Bangladesh

Annex-2

Millennium Development Goals

GOAL 1: ERADICATE EXTREME POVERTY AND HUNGER

Target 2: Halve, between 1990 and 2015, the proportion of people who suffer from hunger

Situational Analysis

Prevalence of underweight children[1]

The prevalence of moderately[2] underweight children (6-71 months) has declined noticeably from 67 percent in 1990 to 51 percent in 2000, while that of severely[3] underweight children of the same age group has been halved from 25 to 13 percent roughly during the same period. Also, the proportion of moderately underweight children under the age of five years decreased from 56 to 48 percent during the period 1997-2000.

Child malnutrition

Despite the progress achieved, child malnutrition in Bangladesh remains among the highest in the world, and more severe than that of most other developing countries, including the countries of sub-Saharan Africa. The proportion of underweight children in Bangladesh is 16 percent higher than 16 other Asian countries at similar levels of per capita GDP. Nearly, half the children are underweight or stunted, with 13 to 19 percent being severely underweight or stunted in terms of being more than three standard deviations below the relevant NCHS standards.[4] This suggests that children in Bangladesh suffer from short-term acute shortfall in food intake as well as longer-term under-nutrition. Much remains to be done in this vital area.

Trends in various indicators of malnutrition in children

Source: Various CNS and BDHS Reports

Vast differences exist in child malnutrition rates across economic groups. Child malnutrition is pervasive among the poor. More than 60 percent of the children of 6-71 months old, suffering from stunting, belong to the bottom consumption quintile. Contrary to expectation, however, nearly a third of the children from the richest quintile also suffer from malnourishment. This suggests that factors other than income play an important role in this phenomenon.

Such factors include per capita household food intake; infant feeding practices; maternal schooling and hygiene practices; access to safe drinking water, sanitation and health facilities; quality of village infrastructure; and protection against natural disasters. Presence of NGOs and public relief programmes have been found to have strong correlation with reduction in child malnutrition in the lowest consumption quintile.

Challenges

Much will need to be done to achieve the MDG target of halving the proportion of poor whose income is less than one dollar a day, and halving the proportion who suffer from hunger and malnutrition. Bangladesh has nearly 63 million poor - the third largest poor population in any country after China and India - and one of the highest rates of child malnutrition in the world. One third of the population lives in extreme poverty, and nearly half of Bangladesh's children are underweight. Demographic changes in upcoming years are likely to affect poverty and hunger in adverse ways. Achieving the MDGs within the next decade will require Bangladesh to develop and implement more ambitious and effective strategies. The primary challenges and actions needed to address them are summarized below.

Challenge 1: Addressing income poverty: Promoting strong economic growth

Various empirical analyses have concluded that economic growth is the most important factor contributing to poverty reduction. Achieving and sustaining strong economic growth will require attention on many fronts such as:

     Pursuing monetary and fiscal policies that sustain macroeconomic stability.

     Improving transparency, accountability and efficiency of the Government in all key areas, including taxation, public procurement, land administration, law enforcement, administration of justice, and regulation of banking, insurance, and the credit market.

     Enhancing government effectiveness by focusing on core state functions and delivery of public services.

     Expanding national capacity to design and enforce policies, laws, and regulations that facilitate private sector investment.

     Further liberalizing the trade regime to exploit the advantages of the rapidly globalizing world economy.

     Restructuring and privatizing state-owned enterprises and business activities under appropriate incentive and regulatory schemes, and reallocating public resources to the provision of high priority public goods.

     Accelerating development of infrastructure in key areas - such as power, ports, roads, inland water transport, and telecommunications - that have been identified as constraints on the investment climate.

     Strengthening capacity for enhanced absorption of aid resources.

Challenge 2: Reaching the poor: Promoting pro-poor growth

The initial level of inequality of income and ownership of assets and its possible further deterioration will determine the outcome of poverty. Pro-poor growth, therefore, needs to be promoted so that the positive impact of economic growth on poverty reduction is increasingly larger than the adverse impact of income inequality, and the poor are able to participate more actively in the growth process and derive increasingly higher benefits from it. Creation of more jobs and opportunities for entrepreneurship and self­-employment by the poor will need to be speeded up aggressively, so as to address the massive backlog of underemployment, as well as the large annual addition to the labour force on account of demographic factors. Income growth in rural areas has proven to be pro-poor in Bangladesh, and its continuation will need to be promoted proactively. Coordinated actions will be required in areas such as:

     Building income generating capacities of the poor by pursuing social sector programmes and policies that develop their human capital. This should include improving poor people's access to the Essential Health Service Package (ESP), addressing the problem of child malnutrition, and undertaking a comprehensive programme to improve the coverage and quality of education and skill development.

     Enabling the poor to participate more actively in economic activities through initiatives to facilitate their access to markets for credit, land, and labour. Expanding national capacity to design and enforce policies, laws, and regulations that facilitate pro-poor activities of the civil society.

     Enhancing cooperation and partnership among Government, the private sector, and civil society in scaled-up efforts to implement the PRSP.

     Identifying and addressing policy and institutional biases - in public spending, taxation, trade and regulation; for example those, which may work against the rural sector and the urban poor.

Challenge 3: Protecting the vulnerable: Supporting effective and sustainable safety net programmes for the vulnerable in poor areas

The persistence of disparities in poverty and hunger warrants the evaluation of social safety net options that target particular groups and areas. Some groups of the poor and hungry are chronically vulnerable, and some face vulnerabilities that are regional or seasonal in nature. Targeted interventions will need to be designed and prioritized, taking into account their financial sustainability and the country's other demands for pro-poor spending. Trade-off between reaching the poorest and the not-so-poor, and the distinction between short-term palliatives and long-term measures, to enhance the prospects for poverty reduction, must be recognized.

Types of targeted interventions that should be introduced include:

     Identifying and promoting infrastructure investment projects with high expected impacts on employment, growth, and market access in poor (especially rural) areas.

     Supporting safety nets for protection against natural disasters and the associated hardships in disaster-prone areas.

     Undertaking targeted nutrition interventions for vulnerable groups and areas by, for example, expanding the reach and effectiveness of the National Nutrition Programme.

Challenge 4: Reducing hunger and malnutrition: Comprehensive programme of integrated actions on many fronts

Halving the proportion of people who suffer from hunger will be a challenging task. Speeding up per capita income growth and pursuing targeted safety net programmes as discussed under Challenge 1 above, are needed for the expansion of household food intake. A comprehensive programme to address hunger would include interventions in the following additional areas:

     Promoting food security by sustaining strong growth of domestic food production and implementing a liberalized regime for food imports. Promoting change in food habits for increasing the nutritional intake of vulnerable people.

     Promoting improved infant feeding practices, including breast feeding practices; supporting maternal schooling and hygienic practices.

     Improving access to safe drinking water, especially by addressing the threat of arsenic contamination of underground water.

     Improving access to sanitation.

     Improving access to basic health facilities.

     Supporting safety nets for protection against natural disasters.

     Promoting partnership among the Government, private sector and NGOs in designing and implementing interventions to promote food security.

GOAL 4: REDUCE CHILD MORTALITY

Target 5: Reduce under-five mortality rates by two-thirds between 1990-2015

MDG 4 indicates that under-five mortality rate must be reduced from 151 deaths per thousand live births in 1990 to 50 in 2015.

Situational Analysis

Under-five mortality

While there has been an appreciable drop in under-five death rates from 151 deaths per thousand live births in 1990 to 88 in 2003,. From this base, it will be necessary to maintain a pace of annually reducing under-five deaths by at least three deaths per thousand live births to achieve MDG 4 by 2015.

Child mortality rate is a reflection of the care, health and nutrition status of children below the age of five years and also indicates the social, cultural, and economic progress of the country.

In the case of under-five children, neonatal and perinatal causes contribute to 48 percent of the deaths. Other factors include very low rates of institutional deliveries (8.6%), low attendance of deliveries by skilled personnel (13 %), and low utilization of antenatal care at least one visit (56 %). More than 71 percent[5] of these neonatal deaths were due to non-­communicable diseases, mainly birth-related ailments as well as neonatal tetanus.

Other major causes of under-five deaths are pneumonia (18%), diarrhoea (6%), injuries and drowning (8%), and measles with malnutrition underlying most other causes (13%). Poor care-seeking behaviour and practices are also important contributing factors. Only eight percent of parents of sick children under the age of five seek care from qualified healthcare providers.

In order to reduce deaths from diarrhoea, the oral rehydration therapy (ORT) campaign has been in effect for several decades. The use of oral rehydration solution (ORS) has increased from 62 percent in 2000 to 68 percent in 2003.

Unit: Per 1000 births

Malnutrition contributes to over one half of child deaths, with low birth weight estimated to affect 30 to 50 percent of infants. Over the years, appropriate interventions have helped to reduce the proportion of underweight children from 66.5 percent in 1990 to 51.1 percent in 2000 to 48 percent in 2004, and child stunting from 65.5 to 48.8 to 43 percent. In spite of this, the prevalence of child stunting and underweight is still very high according to WHO criteria. To address child malnutrition, it is essential to improve the nutritional status of adolescent girls and mothers, because if mothers are malnourished, their children are much more likely to have low birth weight and remain affected throughout their lives. Although chronic energy deficiency in non-pregnant women has declined from 52 percent in 1997 to 45 percent in 2000, it still remains at high levels.

Since 1997, the prevalence of night blindness, an early indicator of Vitamin A deficiency, has been maintained below the one percent threshold that indicates a public health problem. This success has largely been due to the Vitamin A supplementation programme, which increased coverage from 41 percent in 1993 to over 85 percent in the second half of the decade by linking the distribution of Vitamin A capsules with the National Immunization Days (NID). Coverage of iodized salt increased from 19 percent in 1993 to 70 percent in 1999, and correspondingly, the prevalence of iodine deficiency fell from 69 to 43 percent.

While these findings are encouraging, they mask the fact that infants and children continue to consume diets that are grossly inadequate in Vitamin A, iron and other micro-nutrients. Anaemia, which is largely due to iron deficiency, affects about 50 percent of under-five children, a prevalence level that denotes a severe public health problem. Breastfeeding is rarely exclusive for the first six months of life, and complementary foods are often introduced too early or too late and are of poor quality.

There is urban-rural difference in under-five mortality rates. In 2001, the rate in urban areas was 52 percent while in rural areas it was 89 percent. Similarly, there is also difference in under-five mortality rate between boys and girls. In 2001, the under-five mortality rate for boys was 84 percent and for girls 81 percent.

There has been an epidemiological transition of mortality pattern in Bangladesh. Due to the relative decline in deaths caused by infectious diseases, statistics now reveal that injuries and accidents are also important causes of deaths. For example, eight percent of all under-five deaths and 30 percent of total deaths among children aged 1-4 years have been found to be caused by injuries and accidents such as drowning.

Infant Mortality

The trend shows that there has been a steady decline in the infant[6] mortality rate (IMR) from 94 per thousand live births in 1990 to 56 in 2001 to 53 per thousand in 2003.[7] About two-thirds of infant mortality are from neonatal deaths, which are a direct consequence of factors such as low birth weight, pre-term delivery and birth asphyxia.

Unit: Deaths per 1000 live births

It is estimated that to achieve the goal of 32 deaths per thousand live births, the current declining rate must be sustained. That is, infant death rates must be reduced annually by at least two deaths per thousand live births between 2005 and 2015.

Immunization

Access to vaccination has been among the foremost interventions that have helped reduce mortality rates in Bangladesh. NID has been observed for many years and has proved very successful. Since 2001 not a single case of wild polio virus transmission has been confirmed in the country until 2006, when there were 18 cases. The percentage of fully immunized children increased from 53 percent in the 1990s to 69 percent in 2000, but the coverage remains below expectations.[8] Measles coverage was 77 percent in 2005.

The reasons for the low rates, from the demand perspective, include drop-out resulting from the lack of awareness of the need for immunization, lack of information on the medical aspects of the vaccines, and distance of the vaccination centers. From the supply side, the low rates arise from the absence of medical personnel in the health centres, irregular review of the immunization programme, and inadequate supervision costs.

To offset some of these problems, supplementary immunization activities have been introduced and currently 86 percent of new-born are protected at birth against neonatal tetanus. Since 2003, under the Expanded Programme of Immunization (EPI), Hepatitis B vaccination has been introduced, along with the use of auto destruct syringes. The programme has been activated in seven districts and one City Corporation, and by 2005 will cover all districts in the country.

It is estimated that to achieve the goal of 32 deaths per thousand live births, the current declining rate must be sustained. That is, infant death rates must be reduced annually by at least two deaths per thousand live births between 2005 and 2015.

Immunization

Access to vaccination has been among the foremost interventions that have helped reduce mortality rates in Bangladesh. NID has been observed for many years and has proved very successful. Since 2001 not a single case of wild polio virus transmission has been confirmed in the country. The percentage of fully immunized children increased from 53 percent in the 1990s to 69 percent in 2000, but the coverage remains below expectations.⁸ In 2003, BCG coverage was 96 percent, while measles coverage was only 69 percent.

The reasons for the low rates, from the demand perspective, include drop-out resulting from the lack of awareness of the need for immunization, lack of information on the medical aspects of the vaccines, and distance of the vaccination centres. From the supply side, the low rates arise from the absence of medical personnel in the health centres, irregular review of the immunization programme, and inadequate supervision costs.

To offset some of these problems, supplementary immunization activities have been introduced and currently 86 percent of new-borns are protected at birth against neonatal tetanus. Since 2003, under the Expanded Programme of Immunization (EPI), Hepatitis B vaccination has been introduced, along with the use of auto destruct syringes. The programme has been activated in seven districts and one City Corporation, and by 2005 will cover all districts in the country.

Challenges

Challenge 1: Cost of immunization

The multi-year EPI plan estimates that to fully immunize the under-one population at 80 percent per annum will require US $ 57 million per year.[9] An additional US $ 5.2 million per year will be required for scaling up the Integrated Management of Childhood Diseases (IMCI), an important component of the Health, Nutrition and Population Sector Programme (HNPSP) that addresses childhood mortality. The nutrition component of the same programme is estimated to cost US $ 36.9 million annually. The cost of other related programmes will add to the financial requirements.

Challenge 2: Sustaining Success

Success has been achieved in Bangladesh because of the close attention paid to infectious and parasitic diseases in the past two decades. To achieve MDG 4 by 2015, this momentum has to be sustained by:

     Consolidating and strengthening achievements in on-going interventions that address fundamental causes of childhood mortality. These include routine immunization, control of diarrhoeal diseases and acute respiratory infection, accelerating the pace of reduction in neonatal mortality through ensuring antenatal care, skilled attendance at birth, and emergency obstetric care for those in need.

     Enhancing the effectiveness of interventions for reducing malnutrition among children and women, with a special focus on adolescent girls, through bridging deficiencies of both macro and micro-nutrients (especially iron and iodine).

     Exploring interventions required to address the contemporary causes of mortality, i.e., accidents and injuries, specially drowning.

     Strengthening partnerships among the Government, NGOs, specialized agencies and local government institutions.

     Integrating vertical programmes for reduction of childhood mortality such as ARI and CDD, to achieve efficiency gains for both care seekers and providers.

     Focusing on consumer awareness and communication strategies for promoting behavioural change.

     Ensuring need-based targeting of un-reached and un-served populations, especially for area-specific health and nutrition interventions in urban slums, the Chittagong Hill Tracts and coastal areas.

     Strengthening the management information system through establishing a database for informed decision support, information gaps, consistency and veracity.

GOAL 5: IMPROVE MATERNAL HEALTH

To achieve MDG 5, Bangladesh must reduce maternal mortality from 574 deaths per 100,000 live births in 1990 to 143 by 2015; and increase the proportion of births attended by skilled health personnel to 50 percent, and reduce the Total Fertility Rate to 2.2 per woman by 2010.[10]

In addition to the above, a third target[11] for Bangladesh is Reproductive Health (RH) Services for All, as this is closely linked to maternal mortality and morbidity. The indicators for RH are maternal malnutrition and median age at marriage. The target is to reduce maternal malnutrition from 45 percent in 2000 to less than 20 percent by 2015, and to increase the median age of girls at first marriage from 18 to 20 years.

Situational Analysis

Maternal Mortality

In spite of the fact that maternal mortality has declined from nearly 574 per 100,000 live births in the 1990 to between 320 and 400 in 2001,[12] the Maternal Mortality Ratio (MMR) in Bangladesh remains one of the highest in the world. It is estimated that 14 percent of maternal deaths are caused by violence against women, while 12,000 to 15,000 women die every year from maternal health complications. Some 45 percent of all mothers are malnourished.[13]

The population of Bangladesh is relatively young, with a third falling within the age group of 10-24 years. Nearly half the adolescent girls (15-19 years) are married, 57 percent of them become mothers before the age of 19, and half these adolescent mothers are acutely malnourished. Thus, MMR among adolescent mothers is 30-50 percent higher than the national rate.

The chief causes of maternal deaths are hemorrhage, unsafe abortion, and the ‘three delays dynamics’. The first delay, arising mainly from poverty, is in seeking professional care; the second delay is logistical as most of the health centers and private clinics are located in district towns, whereas 70 percent of the population are rural based; the third delay arises from the lack of adequate human recourses and trained personnel at the service centers.

Births attended by skilled health personnel[14]

The number of births attended by skilled health personnel has increased from 5 percent in 1990 to 12 percent in 2000 to 13 percent in 2004. In the context of Bangladesh, the increase is insignificant, as the majority still do not receive such services. However, there are wide variations among income groups: 40 percent of births in the highest income quintile are attended by skilled health personnel, compared to only four percent in the lowest quintile.

Total Fertility Rate

There has been significant decline in the total fertility rate (TFR)[15] from 6.6 in the mid 1970s to 3.3 in the mid 1990s with regional variations in the reduction pattern.[16] However, in spite of a steady increase in contraceptive prevalence rate from 45 percent in 1994 to 54 percent in 2000 to 58 percent in 2004.

Several measures have been taken to address these problems. The Essential Obstetrics Care (EOC) programme through the Maternal and Child Welfare Centres (MCWC) was introduced in the early 1990s. Subsequently, a more holistic approach was adopted through the National Maternal Health Strategy 2001, which takes a rights-based approach to maternal health with Safe Motherhood as its central theme. The Strategy has been integrated into the Health and Population Sector Programme (HPSP 1998-2003), and into its follow-up, the Health, Nutrition and Population Sector Programme (HNPSP 2004-2006).

Interventions such as Safe Motherhood Services that provide iron, folic acid and vitamin A supplements to the target population[17] have been included in the HNPSP, with the objective of reducing maternal malnutrition to below 20 percent by 2015. Other interventions under this project include training programmes for skilled health personnel.[18]

Both the Government of Bangladesh and the donors are giving priority to the promotion of safe motherhood from the grassroots level upwards, through antenatal care, safe delivery, pre-natal care, essential obstetrical care and family planning.

Challenges

Challenge 1: Reducing the Total Fertility Rate

If the population of Bangladesh stabilizes by 2035, there will be over 40 million women of reproductive age (15-45 years) in 2015 who will be the target population for preventive and awareness raising programmes on safe motherhood. In order to further reduce TFR, studies must be conducted to analyze the causes of its current stagnation. Advocacy programmes must be introduced on population stabilization.

Unit: Persons of Age 15 to 45

Challenge 2: Achieving MDG 5 -Target 6: Reduce the maternal mortality ratio to 143 per 100,000 live births by 2015

If MMR is to be reduced to 143 per 100,000 live births by 2015, the decrease will have to be at substantial rates:

     During 2005-08 MMR must be reduced by 5.6 percent points a year.

     During 2008-11 MMR must be reduced by 7 percent points a year.

     During 2011-14 MMR must be reduced by 8 percent points a year.

     During 2014-15 MMR must be reduced by 12 percent points a year.

Meeting this challenge will require the following:

     Bringing about a fundamental change in knowledge, attitude and behaviour towards safe motherhood and gender equality through an advocacy campaign on safe motherhood involving 13 relevant ministries.

     Increasing access to quality health facilities through public, private and NGO initiatives.

     Increasing financial investments in the health sector including in skills development.

     Specifically targeting the poor for reproductive health interventions, as maternal mortality and morbidity is highest in the lower income groups.

     Accelerating the reduction of malnutrition, especially for females of reproductive age.

Challenge 3: Rapidly increasing the proportion of births attended by skilled health personnel

If population is stabilized by 2035, 2.52 million children will be born in 2010; 2.56 million in 2013 and 2.6 million in 2015. The 2001 Bangladesh National Strategy for Maternal Health calls for 50 percent of all deliveries to be attended by skilled health personnel by 2010. This implies that 1.26 million deliveries will be attended by skilled health personnel in 2010. To achieve this target, there must be a rapid increase in the rate of growth of births attended by skilled health personnel, which will in turn require an accelerated increase in the number of trained personnel.

Challenge 4: Increasing by two years the median age of girls at first marriage

There is a significant relationship between delayed marriage and lower fertility and greater health seeking behaviour. Thus, increasing the median age of marriage of girls by two years can significantly lower adolescent fertility, reduce MMR, slow the rate of population growth, and improve the nutritional level of young mothers and children.

This can be achieved by providing greater access to higher education for adolescent girls through scholarship and stipend programmes. Such interventions must be accompanied by advocacy and awareness raising campaigns on safe motherhood to promote changes in attitudinal and cultural behaviour.

Challenge 5: Providing reproductive services to all by 2015[19]

In addition to the MDG 5 global targets, Bangladesh will also attempt to achieve the following RH target by 2015[20]:

     Halve maternal morbidity

     Halve maternal malnutrition

     Reduce TFR to 2.2

     Improve adolescent reproductive health

     Eliminate violence against women

Constraints

In aiming for such ambitious targets some constraints need to be taken into consideration:

     Reliable national estimates are not available for morbidity. Age specific female mortality rates will serve as proxies until better parameters are identified.

     The maternal malnutrition is severe in Bangladesh - 45 percent of all mothers are malnourished and only one percentage point decline has been achieved per year. In a business-as-usual scenario, by 2015, about 25 to 30 percent of mothers will still remain malnourished. It is expected that the new HNPSP will address some of the challenges relating to maternal malnutrition.

     Adolescent reproductive health (ARH) has to receive increased attention to ensure an improved health life cycle, and to put early preventive measures to the threat of the spread of HIV/AIDS. As data on ARH is scanty, teenage (15-19 years) pregnancy and motherhood can be used as a proxy. A survey carried out in 1999-2000 shows teenage pregnancy to be as high as 35 percent. A comprehensive strategy has to be developed if it is to be almost eliminated by 2015.

     Violence against women is a major concern for health, productivity, dignity and maternal mortality in Bangladesh. It is estimated that 14 percent of maternal deaths are caused by violence. Inclusion of this indicator when monitoring the MDGs will help raise awareness of this national problem. It will also promote quantitative methods for monitoring the progress towards the elimination of violence against women.