The Financial Express

Health systems and outcomes

| Updated: June 29, 2019 21:27:22

Lankabangla and Fianancial Express Lankabangla and Fianancial Express
Health systems and outcomes

Bangladesh has emerged as a lead player in the use and integration of research into development decision-making. Notably, this applies in relation to health systems, nutrition, social protection, agriculture and poverty.  The author recollects that a few years back an international conference held in Dhaka, among others,  aimed at projecting how high quality research could  be embedded within progarmmes, showcase research findings, discuss challenges of integrating research with programmes, highlight successful examples and discuss future needs etc.

A rundown of the findings through memory lanes throws important insights on our country's progress:  "There have been remarkable improvements in welfare and human development in Bangladesh in recent years. These have been supported by rapid economic growth and many successful social and health programmes undertaken by the government and non-government organizations, shrinking family sizes and growing access of women to education. Overall improvements in child nutrition measured in terms of reduced child stunting can be seen as part of this success story, though there are still many areas of nutrition in significant need of attention".  With the good news on board, we have the bad news that the proportion of stunted children remained almost constant for a couple of years. However, we also notice that the association between improved health services and improved nutrition in Bangladesh is very strong. "It does however rest on a relatively weak health system, in which general morbidity remains high….Antenatal coverage for births increased from 58 per cent in 2004 to 79 per cent in 2014, and 64 per cent of women in 2014 benefited from services by a trained antenatal care provider. Birth attendance by a trained skilled provider nearly tripled over a decade from about 16 per cent in 2004 to 42 per cent in 2014. As maternal and infant mortality have declined, so have stunting rates". The picture on sanitation is promisingly  positive as Bangladesh is reported to be one of the 16 countries that reduced open defecation by over 25 percentage points in the MDG period; also  the access to pure drinking water tremendously increased. . Reduction in open defecation led to reduction in stunting, although, absolute child stunting levels are still high at 36 per cent. By and large, researchers are of the view that  nutritional indicators seem to lag behind health indicators in the country.

Note that much of improvement in nutrition in recent years is likely to be associated within these broad improvements in human development and poverty reduction, "within a wider enabling environment of pro-poor economic growth, rather than through programmes specifically aimed at improving nutrition. As Bangladesh moves on, having already made many nutrition-sensitive gains, a more concerted effort on nutrition-specific community programmes is needed, if substantial remaining gaps and future challenges (including obesity) are to be addressed.

By and large, much of the improvement in nutrition in Bangladesh in recent years is likely to be explained by what can be seen as 'nutrition-sensitive drivers' within wider enabling environment of pro-poor economic growth that  is linked to improved agricultural production and diversification; a vibrant NGO sector supporting income generation; expansion of non-farm business and manufacturing sectors creating employment opportunities; remittance from labour migration, and improving infrastructure and electrification. Also contributed to this improvement:  (a) improved access to education, health and family planning services use and availability, (b) demographic change, such as smaller family size, increased birth intervals, and lower age at pregnancy, and (c) more widespread use of safe water and better sanitation. "These drivers are also largely the result of economic and social development, not of programmes and interventions specifically intended to improve nutrition.

Both direct and indirect drivers - result of economic and social development - played pivotal role in improving health situation in Bangladesh. In fact it is a paradox that Bangladesh performed well with a weak health system. "Yet many millions of children in Bangladesh still grow up stunted because of poor nutrition and levels of acute nutrition deficiencies…the challenge is to make further improvements….Taken together, a major recommendation is that nutrition specific interventions will need to take on (a) greater role in Bangladesh than they have done to date."

The conference concluded with a plenary session. Panellists focused on three main issues of contemporary concerns. First, why is it that, unlike smaller ones, large interventions are difficult to scale up? The panellists identified a few constraints to this effect - lack of political commitment, resources and transparency, structural problems, stakeholders' political decision. Second, who sets research agenda and to what relevance? In some cases, the agenda is dictated by donors but most of the programmes could set their own research agenda given sufficient capacity building; sometimes dictated agenda could outperforms indigenous agenda in terms of relevance and reality on the ground.    Panellists also suggested a drift away from traditional research reasoning and argued for more relevant research. There was  a clarion call for more integrated approach among various stakeholders ranging from conceptualisation to planning to implementation to measurement of outcomes. More importantly, in a regime of dwindling aid and grants,  both practitioners and researchers should eye on home-grown sources of funding. Perhaps technological development, especially the spread of  mobile phones could impart positive impacts on health access although adverse impacts should duly be taken into account.

We expected that the National Budget 2019/20 would  say something about the prevailing lack of political commitment, resources and transparency, structural problems, stakeholders' political decision regarding health sytems and nutrition in Bangladesh. Unfortunately, the omission has been quite conspicuous.

Abdul Bayes is a former Professor of  Economics at Jahangirnagar University

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