Bangladesh has covered many miles on the road toward reduced fertility and childhood mortality in its first three decades since Independence in 1971. It is the only country among the 20 poorest that has recorded a sustained reduction in birth rates over the past 15 years. On average, in the 1990s women had 3.3 birthsone-half the number in 1974. Infant mortality has dropped from about 140 to 88 per 1,000 live births. The government''s strategy is now directed toward reducing the high levels of maternal illness and deaths, tackling malnutrition, and consolidating and sustaining the gains already made.
For more than 25 years, the World Bank has had an important connection with Bangladesh''s achievements in reducing fertility. The Bank''s consistent attention to maternal health issues during this time has been one of the driving forces behind the government''s commitment to an essential package of services that addresses broader maternal health issues.
Embarking on the Journey
The World Bank''s dialogue with Bangladesh on health and population issues began in 1973. Initially the Bank helped mobilize support from six cofinanciers; since then, additional donors have been engaged in follow-up projects, each of which has almost doubled the amount of money invested. These development partners are now organized into a consortium, with the Bank acting as coordinator on various aspects of the projects. The Bank also represents the consortium in health policy dialogues with the government.
The Bank''s initial involvement with lending to Bangladesh for health, population, and nutrition began in 1975 with a US$15 million credit from the International Development Association (IDA), the World Bank''s concessionary lending affiliate, for the Population I project, which lasted until 1982. Four more projects, all supporting the government''s five-year plans, followed.
Population I, which focused on reducing fertility, led to a marked increase in the use of contraceptives. By involving a number of donors, it kept attention focused on the population program. It eventually became the vehicle for ongoing dialogue with the government. Population and Family Health II (197986; US$32 million) succeeded in consolidating, strengthening, and expanding the activities started under Population I. The project assisted the government in implementing its program, which included components for delivery of family planning and maternal and child health services and for communication, training, monitoring, evaluation, research, and women''s development. The project was crucial for sustaining increased contraceptive use.
Population and Family Health III gave greater attention to the issue of maternal health, while continuing the program activities included in the second project. The third project achieved its objectives of lowering birth rates and, to a more limited extent, reducing the high number of infant deaths, but the goal of reduced maternal mortality remained elusive.
The Bank''s assistance to Bangladesh continued with Population and Health IV, which aims to sustain lower birth rates while further improving infant, child, and maternal health.
As this project comes to a close, Bangladesh is close to achieving complete national coverage by community health workers; 21,000 health assistants and 23,500 family welfare assistants are providing family planning and limited primary health care services to communities. Contraceptive use has increased during the project, and infant mortality has dropped; maternal mortality has been more difficult to measure. Despite extensive training of traditional birth attendants under the project, 75 percent of pregnant women still do not receive prenatal care or assistance from a trained attendant when giving birth.
On the Right Path
The outlook for reducing fertility and child mortality was first assessed in 1980 and 1983 in the studies "Fertility and Its Regulation in Bangladesh" and "Population and Family Planning in Bangladesh: A Survey of the Research," both prepared jointly by the Bank and the government.1 A 1992 study, "The Determinants of Reproductive Change," reviewed the demographic history of Bangladesh, with particular attention to evidence of reproductive changes in the postindependence period.2 Bangladesh''s success in reducing fertility demonstrates that comprehensive programs supported by true commitment at the highest levels can work in spite of severe constraints, including widespread poverty.
Maintaining the Pace
The government of Bangladesh has also been increasingly concerned with nutrition-related health problems. Nutritional indicators in Bangladesh are among the worst in the world9 out of 10 children are malnourished, every other child is stunted, and some 600 children die daily from causes related to malnutrition.
In close collaboration with the United Nations Children''s Fund (UNICEF), the Bank is supporting the Bangladesh Integra-ted Nutrition Project (BINP) with a US$59.8 million IDA credit. This pilot project initiated a national program of nutrition with the ultimate goals of reducing malnutrition, so that it ceases to be a health problem, and improving the health status of the population, especially children under five, women, and adolescent girls. The project uses community-based, participatory activities for malnourished women and childrenas a way of changing behaviors and attitudes relating to decisions about nutrition. NGOs are key to implementing this community based approach, which builds on NGOs'' capacity for social mobilization, training of health workers, and supervision.?
(Source: Based on a World Bank Report)