EQUITY GAUGE PROFILES: BANGLADESH

Introduction

Over the last two decades, Bangladesh has witnessed a large decline in mortality despite economic backwardness and inadequate health services. During the period from 1981-1996, the crude death rate dropped from approximately 15 to 9 per 1,000 population. In the same period the child mortality rate also dropped from approximately 20 to 7 per 1,000 population (Bangladesh Bureau of Statistics 1990, 1996). Bangladesh ranks among the poorest and most densely populated countries in the world, with less than 45 percent of its population having access to primary health care services beyond childhood immunization and family planning (United Nations Development Program 1997). Malnutrition rates are among the highest in the world, with more than one-third of infants born annually classified as being of low birth weight (<2.5 kg). Approximately two-thirds of children under six years of age are underweight or stunted, and over 17 percent are moderately to severely wasted (Bangladesh Bureau of Statistics 1997). With its growing population and rural to urban migration, the size of the population living in urban slums has been growing rapidly. It is estimated that a large proportion of the Bangladesh population will live in urban slums in the next 30 years.

Summary

While the decline in mortality and the sign of reducing the socioeconomic and gender gap is impressive, it is not known whether the trend will be continuing? Or is there any new group who is not gaining as others? What is the situation in the urban slums or in difficult to reach areas usually inhabited by ethnic minorities compared to the rest of the country? Similar questions can also be asked about the morbidity, nutritional status, utilization and accessibility of the healthcare services. Also important to know whether the large-scale public health and social and economic development programmes such as Bangladesh National Nutrition Programme (NNP), mitigation of arsenic contamination in underground water, micro-credit, HIV/AIDS awareness raising programme are having equitable impact to various socioeconomic and hard to reach areas? Is the resource allocation and expenditure on health services by the public and private sector equity sensitive? Based on the answers of the above questions on a continual basis policy makers and programme personnel can devise appropriate strategies to avoid inequity in health status of the population.

The "measurement/monitoring" pillar consists mainly of primary data collection, and of the design and implementation of an integrated, real time data collection and analysis system that allows longitudinal demographic information to be combined with panel surveys, focus groups, and in-depth interviews. The surveys are integrated, and include demographic information on individuals collected every three months as well as supplementary panel surveys on education, housing, health, migration, etc. This component of the Gauge feeds directly into the interventions. For example, for a population of 5000, the nutrition program recently identified all households with children under five, scheduled 600 appointments, weighed and measured all the children (and got a 95% response rate), verified the data, and enrolled the children in supplementary feeding programs, all in less than 4 weeks.

To date, the computer program for information management has been completed and tested in the field, and analysis of the information has been successfully used for a pilot intervention on malnutrition. Currently, the team has two pilot sites, one of which is an informal zone and the other of which is a formal zone. Each has about 500 households.

Highlight to government planners, bilateral donors, and the public that levels of health among the poorest of the poor and the ultra-poor in Bangladesh [disadvantaged group in Ouaga are comparable to, if not worse than, the situation in many rural settings currently targeted for aid. Provide evidence-based urban health policy recommendations and strategies to the government and international aid decisionmakers.

Activities for Advocacy and Public Participation:

• Newsletters, working papers, reports, website, IT comm.
• Training: focus on poverty and equity in Health Systems Trust National courses on measuring poverty and health (from economic perspective).
• Looking at IT based training (internet or CD ROM).
• Fact sheets.
• Workshop.
• Public release of information.

ICDDR,B and BRAC provide significant community support activities in the form of health care delivery, health education, microloan programs. The project's focal health issues closely match the priorities of the people identified through surveys and participative community assessments, especially for general health issues, malaria, and AIDS among adolescents. Nutrition and maternal/child health have been largely neglected among the urban poor, but those populations have also expressed great concern for those issues