On World Health Day, recalling Bangladesh’s many achievements and milestones achieved in the health sector
When Bangladesh started its journey as an independent nation, one in five children died before their fifth birthday and life expectancy was only 46 years. 50 years later -- far from the cynical “basket-case” stereotype -- the country is celebrated globally as a model for human development. How did that happen?
As BRAC learned in the post war context, human development is largely determined by the health of its population. “Illness, malnutrition, and uncontrolled fertility” were major challenges, as observed by the late Sir Fazle Hasan Abed.
So, Abed Bhai -- as we affectionately refer to him -- decided to tackle exactly those issues. What began in 1972 as the “Sulla project” has branched out into several programs; some of them resulted in groundbreaking approaches in reducing poverty and saving lives. As we step into the 50th year of operation, we look back at some of our success stories in ensuring health for all.
Functional literacy for family planning
Wary of the perils of a large population, policy makers had initiated family planning services as early as the 1960s. These initiatives emphasized on permanent birth control methods and were overly reliant on doctors based in facilities. BRAC realized that these conventional methods were not working. Inclusion of family planning education in a functional literacy program was innovated in 1972. Using participatory methods, the program explained the various economic benefits of having small families.
Research into the efficacy of the model soon revealed that women were most often not in a position to make these decisions themselves. It was the husbands who decided to have children. This learning was quickly incorporated into the program design. Husbands were engaged together with their wives when imparting knowledge on family planning.
The intervention instilled a sense of empowerment and enabled the beneficiaries to make smart decisions on their own. In the span of three years, uptake of birth control services in BRAC intervention areas had risen ten fold from 2% to 20%.
Learning and incorporating research into our work has also led to sustainable, long run changes. The demand for birth control services has steadily grown over the years. Today, the population growth rate in Bangladesh is only 1.04%, significantly down from 3.23% observed during the late 60s.
Simple solutions for deadly communicable diseases
During the 1970s, diarrheal diseases were the leading causes of deaths among children under five. At the time, the standard treatment protocol was to administer intravenous (IV) fluids. These were expensive, scarce in supply, and increased reliance on trained medical professionals -- all factors that made it completely inaccessible for the rural poor in Bangladesh.
Around the same time, oral saline as we know today -- formally referred to as oral rehydration therapy -- had been invented by Harvard University’s Richard Cash and scientists of icddr,b. The World Health Organization had not mandated the use of oral saline then and recommended the continuation of IV usage to treat diarrheal diseases.
It was then that Abed Bhai decided to bring oral saline -- dubbed as the “greatest medical discovery of the 20th century” by the Lancet in 1968 -- from the world’s sophisticated labs to households across rural Bangladesh.
Challenging the World Health Organization’s mandate, BRAC led the adaptation of precise scientific measurements into a simple homemade solution. Using a pinch of salt, a fistful of molasses, and half a litre of water, community health workers taught 13 million women how they themselves could save the lives of their children.
This program came to be known as the Oral Therapy Expansion program (OTEP) and marked the beginnings of BRAC’s nationwide expansion.
Research found that teaching mothers was not enough, as fathers took most decisions regarding the health care decisions of children. Initially, uptake of oral saline hovered around 10% among the target group. When fathers were engaged and educated, the uptake levels shot to 80%.
The program soon evolved to group demonstrations and mass media campaigns. When it ended, diarrheal disease was no longer the leading cause of death among children under five. Such was its success that neonatal mortality had fallen to two thirds of post war levels. Today, 80% of the population in Bangladesh use some form of oral saline to treat diarrheal disease at home -- the highest rate in the world.
Similar principles of scale and convenience were employed to address tuberculosis, which was a leading cause of death among adult males. For many rural poor, a tuberculosis infection meant certain, slow death. It also meant that economic lifelines of entire households were upended. Treatment was facility centric and only available in few dedicated public hospitals, which was rarely availed due to the stigma attached to tuberculosis infection.
Seeing the need for a community setting, BRAC stepped in with a pilot project powered by community health workers. To ensure compliance, community health workers delivered the necessary medicine to patients’ families everyday throughout the treatment period.
Various improvements in this pilot led to the adaptation of the directly observed therapy, short course (DOTS) strategy during the mid 80s. DOTS innovated a simple form of cross accountability. Patients enrolling in the program had to make a minimal deposit which was refundable only if the treatment course was completed.
Community health workers were given financial incentives if they could ensure a patient complied with the entire treatment course. Research showed that detection rates and compliance rates went up as soon as the cross accountability mechanism kicked in. DOTS is also credited with giving rise to the community health worker model as we know today.
Eventually, BRAC became the first NGO to partner with the government for a national level tuberculosis control program. By the turn of the millennium, case detection rates and cure rates were as high as 70% and 90% respectively. Today, “jokhha bhalo hoy” (tuberculosis can be cured) is a household statement and the disease burden has reduced to a great extent.
Nationwide immunization against preventable diseases
On the eve of independence, Bangladesh was still recovering from a smallpox epidemic. Diseases such as measles, whooping cough, and polio caused significant deaths among children.
Yet, by the mid 80s, less than 5% of children had been immunized -- despite the availability of vaccines and the government’s commitment to reach the last mile. Many superstitions prevailed regarding the effects of vaccines, a sadly relevant observation even today.
BRAC understood that the supply of vaccines was not enough unless people demanded them. A decade of effort and prudent behaviour change communication by community health workers in BRAC areas resulted in 78% immunization coverage. Today’s national vaccination campaigns achieve nearly universal coverage rates and many fatal diseases such as polio and smallpox have been eradicated with vaccines.
Formula for success
What did BRAC do differently to achieve such unprecedented levels of success? Three key themes emerge from experience.
First and foremost, the communities in need were always put at the heart of the interventions. Rather than placing the burden of service utilization on them, the programs prioritized the communities’ active participation in solving problems, especially by the marginalized populations and women.
Emphasis is placed on developing and adapting effective interventions that empowers to realize their potential. Instead of adopting a normative approach, communities are inspired and empowered to bring about positive changes on their own. The focus has always been on understanding community perspectives and incorporating them.
Next, BRAC did not shy away from risks and lofty ambitions. Rather than sticking to small localities and concentrated solutions, BRAC scaled its work while continuously adapting to varying ground realities. As Abed Bhai aptly put, “small is beautiful but scale is necessary.” He realized that, to create any social impact, any intervention has to reach a significant number of population.
Lastly but most importantly, BRAC has always relied on research to design interventions. What works and what does not is evaluated through rigorous studies. Models are created, changed, and scrapped depending upon the evidence generated. Whether impact sustains is evaluated over time and lessons are incorporated in future designs.
Standing today as the world’s topmost NGO for the fifth row in a year -- it would be superficial to claim that all of our gains in health are for us to celebrate. The country still faces many uphill battles in achieving universal health coverage. What will lead us forward though, is the incomparable resilience and strength of our communities, who have internalized Abed Bhai’s vision of an equitable Bangladesh and never gave up on their hopes of a better life.
Dr Morseda Chowdhury is the Associate Director and Syeda Nafisa Nawal is a Manager at BRAC’s Health, Nutrition and Population program.