen to growth and reducing poverty has centres. The situation has been made 12%. become a policy imperative. worse by the poor quality of ser­ vices, shortages of drugs and sup­ plies, and poor maintenance of the A numerous underclass How poverty and health affect facilities . Solutions that are currently each other on offer envisage a much greater There are controversies over how to role for NGOs and local govern­ measure poverty, but three main ment, with less emphasis on a bu­ findings of poverty analyses are It is hardly surprising that poverty reaucratic, centrally managed public inescapable. First, the poor are not increases the likelihood of getting health system. • homogeneous: sharp differences sick, but this is only one (and per­ exist within their ranks in terms of haps not the most important) aspect income, calorie intake or standard of of the connection between health living indicators. By the conven­ and poverty. For instance, the very Dr Binayak Sen is currently Research Fellow at the Bangladesh Institute of Development tional criterion of income about 52% lack of adequate health care places Studies (BIDS), E· 17, Agargaon, Sher-e-Bangla of the rural population lived in the rural households at even greater Nagar, Dhaka I 207, Bangladesh, and absolute poverty in 1994, and they risk of slipping into the downward Dr Shambhu Acharya, formerly W HO Programme Manager in Bangladesh, is now could be divided into two di stinct spiral of poverty. The extremely Programme Management Officer at the WHO groups: moderately poor (29%) and poor households in Bangladesh Regional Office for South·East Asia, W orld Health House, lndroprostha Estate, Mah atma extremely poor (23 %). The exis­ currently spend between 7% and Gandhi Rood, New Delhi· I I 0002, In dia. tence of a very numerous underclass 10% of their income on health, of extremely poor people is some­ which is a sizeable burden by any thing which national policies must reckoning. Easing it through public come to terms with, whether they are health care would be a substantial designed to improve health or reduce step towards alleviating poverty. poverty, or both. Poor households are acutely Second, the incidence of poverty vulnerable to unexpected health­ varies significantly according to related setbacks, often leading to individual, household and commu­ loss of income and employment. nity circumstances. Poverty is usu­ Data from the Bangladesh Institute ally higher among those who possess of Development Studies show that little land and is endemic among health-related setbacks account on those who earn their livelihood average for 16 % of the causes of mainly through agricultural labour. deterioration experienced by house­ It is concentrated in areas with holds during the 1990-94 period. underdeveloped transport and elec­ To a large extent, health hazard­ tricity services. Again, gender differ­ related risks explain the vulnerabil­ ences in poverty are notable. For ity of tomorrow 's poor. While instance, the incidence of rural poverty alleviation programmes, poverty is about 12% higher in usually run by NGOs, provide ac­ female-headed households than in cess to credit or training and thus Access to safe water has considerably male-headed households. help the poor to generate additional improved in recent years in underserved areos Third, there has been a decline in income, the net impact of such of Bangladesh. Photo Still Pictures/) Schytte © .
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