Inequality fuels poor sexual and reproductive health

Bangladesh is widely recognised as a success story and as a somewhat exceptional case when it comes to the improvement of maternal and newborn health. During the 15-year era of the Millennium Development Goals (MDGs) (2000-2015) maternal mortality was halved and the number of couples, mostly women, accessing contraception increased to 62 percent. Is Bangladesh thus winning in the pursuit for universal sexual and reproductive health care services for all of its citizens? Unfortunately, it is not quite as straightforward; the many achievements already made are still outweighed by some significant challenges the country faces – especially girls and women. Concerted efforts at ensuring universal access to sexual and reproductive health related information and services, placing women and girls at the heart of the initiatives, will be key to achieving the Vision 2021 and the global Agenda 2030 including the Sustainable Development Goals (SDGs). 

Each year, 5,200 women die due to pregnancy and childbirth related complications in Bangladesh. This amounts to nearly 15 women losing their lives every day. A number of reasons contribute to this human tragedy. Despite Bangladesh not being a very large country the extremely high population and varied topography, compounded by a lack of systematic investments in human resource development, have led to an acute shortage and uneven distribution of health care workers. Especially the life-saving emergency obstetric and newborn care is often not available or is of poor quality. 62 percent of women still give birth at home and 58 percent, without skilled birth attendance. This doesn't come as a surprise when taking into account that the health portfolio receives only 4.1 percent of the government budget, opening up opportunities for private facilities, which in turn can lead to high out-of-pocket expenditures for patients. Limited infrastructure and a fear of high costs and poor quality, paired with harmful social norms which limit girls' and women's decision-making power, leave Bangladesh in a situation where adolescents, young mothers and couples can't access the care they need.

Poor sexual and reproductive health doesn't however affect all men and women in the same way across the country. Certain socioeconomic groups are disproportionately affected by maternal morbidities, mortality and unmet family planning needs. These inequalities are due to poverty and disparities in health infrastructure that persist across geographic regions in the country. In addition, the development needs of adolescents, including their sexual and reproductive health, tend to receive inadequate attention or be legally constrained. Women with no education and living in the poorest households are far less likely to be assisted by a skilled attendant during delivery. 

Hard-to-reach areas like Cox's Bazar and the Chittagong Hill Tracts report significantly worse development indicators in general, again underscoring continuing wide disparities among women. 

Many of the development challenges that Bangladesh continues to face arise from the same or similar root causes, constraining the realisation of the full spectrum of rights among all of the country's women, youth and adolescents. Key root causes of major disparities include:

*     The persistence of widespread poverty despite national economic progress, which continues to influence the life choices of many families and women

*     Weak systems and institutions, including at sub-national levels, as well as insufficient capacities for equity-based planning, implementation, coordination and monitoring

*     The persistence of social norms and harmful practices impacting adolescents' and women's lives negatively, indicating an acute need to ensure respect for the rights of all women, youth and adolescents

*     A lack of quality services, particularly in disadvantaged areas lagging behind in human development, including hard-to-reach areas and urban slums

*     Inadequate knowledge and awareness, especially at the individual and family level, on good reproductive health and other development practices and their benefits

*     Bangladesh's continuing heightened vulnerability to natural disasters and other emergencies or humanitarian situations 

What has been done so far and what can be done to improve sexual and reproductive health services in Bangladesh?

Improving quality and quantity of appropriate health services personnel and infrastructure

The quality of health services continues to require significant strengthening, and should remain the centrepiece of the health sector plan in the years to come. Major components of the health sector plan focus on: (1) improving health services, including through development of an upazila health system and community clinic-led expansion of primary health care (PHC) services, and (2) strengthening health systems, including prioritising strengthened health governance, supporting local-level planning and demand-side financing, and capacity development of human resources for health. Accountability mechanisms and processes for sexual and reproductive health services, including adolescent sexual and reproductive health, need strengthening. 

Like many countries in Bangladesh the workforce challenge is not just about shortfalls in numbers of health workers; of equal importance is their distribution (rural/urban, primary vs. tertiary) and, critically, the quality of their performance. Compliance with standard quality of care remains a neglected intervention in the public health sector and requires particular attention. The availability of quality infrastructure for delivery of key services also remains limited. Bangladesh has an average of just 0.2 hospitals per 10,000 people, far lower than the ratio for low-income countries globally (0.8/10,000).

Bangladesh is lagging behind other South Asian countries particularly in terms of the ratio of midwives and nurses to population. Depending on the year of measurement, India and Sri Lanka have between five and six times as many midwives and nurses as Bangladesh, and Pakistan has almost twice as many. Bangladesh has only 2.2 nurse-midwives per 10,000, who do not meet a global standard of midwifery, and which is less than half the global average for low-income countries. Overall, workforce density is well below the internationally recommended figure of 22.8 per 10,000 required to achieve relatively high coverage for essential health interventions in countries most in need.

Midwives taking the lead in sexual and reproductive health care

Midwifery is a key element for achieving universal access to sexual, reproductive, maternal and newborn health, and for achieving the SDGs. Investing in midwives is also considered a "best buy" in primary health care, and many recent reports mirror the growing international consensus on the critical role of midwives in reducing maternal and neonatal mortality. Midwives who are educated and regulated to international standards can provide 87 percent of the essential care needed for women and their newborns; investing in midwifery education and deployment to community-based services can potentially yield a 16-fold return on investment in terms of lives saved and costs of caesarean sections averted.

To advance this, the government has established two midwifery training courses: a six-month post-basic Certificate in Midwifery course for registered nurse-midwives (who have completed the three-year diploma in nursing and midwifery) and a three-year direct entry course leading to a Diploma or Registration in Midwifery (RM). While work to date in this area has been impressive, it is important to recognise that the profession of midwifery is very new in Bangladesh and a lot needs to be done to make the profession work. Strengthened legislation to recognise the autonomy of the profession and to empower midwives; investment in improving the quality of midwifery education with a focus on faculty; creating an enabling environment for the midwives to practise and making the profession attractive for young girls are going to be critical in the coming years.

Striving towards Universal Health Coverage

Notably, Bangladesh has a very ambitious agenda for scaling up Universal Health Coverage (UHC) by 2032. In 2012, only 1 percent of Bangladesh's population was covered by some form of health insurance. The movement to UHC will potentially benefit the whole health system, and hence, effective services for women. At the same time, a scale-up of that nature requires strong policies, regulations and increased health workers and supplies to meet increased demand. Scaling up UHC further likewise requires a strong and sustainable financing platform so as to collect and pool premiums, which will be particularly challenging given the extent of informal-sector employment and persistent poverty. Rapid scale up of maternal voucher schemes to benefit the poorest and the most marginalised communities are needed. The government's Shasthyo Surokhsha Karmasuchi also offers great hope and should be scaled up rapidly. 

Identifying emerging challenges and opportunities

The risk of child marriage, and subsequently adolescent pregnancy, might be exacerbated from Bangladesh's heightened vulnerability to climate disasters that threaten loss of property and exacerbate mass migrations to urban centres. There needs to be a critical discourse on how to address as well as prevent such circumstances from undermining achievements in adolescent sexual and reproductive health so far. The country's large proportion of adolescents and youth will require strengthened attention to sexual and reproductive needs specific to this segment of the population, including culturally and socially acceptable sex education. On the positive side, innovations on the digital front allow health planners and policy makers to tap into unprecedented opportunities using new media and virtual classrooms as have been provided through the new "Teacher's Portal". These can be used as platforms for improving sexual and reproductive health literacy among the mass population and also to provide e-learning courses for health care professionals such as midwives. 

The need for emphasising underlying social determinants of health

It is easy to miss underlying social determinants of health in the face of more immediate clinical and biological factors that threaten population health. Going forward, it is crucial to critically appraise how cultural norms, social practices, religious perspectives and political agendas' define sexual and reproductive health in this country. We need to design our public health programs with these considerations; to address these issues in a way that will be socio-culturally acceptable and feasible, yet achieve what they are set out to do: improve sexual and reproductive health in the population. It will also be important to draw in perspectives from all stakeholders such as civil society organisations, government partners, health professionals and specially underserved females and youth groups. Only then can we hope to achieve successful and sustainable sexual and reproductive health programming in Bangladesh. 

The concept of integrated development

Moving forward towards Vision 2021, it is more important now than ever before to critically appraise our approach towards achieving universal access to sexual and reproductive health; this is also an opportune moment as the country gears up to adopt the 2030 Agenda for Sustainable Development. Empowering girls and women is pivotal in achieving all SDGs; and ensuring universal sexual and reproductive health and rights for females is fundamental to this process of empowerment.

Critically, it will be key to focus on reducing the relevant, widespread inequalities and vulnerabilities that exist in Bangladesh, particularly in the social sectors, with special attention to those arising from poverty, gender or age inequalities, and vulnerability to disaster, including humanitarian situations. Furthermore, new focus should be given to strengthening systems and institutions so as to assist the evolution of public service capacities at national and local levels alike, which will be central to sustaining Bangladesh's development gains. In specific programme components, critical emerging issues worth highlighting are:

    * Addressing key gaps in knowledge of women's issues of morbidity

     * The need for increasing priority to promote midwifery profession

     * The growing recognition of gender-based violence as a national development crisis

     * An enhanced focus on child marriage and issues related to early childbearing

     * Special issues related to lagging behind human development indicators in urban slums, CHT and among other hard-to-reach populations and areas

     * The importance of quality secondary education and TVET, and key linkages to the acute need for strengthening of life skills for adolescents and youth alike

     * Support for improved sex- and age-disaggregated data

All will need to be approached from an integrated development perspective, so that achievement of the SDGs in Bangladesh gets the best start possible, while also bringing Bangladesh closer to its vision of becoming a middle-income country. As such, universal access to sexual and reproductive health needs to be thought of as a means to realising Vision 2021 and the 2030 Agenda rather than an end goal in itself.

Sathyanarayanan Doraiswamy is Chief of Health, United Nations Population Fund (UNFPA), Bangladesh. Nabila Purno is International Research Associate, UNFPA, Bangladesh.