The Lancet – Self-assured commentators who saw Bangladesh as a “basket case” not many years ago could not have expected that the country would jump out of the basket and start sprinting ahead even as expressions of sympathy and pity were pouring in. This informative Lancet Series on Bangladesh1—6 helps to explain what happened—and why. It is important to understand how a country that was extremely poor a few decades ago, and is still very poor, can make such remarkable accomplishments particularly in the field of health, but also in social transformation in general.
The lessons are important for Bangladesh’s own future, and for what The Lancet Bangladesh Team describe as the construction of “a second generation of health systems”.6 But the messages from Bangladesh’s experience are also of great relevance for many other countries in the world that suffer from debilitating poverty. It might not be good manners for Bangladesh to start lecturing the world on what to do, so soon after jumping out of the basket to which it had been relegated, but the country’s experience has important lessons for other developing countries across the globe.
These lucid and helpful papers discuss the main avenues of change on which Bangladesh has travelled. I will not summarise the findings: this has been nicely done in the introductory paper by Mushtaque Chowdhury and colleagues.1 Instead I will concentrate on a small number of striking features of the strategy followed by Bangladesh in moving rapidly towards health transition.
One direction of change is the emphasis that the country has placed on reducing gender inequality in some crucially important respects. The impetus for the change was linked in many different ways with the politics of liberation that made the issue of freedom, including the liberation of women, a part of the progressive agenda of what people wanted and were ready to fight for. There are inescapably complex issues to be addressed in order to explain more fully how exactly that happened. It can be argued that there were historical elements in the culture of Bengal, and particularly in the emergence of radical movements in various forms in that province throughout the first half of the 20th century, that leant them to include a serious concern for gender equity. But it was the nature of the struggle for independence of Bangladesh, particularly in focusing on the contrast with West Pakistan, that made it possible to make an effective political translation towards empowering women.
The causation of this move towards gender equity cannot but remain somewhat speculative, but its consequences are clear enough. Schools focused particularly on expanding the education of girls: Bangladesh is one of the few countries in the world where the number of girls in school now exceeds the number of boys. Public services, including school teaching, health care, and family planning, employ a much higher proportion of women workers than is the case in most developing economies, including in Bangladesh’s neighbouring countries. Women have also entered the economic workforce in plentiful numbers, led by such industries as garment making that provided easy entry to female labourers, even though the neglect of safety at work has been a huge blot in the record of that industry, a serious deficiency that is only belatedly being addressed, and perhaps not yet strongly enough.
Women have also received special attention from Bangladesh’s powerful non-governmental organisations (NGOs)—from large initiatives like BRAC and Grameen Bank to smaller organisations—and the mobilisation of the active agency of women has been a distinctive feature of the vision that has moved Bangladesh forward. And there has been a general determination in post-independence Bangladesh to target the elimination of female disadvantage in different fields of action, including maternal and child survival.4
Full-size image (153K) Shehzad Noorani/Still Pictures/Robert Harding
The removal of female disadvantage and the use of female agency have raised Bangladesh’s record of achievement even on its own, but it is in fact the case that women’s agency has also contributed greatly to the advancement of the lives and freedoms of all—men, women, and children. The unlocking of the power of women’s active role in the society and in the economy has been an extremely productive move for Bangladesh and contrasts with what has happened in much of India.7 Bangladesh’s powerful achievement in making much greater use of women’s agency is a remarkable affirmation of the importance of what Mary Wollstonecraft called, in 1792, “the vindication of the rights of woman”.8 Indeed it turns out that the removal of the social shackles that restrain women has a crucial part to play in the progress of all people—of both sexes and of all ages.
A second striking feature of the Bangladesh story is the general acceptance of a multiplicity of instruments in the public and private sectors for rapid social advancement. Just as state initiatives have been seriously undertaken, NGOs and private enterprises have been forcefully supplementing the efforts of the public sector. As Syed Masud Ahmed and colleagues2 argue, the use of pluralism has allowed Bangladesh to get off to a quick start bringing the country a little closer to a health transition.
Full-size image (89K) GMB Akash/Panos
Man receiving treatment at the International Centre for Diarrhoeal Disease Research, Bangladesh, in 2009
This is not to deny that the mixture of instruments that characterise Bangladesh’s path of development will demand critical examination over time, since substantial overall advancement can coexist with persistent inefficiency and inequalities in the sharing of the benefits of health transition. These evaluative issues remain open to scrutiny and critical examination, but what has to be immediately—and firmly—recognised is that Bangladesh has been, in its own way, going ahead rapidly, rather than remaining paralysed by the slowness that is often entailed by the pursuit of “purity” in more ideologically oriented initiatives which favour either exclusive reliance on private enterprise or exclusive use of state-based programmes. The pragmatism that Bangladesh came to accept through a complex political and social process has yielded noticeable success, which has impressed—and to a considerable extent surprised—the world.
A third feature, closely related to the second, is the intelligent use of community-based approaches in the delivery of health services and medical care. As Shams El Arifeen and his coauthors3 outline, the mobilisation of community-based participation has many advantages, not only for the fostering of social cooperation, but also for extending the reach of the health initiatives and their impact. The innovations in health-service delivery from which Bangladeshis have benefited have been possible partly because of these participatory features in the process of social change. The importance of innovations is also discussed in the context of equity in the paper by Alayne Adams and colleagues.4
A fourth feature, which demands particular attention in Bangladesh, is the country’s improved ability to face natural disasters, such as storms, cyclones, floods, and droughts. These natural calamities have acted as a persistent drag on the country’s progress. As the contributions by the Richard Cash and colleagues5 highlight, the deep vulnerability of the disaster-prone country to unruly forces of nature, which needed to be subdued, has indeed been, to a considerable extent, reduced. The elimination of these problems would, however, demand much more security-oriented progress in future years, especially if the threats for climate change become stronger.
I have pointed to a few of the special features in Bangladesh’s progress towards a health transition, and many other features have been explored in this valuable Lancet Series. One very important aspect of this compendium of investigations is the continued focus on a call to action6 that nicely supplements the appreciation of what has been accomplished. Bangladesh has still a long way to go. This Lancet Series shows how Bangladesh has firmly placed itself on the way to that long journey (and has made an excellent beginning), but also points to further problems that have to be tackled as the journey proceeds. The key to Bangladesh’s laudable success has been the avoidance of the twin dangers of inertia and smugness. The future will demand more from these virtues.
I declare that I have no conflicts of interest.
1 Chowdhury AMR, Bhuiya A, Chowdhury ME, Rasheed S, Hussain Z, Chen LC. The Bangladesh paradox: exceptional health achievement despite economic poverty. Lancet 2013. published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(13)62148-0.
2 Ahmed SM, Evans TG, Standing H, Mahmud S. Harnessing pluralism for better health in Bangladesh. Lancet 2013. published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(13)62147-9.
3 El Arifeen S, Christou A, Reichenbach L, et al. Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh. Lancet 2013. published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(13)62149-2.
4 Adams AM, Rabbani A, Ahmed S, et al. Explaining equity gains in child survival in Bangladesh: scale, speed, and selectivity in health and development. Lancet 2013. published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(13)62060-7.
5 Cash RA, Halder SR, Husain M, et al. Reducing the health effect of natural hazards in Bangladesh. Lancet 2013. published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(13)61948-0.
6 Adams AM, Ahmed T, El Arifeen S, Evans TG, Huda T, Reichenbach Lfor The Lancet Bangladesh Team. Innovation for universal health coverage in Bangladesh: a call to action. Lancet 2013. published online Nov 21. http://dx.doi.org/10.1016/S0140-6736(13)62150-9.
7 Dreze J, Sen A. An uncertain glory: India and its contradictions. London: Penguin, 2013.
8 Wollstonecraft M. A vindication of the rights of woman. London: Penguin, 2004.
*Department of Economics, Harvard University, Littauer Center, Cambridge, MA 02138, USA