Bangladesh Med J. 2015 Jan; 44 (1) Review Article Current status of health sector in Bangladesh Hossain R Introduction ratio is 104.9/100.0. Most people are living in the rural Over the last 42 years since independence Bangladesh has area (74%). Crude birth rate is 19.2 per 1,000 population made lot of strides in the Health Sector. Visibly there is and crude death rate is 5.5 per 1,000 population with net proliferation in health infrastructures - medical colleges, reproduction rate (NRR) per woman (15-49 year) is 1.03. medical university, private medical colleges, private clinics, Life-expectancy at birth (year) is 69.0 for both sexes: 67.9 private hospitals, district hospital, rural health centers and for male and 70.3 for female.3 (Table-I) community clinics. Many NGOs are also engaged and contributing toward health care delivery system. Much Table-I : Bangladesh-basic statistics progress has been made in the pharmaceutical sector providing aordable medicine, intravenous uids, anti Area (sq. km) 147,570 cancer drugs etc. ere is also increased awareness in the Population density (per sq. km) 926 general public on health issues. National and private level Crude birth rate (per 1000 population) 19.2 campaigns are ongoing to promote mental and child Crude death rate (per 1000 population) 5.5 health, vaccination programmes, mass deworming programmes, use of safe water and latrines, hand washing Life expectancy at birth m/f (2011) 67.9 /70.3 etc. Current health workforce A satisfactory level of progress has also been made in An eectively performing health system is essential in family planning. e population growth rate has been im¬proving the population’s health status, providing brought down. A huge and thriving network of private safe¬guard against health-related nancial threat and physicians stretched and spread to all over the country is enhancing the health sector’s responsiveness to customer’s trying to meet the needs of day to day medical problems. needs.4 Health sector reform is not only a health-related issue but also a development issue as health care systems ere have been signicant gains in terms of polio & account for 9% of global production and a sig-nicant small pox eradication. Extensive vaccination, case isolation portion of global empowerment.5 has resulted in diminishing number of diphtheria and tetanus. With improvement of overall hygiene and Pluralistic governance exists in the Bangladesh health sanitation standard there is a discernible reduction in system i.e. dierent stakeholders with their respective roles cholera, typhoid and dysenteries. A great no of are working in various competitive and collaborative tuberculosis satellite clinics now oer free treatment with combinations. ere is at least four such stakeholders. contribution from NGO’s. HIV & AIDS are at a low level First is the existence of a government sector with a of prevalence but remains a threat because of international mandate to not only set policy and regulate, but also to employment. Kala Azar and malaria has been signicantly provide comprehensive health services. Almost two-thirds curbed down. of total health expenditure is household expenditure in the private (formal and informal) sectors. ird is the Basic statistics vibrant and large non-government organisation (NGO) Bangladesh has a population of about 153 million, and is sector that focuses resources on the health needs of the 1 the eighth most populous country in the world with a poor, often as part of a broad array of development 2 annual Population growth rate of 1.37%. Male: female interventions. Fourth is the donor community that exercises disproportionate inuences in determining policy and programmatic priorities, orchestrates technical *Professor Major General Dr Rabiul Hossain assistance, and directs delivery strategies e.g. urban Consultant Physician General primary health care.6 DGMS Oce, Dhaka Cantonment, Dhaka Email : [email protected] Bangladesh has low ratios of credentialed professionals-only 0.5 doctors and 0.2 nurses per 1000 *For correspondence people, far less than the minimum standard of 2.28 per 46 Bangladesh Med J. 2015 Jan; 44 (1) 7 1000 recommended by WHO. (Table-II) Bangladesh Homoeopaths 5·9 (4%) Physicians, nurses, also has a shortage of skilled health workers (gure-1). dentists 7·7 (5%) with twice as many doctors as nurses clustered 8 Community disproportionately in urban areas. ere are high levels of health workers out-of-pocket and informal payments for health services 9·6 (6%) and medicines that are exhausting millions of households9 (gure 2). Despite these endemic shortfalls in key areas of Drug sellers 11·4 (8%) Traditional the health system, pronounced and rapid progress in the healers Village doctors 12·5 (8%) most important health measurements - e.g. infant and 64·2 (44%) child mortality, maternal mortality, fertility, and contraceptive prevalence—are remarkable.10 Traditional birth attendants 33·2 (23%) Table-II: Health Workforce of Bangladesh Workforce Total Figure-1: Density of dierent types of health-care providers per 10 000 population (Data from e state of health in Total Registered Graduate 53063 Bangladesh 2007)11 Doctors Estimated total doctors available 43,537 Million Taka (Tk 69=US$1) Private rms 1325 in the country Rest of world and private insurance 12391 (8%) 314 (1%) % of Doctors working under 35 % MOHFW % doctors working under other 3% Public sector Ministries 41318 (26%) Household out-of-pocket % of doctors working under the 58% expenditure private sector 103459 (64%) Medical Ocers (MCHFP) under 540 DGFP NGO 2092 (1%) Population per physician 3012 Population per bed 2665 Figure-2: Sources of nancing for health expenditure in Registered diploma nurses 26 899 Bangladesh, 2006–07(Data from Bangladesh National Health Accounts 1997–2007)12 Population per nurse 6342 Estimated Nurses currently available 15,023 Trends of health indicators Bangladesh stands out as a country that has taken giant Dental Surgeons 4165 steps in healthcare and has made signicant improvement Family Plan- ning Ocer (TFPO) 546 in health sec¬tor, which make it an example for other developing coun¬tries even though being a resource poor Assistant Family P lanning Ocer 1440 country. Over the last decades, key health indicators such as life expectancy and coverage of immunisation have Registered medical technologists 20035 improved notably, whilst infant mortality, maternal mortality and fertility rates have dropped signicantly.4,13 Medical Assistants 7365 Long before the emergence of contemporary global health Health Assistants (HA) 2 1016 initiatives, the government placed strong emphasison the importance of childhood immunisation as a key Assistant Health Inspector 4202 mechanism for reducing childhood mortality. Family Welfare visi tors 5 705 e Expanded Programme on Immunisation (EPI) in Bangladesh is consid¬ered to be a health system success Health Inspectors 1401 because of its remark¬able progress over the last two decades. It provides almost universal access to vaccination 47 Bangladesh Med J. 2015 Jan; 44 (1) services, as measured by the percentage of children under in 2010 (modern contraceptive 52%; traditional method 1 year of age who receive BCG (a vaccine against 9%).18 tuberculosis). is increased from 2% in 1985 to 99% in 2009. Coverage of other vaccines has also improved is great reduction of fertility rate undoubtedly substantially.14 contributed to the speed and magnitude of improvements in mortality, particularly in women. Major shifts in cause Maternal mortality has decreased by 75% since 1980,15 of death have occured because of these reductions in infant mortality has more than halved since 1990, and life mortality and birthrate.16 Similar to many countries that expectancy has risen to 68•3 years, higher now than in have had epidemiological and demographical transitions; neighbouring India and Pakistan.10 Progress in infant, Bangladesh has had a decline in infectious diseases and a child, and maternal mortality has been substantial and rapid onslaught of non-communicable chronic diseases in steady during the past four decades. e steepest gains an increasingly urban and ageing population. have been made in maternal mortality and mortality of children younger than 5 years, and slower gains have Compared with the country’s Asian neighbours, occurred in infant mortality. Bangladesh shows exceptional health achievement. In addition to neighbouring countries in south Asia and e unprecedented reversal in excess mortality of girls southeast Asia, Bangladesh’s national GDP puts it in the compared with boys is startling.16 is nding is a lowest income group of countries and regions, in the same remarkable empirical demonstration that gender-based range as neighbours such as Nepal, West Bengal, and health and social interventions can reverse marked biases Cambodia. However, Bangladesh’s life expectancy is in the care and treatment of children. superior to that for the other countries, except for Nepal. Maternal mortality was reduced from 574 deaths per 100 Bangladesh’s infant mortality, under-5 mortality, and 000 live births in 1991, to 194 deaths per 100 000 live maternal mortality rates are also superior to those for the births in 2010.17 As a surprise to many sceptics, other neighbouring countries and regions, except for West Bangladesh also had pronounced reductions in birth rate Bengal. Bangladesh is ahead of Pakistan in all education (fertility) from about 7•0 children per woman in 1970, to and health indicators. us, Bangladesh is a so-called 2•3