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: