Introduction

While many nations across the world still continue to struggle to achieve near optimum and desirable health outcomes in various areas including public health, education and so on and despite being economically well-off and bestowed with robust resources; Bangladesh as a so-called “one of the poorest nations” has set an example in redefining its position on the world map by achieving some outstanding achievements in the health sector [1,2]. With a current population of over 153 million, ranking eighth on the list of most populated nations globally and despite once being labeled as “the country without hope” after its independence in 1971, Bangladesh has strived to overcome various odds in the health sector which go in parallel with other endeavors [3,4]. It is commendable that only after four decades of its independence, in the year 2010, UN acknowledged Bangladesh as a country for setting milestones in achieving extraordinary progress in Millennium Developmental Goal (MDG 4) in combating child motility [2].

While on the other hand, this goal has not been achieved in most of the neighboring countries in Asia, even with much higher GDP than Bangladesh. Moreover, Bangladesh has also achieved its goal of being parallel in the direction of significantly reducing maternal mortalities (MDG5) [5]. In this report we will uncover the extraordinary journey of this budding nation and its remarkable achievements in ten points, especially in the health sector, and how other nations could employ these strategies to achieve their national health care goals, and simultaneously its implications in the global health arena. Moreover, the implications of its achievements which go in parallel with current and future challenges, in combination with the national and international stakeholder involvement, the changing dynamics of the health and other priorities, not only put Bangladesh at the forefront of the global health arena but prepares a diverse global audience of international leaders, policymakers, health advocates, other stakeholders and its future generations to mark not only on how these new challenges are conquered but also on how the existing milestones are sustained.

Objective

In this report, I will discuss some of the incredible achievements of Bangladesh in enhancing its health care system and its relevance in global health. Secondly, this report presents an evidence-based window to the nations in the West and across the globe to consider strategies, planning, and implementation mechanisms in their governance, thereby focusing on achieving and enhancing their goals in health care. Finally, while I discuss these achievements, the paradox behind the reason that this nation is called a “Positive Deviant”will become more clear, thereby confirming the interplay of its visionary leadership, timely intervention and navigation and investment of adequate resources amid a low resource setting.

Rationale for Choosing Bangladesh as a Country in Focus

Before India got its liberation from British Rule in 1947, Bangladesh and Pakistan were still part of India. However, with a new Muslim majority Pakistan formed its own independent country on August 14, 1947, and huge part Bangladesh was part of it. However, clashes began when Bangla was scrapped as the national language of Pakistan, and Urdu was announced to be the new official language in the region. After years of oppression, Bangladesh became an independent nation in the year 1971, late in comparison with both India and Pakistan. However, Bangladesh with its persistence, resilience, smart planning, strategy, and implementation of tailor-made policy and mobilizing its national human resources by seeking bilateral and international support made it a real achiever in health gains, which are some of the main points to discuss in this report. Because of these inspiring facts, Bangladesh has achieved some incredible milestones in the sector of health, which countries like India and Pakistan have still not yet achieved. Moreover, in the global health arena, narrating the success story of the neighbor who has done incredibly great in achieving these milestones could open new insights to get inspiration not in only changing the perception in bi-lateral information and exchange on employing sustainable methodologies in a country for example, India, Nepal, Pakistan and so on, but also the nations across the globe, who have not a higher GDP (please see appendix) but are also bestowed with better health infrastructure, resources (including human resources), technology, innovation and so on.

The saga of Bangladesh’s success story is summarized in following ten points:

a. Health at low cost: Bangladesh is the first country in the region of Southeast Asia and East Asia to have an economic and user-friendly health policy, which is not implemented timely but is accessible to the wider subjects including the poorest in this nation. For this landmark achievement, Bangladesh was acknowledged and praised for its innovation for “Health at low cost” [6].

b. Prioritizing Health issues and mobilizing resources: After its independence in 1971, Bangladesh started its nationwide developmental process characterized by factors such as social mobilization, institutional pluralism, and civil dynamism, which set up a forging ground for various stakeholders, government, non-governmental organizations (NGOs), informal providers, international donors, and commercial enterprises. All the stakeholders involved worked for a common goal of providing health-service delivery with the foundation of equity and inclusion. This was achieved by focusing on the high-priority issues in health, which included family planning, immunization, oral rehydration therapy, tuberculosis, vitamin A supplementation, and so on [7].

c. Integration of women empowerment, gender equity, and health targets together: Another exceptional feature of Bangladesh’s success story in the health sector is that these health strategies, actions, and endeavors emphasized the importance of women’s empowerment and gender equity and its implication on sustainable achievement of health goals. Both these targets were achieved by smartly integrating them. This was acknowledged and implemented at the very early stages of the nation’s history as an independent country. Therefore, Bangladesh despite having a low gross domestic product (GDP), was still able to enter the medium range of the UNDP Human Development Index category in 2003 [8].

d. Timely development, adoption, and dissemination of health policies: Bangladesh under her ambitious governance, visionary leaders, and strategic policymakers not only pushed its health sector goals by introducing pioneering innovations for new policies, products, and processes but were also timely developed, rapidly adopted and widely disseminated among masses making sure that the benefits are reached to even most vulnerable. All the prioritized health actions were scaled-up to the entire country through the huge and remarkable deployment of diverse stakeholder involvement, the key to which is involving mostly its female frontline health workers who reached out to every household even in the most unreachable and infrastructurally inaccessible geographic areas [9-11].

e. Endorsement of active family planning initiative: Bangladesh is one of the first developing countries in the region to strongly endorse a national family planning program. This has resulted in an outstanding reduction in fertility rates among women aged 15 to 49 years from 6.6 births per woman in 1994 to 2.7 in 2007 among the same age group in the nation. Although inequalities among birth rates still exist, where poorer women still have approximately one child more (3.2) than well-off women (2.1). However, this indicator is far better than the other neighboring countries in the region, despite its lower per capita income [12,13].

f. Involvement of NGOs and foreign assistance: Bangladesh consists of some of the world’s biggest NGOs working in the country including BRAC and Bangladesh Diabetic Samity (BADAS) For example the network of hospitals and clinics associated with BADAS provide low-cost healthcare services to people suffering from diabetes and other disorders throughout the country. Moreover, these NGOs work in different sectors to address issues of poverty, unemployment, health, education, the environment, and so on. The leadership of this country has not only created a sound space for such agencies to work on the ground, but work in collaboration to achieve the common goal [14-16]. This goal has greatly been achieved by foreign assistance and aid, which has seen significant peaks since its independence. For example, external financial investment was up to 70% in 1970 (which was reduced up to less than 10% in 2005). Yet, foreign aid has proven to be fruitful to accelerate the work of the NGOs, which grabbed up to 18% of total aid commitment to the country in 2003 [17]. This is because foreign donors wanted to make sure that their money is reached the people in need therefore NGOs were involved as an effective channel, rather than the country depending only on government aid and assistance. In this way, developmental assistance from foreign stakeholders had a significant impact on the nation’s stride.

g. Outreach on innovation and facility to most vulnerable: Another smart approach towards disseminating and reaching out to people belonging to the most remote areas in the nation in terms of providing health care, was the government move (in collaborating with NGOs) which included creating a sustainable approach which increased the outreach through the creation of new facilities up to the union and lower levels, by recruiting thousands of new workers. These workers were mostly women from the community (called informal providers), who were given basic training and took over the most important program of immunization program by reaching out to almost all parts of the country, even the most remote, thereby increasing the coverage from 2% in 1986 to 59% in 1993–94, to nearly 82% in 2007 [18]. These programs included oral rehydration therapy, which enabled mothers to prepare homemade oral rehydration saline to combat their children’s diarrhea [19,20].

h. Acknowledging the essence of research and evidencebased approach: Since the establishment of Bangladesh as an independent nation, great emphasis has been given to investing in research, especially in the sector of health. This became the backbone of the nation’s program and policy development; efficient monitoring and evaluation thereby leading to their successful implementation and returns. It is noteworthy to mention that this nation hosts some world-class research institutions like the International Centre for Diarrhoeal Disease Research. This nation also developed oral rehydration therapy and pioneered much in health policy and systems research within its national boundaries and across the globe. Simultaneously, The Bangladesh Institute of Development Studies pioneered the basic research that clarified the role of health during increasing poverty. Also, The Lancet commission has shown its deep interest in undertaking a series of studies, which is a testimony of the nation’s research capacity [21,22].

i. Preparedness and resilience towards natural disasters: Bangladesh’s remarkable achievements in the health sector must also acknowledge the contributions made due to its success in mitigating the effects of and showing strong resilience after multiple natural disasters. It is well documented how nations’ innovations in alleviating the effects of natural disasters changed over time and have inspired nations across the globe to follow in their footsteps. For example, the cyclone in 1970, killed more than 500 000 people in the country, in comparison with recent cyclones which on the one hand are of equal force and severity but killed only a few thousand people. This is because the nation developed a smart and sustainable, system of timely and emergency warning, evacuation, and resilience systems in case of such events [23].

j. Education: Non-health parameter with direct impact on health: Bangladesh has shown a phenomenal increase in its primary education enrolment which has increased from 74% in 1991 to 87% in 2005. A larger percentage (almost 80%) of young girls and women in the age group of 15 to 19 years have completed their primary education than boys and men (68.6%) in the same age group. This could be credited to the mass education campaign launched in the mid-1980s to enroll all girls in primary school. This has greatly led to the empowerment of women by high literacy rates, thereby contributing to higher uptake and success in health programs which have led to increased success of health parameters. BRAC is a great example of such a program that emphasized providing primary and secondary education to girls for free including free books and monetary assistance. This reinforced parents to send their daughters to school to receive an education.

The nation of Bangladesh has showcased an inspiring fighting spirit to conquer odds, vigor, and willingness to adapt and endorse innovative policies, pathways, and mechanisms in challenging situations in health care versus a challenging economy. This attitude has not only been witnessed but is being followed by many nations in the world. However, despite its great achievements, this nation is still facing some pressing issues in healthcare and other sectors. The paradox however is, how these challenges will be solved in the coming years? Will this vigor continue to achieve better and more in health and other sectors, given the changing dynamics of its current leadership? How will this nation cope with epidemiological transition and its double burden on health care and population? How will this nation fill the economic and social gaps among its subjects and its implications on health and social parameters? How will Bangladesh continue this path of resilience and positive deviance in the crisis of climate change, global warming, resource scarcity, competition, and increasing national, increasing incidences of NCDs while meeting national and international demands? The answer might still be found by just looking at the achievements of this nation, which started with realistic hope, despite being labeled as “The Nation without hope”. If this nation continues to believe in the manpower, intellect, and passion of its leadership and its proactive approach of openly accepting its vulnerability and achievements, there is no doubt that the future holds a strong hope for this nation to achieve, thrive, and inspire global health systems in future, despite may odds and challenges, but how these hopes are achieved is worthwhile to witness in the global health arena [24,25].

References

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2. The Daily Star Child deaths halved. UN award for Bangladesh. The Daily Star. 
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5. The Economist Bangladesh: out of the basket. The Economist (USA). Nov 2, 2012.
6. Bangladesh Maternal Mortality and Health Care Survey 2010.National Institute of Population Research and Training, MEASURE Evaluation, and International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka 2012.
7. Koehlmoos TP, Islam Z, Anwar S (2011) Health transcends poverty: the Bangladesh experience.in: Balabanova D McKee M Mills A ‘Good health at low cost’ 25 years on: what makes a successful healthsystems. London School of Hygiene and Tropical Medicine London, p. 47-81.
8. UNDP: Human Development Report 2003: Millenium Development Goals: A Compact among Nations to end Human Poverty. United Nations Development Programme, New York 2003.
9. UNDP: Human Development Report 2011.United Nations Development Programme, New York 2011.
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12. Bangladesh Health Watch: The state of health in Bangladesh: health workforce in Bangladesh: who constitutes the health care systems: James P Grant School of Public Health. BRAC University, Dhaka 2008.
13. Standing H, Chowdhury AMR (2008) Producing effective knowledge agents in a pluralistic environment: what future for community health workers?. Soc Sci Med 66: 2096-2107.
14. National Institute of Population Research and Training (NIPORT), Mitra and Associates, and Macro International. 2009. Bangladesh Demographic and Health Survey 2007. Dhaka, Bangladesh and Calverton, Maryland, USA: National Institute of Population Research and Training, Mitra and Associates, and Macro International.
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16. El Arifeen S, Christou A, Reichenbach L, Osman FA, Azad K, et al. (2013)Community-based approached and partnerships: innovations in health-service delivery in Bangladesh. Lancet, pp. 2012-2026.
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18. Chowdhury S, Chowdhury Z (1975) Tubectomy by paraprofessional surgeons in rural Bangladesh. Lancet 2: 567-569.
19. Ahmed S (2004) Aid and NGOs in Bangladesh.in: Centre for Policy Dialogue Revisiting foreign aid: a review of Bangladesh's development 2003. Centre for Policy Dialogue and University Press, Dhaka 2004.
20. Bangladesh Demographic and Health Survey 2007. National Institute of Population Research and Training, Mitra and Associates, and Macro International, Dhaka, Calverton 2009.
21. Abed FH, Chowdhury AMR (1989) Role of non-governmental organizations in international development. In: Reich M Marui (Edt.)., E International cooperation for health: problems, prospects and priorities. Aubern House Publishing Company, Dover, MA 1989: 76-88.
22. Bangladesh Demographic and Health Survey, 1993–94. National Institute of Population and Training, Mitra and Associates, ORC Macro, Dhaka, Calverton 1994.
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Abstract

While many nations across the world still continue to struggle to achieve near optimum and desirable health outcomes in various areas including public health, education and so on and despite being economically well-off and bestowed with robust resources; Bangladesh as a so-called “one of the poorest nations” has set an example in redefining its position on the world map by achieving some outstanding achievements in the health sector [1,2]. With a current population of over 153 million, ranking eighth on the list of most populated nations globally and despite once being labeled as “the country without hope” after its independence in 1971, Bangladesh has strived to overcome various odds in the health sector which go in parallel with other endeavors [3,4]. It is commendable that only after four decades of its independence, in the year 2010, UN acknowledged Bangladesh as a country for setting milestones in achieving extraordinary progress in Millennium Developmental Goal (MDG 4) in combating child motility [2].