The Challenge
Bangladesh has made rapid advancements on several health indicators. Yet, the pace of progress has slowed, and the country now faces new challenges, especially in adolescent health and nutrition. The Global Financing Facility (GFF) is supporting the government to strengthen health systems, improve service delivery and reduce regional inequalities. The GFF is also facilitating a collaboration between the health and education sectors to help improve adolescent health through targeted school-based programs. To ensure sustainable progress, the GFF is helping to strengthen the efficiency of existing health spending while generating evidence to inform policy, build capacity, and advocate for additional funding.
Progress Made but Challenges Remain
Over the past decade, Bangladesh has made notable improvements in women’s, children’s and adolescents’ health and nutrition. Progress is largely credited to community-based cost-effective programs. For example, between 2014 and 2018, improved child nutrition led to a decrease in stunting from 36 to 31 percent and wasting was nearly halved from 14 to 8 percent (DHS 2014, DHS 2018). In addition, from 2010 to 2018 ;maternal deaths decreased by 22 percent. Yet, progress in some areas has slowed with neonatal deaths increasing by seven percent and deaths among children under five only slightly reduced (DHS 2014, DHS 2018).
Some of the gains have been attributed to the government’s focus on educating girls and creating more opportunities for women in the labor force. However, school retention among girls remains a challenge. Girls with less schooling are more likely to marry and have children early, which is associated with higher maternal mortality. Malnutrition is also a threat to women and adolescent girls – almost one in five women and one in three adolescent girls were undernourished in 2014 DHS 2014).
Wide regional disparities in health outcomes across the country further compound these challenges and financing gaps still constrain access to quality health care and financial protection for families. For example, household out-of-pocket payments cover 67 percent of the country’s overall health care expenses, which poses a huge obstacle to families trying to escape poverty. In 2017, the government expended just three percent of its resources in health (GHED-WHO). The share of government budget allocated for health has been slightly increasing since 2017, with 5 percent allocated to health in 2019 and 5.8 percent budgeted for health in 2020 (MTBF). Budget execution may continue to pose challenges, and Bangladesh continues to benefit from external financing in support of its health strategy.
A Sector-wide Approach for Improving Health & and Nutrition Outcomes
Bangladesh has been implementing a sector-wide approach where development partners and lenders are collectively contributing funding to close remaining gaps in health and nutrition. The US$1 billion sector-wide approach funded by several international partners, such as the World Bank, Canada, the Netherlands and the United Kingdom is part of a larger US$14.2 billion health program. The GFF Trust Fund is contributing a US$15 million catalytic grant in co-financing for the US$500 million Health Sector Support Project financed by the World Bank.
respectively, compared to the national rate of 31 percent (Bangladesh nutrition scorecard). The plan also focuses on improving and expanding nutrition services delivered to infants, children and mothers through government systems, and primary and antenatal care services.
In addition to the $15 million grant, the GFF is also providing a US$10 million grant to co-finance the Transforming Secondary Education for Results Program, which provides health services to adolescents through schools. This additional support has enabled the Ministries of Education and Health and Family Welfare to develop programs that focus on incentives for vulnerable girls to stay in school, investment in separate toilets for girls and facilities for menstrual hygiene, inclusion of adolescent health in the curriculum, teacher training, counselling, and awareness-raising on gender-based violence.
Promoting Health Financing Reforms and Strengthening Health Systems
More government spending in health is needed to achieve steady and sustainable progress in the health of women, children and adolescents. Although the investment case does not prioritize an increase in domestic resources, the GFF is supporting evidence generation and advocacy that can inform decisions on resource mobilization. For example, the GFF is supporting implementation of Bangladesh’s Health Care Financing Strategy. The GFF is providing analyses on health equity and financial protection, public financial management bottlenecks, a plan to engage with the private sector, and dialogue on domestic resource mobilization.
The GFF is also helping to promote greater efficiency in procurement and budget planning, preparation and execution. This support has already produced important changes. For instance, the share of the budget allocated to repair and maintenance of frontline health facilities (district-level and below) has increased from 2016; the percentage of national competitive tenders using an electronic system (e-government) rose to almost 18 percent; and an asset management system is now in use in four referral facilities in the districts (MTBF,DLI).
In addition, the GFF has helped the government to explore ways to strengthen engagement with the private sector, a key player in delivering health services in the country. Building on previous experience with public-private collaboration, the GFF has supported initial dialogue on strategies to strengthen this partnership to help expand access to quality care.
Stronger Health Systems, Better Health and Nutrition Outcomes
The collective force of these efforts is already helping to improve the delivery of health services and outcomes:
Better Health Systems
- More than 2,500 midwife positions have been created across the country, a major step toward improving maternal health outcomes. In the past three years, the number of Upazila (sub-district) health complexes that employed at least two accredited midwives rose from zero to 3061.
- In 2019, action plans were approved for emergency obstetric and newborn care services in targeted district hospitals in Sylhet and Chattogram. As a result, seven district hospitals had capacity to provide these services compared to 0 in 2017.
Better child health and nutrition
- Nationwide, stunting among children under five decreased from 36 to 28 percent between 2014 and 2018 (DHS 2014, DHS 2018).
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In Sylhet and Chattogram, child nutrition has improved between 2017 and 2019/2020:
- 25 percent of children under two received specific nutrition services
- The number of children weighed increased from 21 to 28 percent. Infant and Young Child Feeding counseling rose almost threefold from 19 to 54 percent
- The number of children receiving iron folic acid increased from 45 to 54 percent
- 15 districts reached at least 85 percent coverage of measles-rubella vaccination among newborns in 2020 (from 14 districts the year before).
Improved adolescent health
- Between 2014 and 2018, the birth rate among adolescent girls slightly decreased from 113 to 108 for every 1,000 girls, nationally. The government continues to prioritize school-based adolescent health programs in Sylhet and Chattogram, including teacher training and peer-to-peer adolescent girl support.