Bangladesh, which is situated in a resource poor setting with a population of over 150 million, faces the major health challenge of a high maternal mortality rate. In the 1970s, the maternal mortality rate was 700 deaths per 100,000, and now it is still at 320 per 100,000. Although Bangladesh has made progress in reducing its infant mortality, much progress needs to be made to reach the Millennium Development Goals for maternal mortality. Bangladesh will need more than five years to achieve the goals. The Global Health Initiative (GHI) will help address the major health challenges women face in Bangladesh. Bangladesh has successful models of collaboration and public-private partnerships to share with other countries.
Bangladesh’s family planning program is a successful health intervention that can be modeled in other emerging countries. The program started in 1965 focusing only on family planning issues, and in the early ‘80s, maternal and child health services were integrated into the program. And later, reproductive health was also integrated into the program.
The use of Family Welfare Assistants (FWAs)—mostly women—was a very successful element of the Program. The FWAs went door-to-door to motivate women in high risk groups (commercial sex workers) to learn more about health and improve their lives in rural Bangladesh.
The Female Welfare Assistants were mostly young, married women who were hired and deployed as outreach workers, trained to visit homes offering contraceptive services and information. There were 25,000 in the public sector and 12,000 in the nongovernmental sector. Each worker was assigned to eligible couples; they visited them once every two months, and offered health services at the couples’ doorsteps. The FWAs constituted a link between rural populations and the government; the program’s reach was dramatic.
The government-supported family planning program, which incorporated other elements as well, was a great success. During a 30-year span, the total fertility rate in Bangladesh was reduced by half, from six to three children per woman. This is important because high fertility is often associated with increased risk of maternal morbidity and mortality. Contraceptive use by married women rose from 8% in the 1980s to 58% in 2007. Although the original objective was to achieve demographic goals, Bangladesh has done something which only few other countries at its level of socioeconomic development has been able to accomplish: it has created a program that responded to couples’ needs without resorting to coercive measures.
US Secretary of State Hillary Rodham Clinton’s speech last January reflects the strong commitment to bringing women’s health back to the development agenda. She renewed the US’s commitment for family planning and reproductive health as well as for health systems strengthening.
This commitment will be crucial for Bangladesh, as it continues to address major health challenges. Women, most importantly, were the key to the success of family planning interventions. They belonged and served the women in the same community. The Female Welfare Assistants helped women reduce their family size, improve their health, and enhance their economic and social empowerment.
As a GHI Plus country, Bangladesh will have several opportunities to improve its own health sector. Bangladesh will benefit from the systems strengthening efforts of the GHI, especially, scaling up and improving the quality of low-cost package of services reaching mothers, newborns, and most importantly reducing unmet needs for family planning.
The GHI will help define what is “best” and will give more attention to the importance of evidence and research.
Halida Akhter, MBBS, MPH, Dr. PH, is MSH’s Global Technical Lead for Family Planning and Reproductive Health. She is originally from Bangladesh and is a global health expert working in the field for 30 years.