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Executive summary 

The World Health Organization (WHO) has been providing technical assistance to the Government of the Peoples’ Republic of Bangladesh for the development and strengthening of the country’s public health systems since 1972. In 1999 WHO initiated the formulation of Country Cooperation Strategies (CCS) to further strengthen its performance at the country level. The CCS is a medium-term framework that establishes the strategic directions for the organization, and provides country-specific guidance for planning, budgeting and resource allocation. The CCS for 2008-2013 was developed in consultation with government officials, development partners, and other key stakeholders. The primary inputs to the CCS 2008-2013 were a comprehensive analysis and review of the country’s health and development priorities, current and expected development assistance, the impact of recent WHO collaborative work, and the directions given in the WHO global and regional policy frameworks.

There are clear indications that considerable progress is being made to improve the health of the people of Bangladesh. Over the last decade life expectancy at birth has increased, and both infant and child mortality rates have decreased. Signs of a beginning of a demographic transition suggest that strategies aimed at reducing fertility are taking effect, though this also implies that the health system must plan its response to an increasingly older population with accompanying specific health needs. Nevertheless, there remain many areas of concern over health development. For example, maternal mortality remains unacceptably high. Lowering maternal mortality is contingent upon improving the management of pregnancy, though underlying causes including maternal malnutrition must also be addressed.

Child health in general has improved, though the neonatal mortality rate remains high and contributes disproportionately to overall infant mortality. The immunization programme has been recognized for its sustained high coverage; however, only 71% of infants are fully immunized. Measles presents an additional challenge to the immunization programme with an estimated 20000 children dying from the disease each year. Efforts must be intensified to ensure access to safe immunization and strengthen surveillance of all vaccine-preventable diseases. Malnutrition continues to be a serious problem with nearly half of the children being moderately underweight, one-third suffering from stunting and a large number of adolescents, girls in particular, being malnourished. Adolescent health requires closer attention, particularly in the context of reproductive health.

Bangladesh is at risk of an HIV/AIDS epidemic. This is due to the high prevalence of the disease in neighboring countries and the limited access to counseling and testing services on account of social stigma. There are also concerns of HIV-tuberculosis confection, with Bangladesh being among the countries with the highest burden of  tuberculosis. Malaria is endemic in the east and north-east parts of the country with nearly 11 million people at risk of the most dangerous type of infection,  P. falciparum, which has the highest rate of complications and mortality.

Neglected diseases such as kala-azar and filariasis demand more attention if they are to be eliminated as planned. Dengue outbreaks occur on an annual basis in urban areas and more effort is needed to control mosquito breeding. There are also threats from emerging diseases including SARS and avian influenza.

It is estimated that by 2010 noncommunicable diseases (NCDs) will be responsible for 59% of deaths compared to 40% in 1990. Underlying factors that contribute to the increasing burden of NCDs include unplanned urbanization, changing dietary habits, unregulated tobacco consumption, air pollution, road traffic injury and lack of awareness about healthy behaviour. Tobacco in particular is a major risk factor, having caused 57000 deaths and 382000 disabilities in 2004 alone.

Environmental determinants of health contribute to communicable and noncommunicable diseases. The extensive levels of arsenic contamination of the shallow groundwater puts an estimated 20 million people at risk of arsenicosis. More efforts to ensure safe drinking water together with improved sanitation will help reduce the burden of diarrhoeal disease. Other important environmental health issues include indoor air pollution, food safety and climate change.

Bangladesh is prone to natural disasters such as floods and cyclones that lead to outbreaks of communicable diseases. During the floods of 2004, more than 400000 people suffered from different diseases in the aftermath and required treatment. The health system must be further strengthened, both in terms of its preparedness and response capability, to cope with this scale of emergency.

In spite of palpable improvement in various sectors, the country’s health system still requires further development to meet the basic health needs of the population. The centralized management system of state health services contributes to the inequitable access to quality health services, particularly in rural areas. Although the health workforce has been steadily growing, Bangladesh continues to face a chronic shortage of and imbalance in their skill mix and deployment. The supporting roles of community-based health workers and volunteers need to be better integrated into the system. Effective regulation is required to ensure the quality of health professionals’ education and practice, blood safety, and compliance of local pharmaceutical companies with the international good manufacturing practice (GMP) requirements.

At about US$ 12.16 per capita per annum, the total health expenditure is well below the level needed to scale up essential health interventions. Historically, supply-side financing of healthcare services has been used to increase access to essential health services for the poor. Based on a recent review, a consensus has been reached over the piloting of some alternative financing mechanisms. The government is now piloting a “demand side financing” option in the form of maternal health voucher schemes to provide support to poor pregnant women.

In 1998 a sector-wide approach (SWAp) was introduced to increase the efficiency of planning, monitoring and management of national health plans and strategies. The Health, Nutrition and Population Sector Programme (HNPSP) 2003-2010 is based on the sector-wide approach and emphasises focus on vulnerable groups. In line with the Paris Declaration on Aid Effectiveness 2005, efforts are being made to harmonise donor support and bring them in closer alignment with national plans and strategies. Coordination mechanisms include the Health, Nutrition and Population (HNP) Consortium, the Local Consultative Group (LCG) and the United Nations Development Assistance Framework (UNDAF).

The essential focus of the World Health Organization’s work is to provide technical assistance to the government. This includes the development of health-related policies, evidence-based guidelines, norms and standards, capacity building and institutional strengthening, and research. Currently WHO collaboration is grouped into six clusters: Communicable Diseases and Surveillance (CDS); Emergency and Humanitarian Action (EHA); Family and Community Health (FCH); Health Systems Development (HSD); Noncommunicable Diseases and Mental Health (NMH); and Sustainable Development and Healthy Environments (SDE).

Over the last decade, funding for WHO’s biennial budget has increased from US$ 7.6 million in 1998-1999 to a projected US$ 53.7 million in 2008-2009. The increase has mostly come from a substantial flow of voluntary contributions from bilateral agencies and international funds and foundations. WHO constantly seeks to enhance its contribution to the health sector and will identify opportunities for closer alignment with the HNPSP.

The WHO Global and Regional Policy Framework has provided vital direction for the CCS 2008-2013. The Eleventh General Programme of Work (GPW) is currently the highest policy document for WHO. It provides a global health agenda that is aimed at all health agencies internationally. WHO will contribute to this agenda by concentrating on its core functions which are based on its comparative advantages.

The overarching principles of the Country Cooperation Strategy for 2008-2013 are a commitment to primary health care, the human right to health, and gender equality and equity. The CCS Strategic Agenda has been aligned with key national and international development priorities including the Millennium Development Goals, the Health, Nutrition and Population Sector Programme (HNPSP) (2003-2010), and the National Strategy for Accelerated Poverty Reduction (NSAPR). Seven strategic directions have been identified for the CCS 2008-2013. These are:


  1. Promote access of vulnerable groups to health services ensuring a continuum of care throughout the life course.

  2. Enhance capacity for the prevention and control of major communicable diseases and diseases targeted for elimination/eradication, and strengthen integrated disease surveillance.

  3. Promote healthy lifestyles and cost-effective interventions for the prevention and control of major NCDs and injuries, and for mental health promotion.

  4. Enhance equitable and sustainable access to safe water and sanitation, reduce environmental and occupational health risks and promote food safety.

  5. Strengthen multisectoral approaches for emergency preparedness, response and recovery.

  6. Strengthen the health system with a focus on health workforce development and equitable access to quality health care.

  7. Foster partnership and coordination for national health development.

The CCS Strategic Agenda will be implemented through three consecutive biennial, results-based workplans and with strong emphasis on research and knowledge management. In order to ensure its effective and timely implementation, WHO will seek to further enhance its cooperation with the government and strengthen cooperation with key stakeholders. WHO will be proactive in identifying new opportunities for synergy and harmonization of our work with that of other UN agencies and development partners. Above all, WHO commits to providing high-quality technical support to the government to attain the goal of “Health for All” in Bangladesh.

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