Public health lessons for India from Bangladesh
The Bangladesh miracle in public health offers many lessons for India, most importantly, on the central role of women
Bangladesh emerged from its struggle for independence in 1971 as a war-ravaged and impoverished nation. With a broken bureaucracy, fragile education system, and dismal health conditions, many termed it a “basket case”. Today, Bangladesh’s rapid strides in improving its health outcomes over the last few decades are referred to as “one of the great mysteries of global health” by The Lancet.
Bangladesh’s per capita national income (based on purchasing power parity) is less than 60% that of India. The country’s total health expenditure is 2.8% of its gross domestic product (GDP); India’s expenditure is 4.7%. Bangladesh’s health record is not flawless, and the nation has much to accomplish in fixing its ailing public health system. However, Bangladesh’s under-five and infant mortality rate, fertility rate, and life expectancy, are all better than India. The World Health Organization puts Bangladesh’s open defecation prevalence at near zero, compared to 40% for India. The question is how India’s once desolate neighbour achieved these outcomes. What lessons does it hold for India?
The Bangladesh miracle has been studied and written about extensively in the last few years. If we boil it down to look for one single explanation, it is the central role played by women. And even within that, poor women from grassroots communities have led the way. The nation has invested significantly in pro-women policies such as education subsidies for female students, protection of human rights, and microfinance programmes targeting women. Bangladesh’s female workforce participation in 2013 was 57%, more than double that of India. The country surpasses India in female literacy rates, as well as the representation of women in positions of power. Economists Jean Drèze and Amartya Sen explain in their studies, how female literacy and workforce participation play an important role in lowering child mortality and fertility rates through a combination of channels.
Bangladesh’s efforts towards gender equity were strengthened by an increased deployment of women as frontline health mobilizers. Organizations such as BRAC have been training poor rural women across Bangladesh for decades to distribute oral rehydration solutions, conduct house-to-house immunizations, and counsel women on contraception methods. In fact, BRAC believes in creating an enabling ecosystem, whereby poverty alleviation and social outcomes can drive better health. Poor women, who are the victims, the providers and the poverty managers for their families, should indeed be the caretakers of health.
An important question is what enabled Bangladesh to transform the role of its women. There is no clear answer, and this perhaps has historical and cultural roots. But more pertinent is to know whether India can do the same. I have encountered women time and again in northern India whose faces are hidden, voices can’t be heard, thoroughly disempowered. While there is a well-designed cadre of female frontline workers, implementation on ground is weak. The frontline workers serve overlapping beneficiaries, rarely share data, and follow chaotic record-keeping practices. They are governed by two ministries—the women and child development and the health ministry —that are usually at loggerheads.
From my public health experience so far, and from what Bangladesh reinforces, I strongly believe that communities of the poorest women are the only way —especially when public health systems are broken. In Avahan, the Gates Foundation’s India HIV-prevention programme, thousands of largely illiterate female workers became managers and owners of community programmes across the nation. Women supervisors and grassroots health workers across Rajasthan are leading the scale-up of a solution that involves the arduous task of mapping every house in the village. Initial stages of a programme with adolescent girls in Rajasthan show that they can be key change agents in mobilizing and empowering the community. These are much more than isolated cases of success. Is the explanation to Kerala’s incredible performance in health outcomes also women? Well, that’s another story.
Pretence and posturing are the bane of India’s sorry health situation. The country’s rapid economic development cannot be an alibi for its sluggish progress in health. Grand national health programmes and grandiose health announcements are disconnected with ground realities. We need to shun our inherently blinkered approach and look to the bottom of the pyramid. Men need to make way for women as central to grassroots health problems.
A radical thought maybe, in today’s environment especially—can we swallow our jingoism and take technical assistance from Bangladesh? We may learn something valuable.
Ashok Alexander is founder-director of Antara Foundation. His Twitter handle is @alexander_ashok