Population Program and Reproductive Health including family
planning program in Bangladesh.
Bangladesh with an area of 147,570 sq. km has a population 130 million with
highest population density in the world (except some island countries). Population
density of Bangladesh is 867 per sq. km Annual per capita income of our people is
around US $ 380. Population is expected to stabilize by 2050 at around 258 million. In
the year 1976 over population growth has been declared as the number one problem of
the country by Late Shaheed President Ziaur Rahman. Family Planning Program which
began in early fiftees has achieved a remarkable success with a contraceptive Prevalence
Rate (CPR) of 53.8% and Total Fertility Rate (TFR) of 3.3 per women inspite of
comparative low socio- cconomic development in our county.
The Bangladesh population program has made substantial progress over the last
thirty seven years. The fertility transition is already well underway and the success of the
immunization program is also impressive. The contraceptive prevalence rate has already
reached 53.8 percent from 7.7 percent in 1975 and the fertility rate has declined for 6.3 in
1975 to 3.3 in 2000. The crude birth rate has declined from 47 in 1973 to 22.4 in 2000.
and crude death rate has also declined from 17.1 in 1973 to 8.2 in 2000. The full
immunization rate has peaked up to 69 percent from a very low level of only 2 percent in
1985. The infant mortality rate has declined from 94 for the period 1989-93 to 66.4 per
1000 live births in 2000 and life expectancy at birth has gone up to about 61 years for
both the sexes.
The remarkable success achieved by the Bangladesh Population Program despite
widespread poverty and underdevelopment is a logical consequence of the realization of
the concept of “Population and development” adopted in various development Plans. The
major ingredients attributable to this successful model exhibited by our Population
Program include among others the followings.
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Sustained political commitment,
Maternal and child health based strategy,
Extensive network of field workers and service centers,
Committed field force with women-to- women services,
Cafeteria approach to services,
Decentralized service delivery (Through satellite clinics and EPI out reach centers at
the gross- root level).
Active Government –NGO collaboration.
Advocacy with religious and other community leaders.
Pro-active role of the mass media,
Involvement of the women.
Inter-sectoral collaboration,
Wide use of research in policy making.
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Despite fertility transition and impressive success of the immunization campaign, the
other health indicators are still remaining behind. About 70 percent of mothers suffer
from nutritional deficiency and anemia. Less than 40 percent of the population have
access to basic health care, 67 percent of pregnant mothers do not receive antenatal care,
92 percent of deliveries take place at home and only 12 percent deliveries are attended by
trained personnel.
The current (2001) population size is 130 million and the density is over 867 persons
per Sq. Km Our population is growing at the rate of 1.4 percent per annum. With this rate
the size will be double in about next 40 years, aggavating the population density further.
Bangladesh is the ninth most populous country in the world.
Health and Population Sector Program (HPSP) : a sector wide program
approach. .
To overcome multi-dimensional intersectoral problems and to meet the challenges
according to the spirit of ICPD, Cairo Bangladesh Government has launched Health and
Population Sector Program (HPSP) in 1998 in consultation with the development partners
and the stakeholders to reform the health and population sector to provide a package of
essential health care services to the people and to lower the rate of population growth.
HPSP envisioned poverty alleviation with services responsive to client’s needs
especially those of children, women and the poor and achieve quality of care with
adequate service delivery capacity and financial sustainability.
The Ministry of Health and Family Welfare, the main stakeholder in the health
and population sector, and the development partners have worked with a shared vision for
the sector, which included sectoral objectives and the policy framework for achieving
objectives of the HPSP. Sectorwide approach will be further improved and strengthen
through necessary changes and modification in consultation with partners / key stake
holders and after evaluation of present on going program.
The main objectives of this program are :
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Reduction of infant mortality and morbidity;
Reduction of maternal mortality and morbidity;
Reduction of fertility to reach the replacement level by the year 2005;
Improvement of nutritional status of the people.
These objectives have a specific focus on ensuring access of the disadvantaged groups to
high quality client centered services.
Under the present program the government is implementing Essential Service Package
(ESP), which aims to maximize health benefits at a minimum cost, meet felt needs of the
clients, strengthen service delivery capacity and improve management system . Within
ESP Government’s highest priorities are (a) interventions having public good character
and (b) interventions related to maternal and child health. In line with these priorities the
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elements of ESP are grouped into five major areas; The ESP covers the following five
major areas:
Reproductive Health Care : Safe Motherhood, Family
Planning, Maternal
Nutrition, Unsafe Abortion, Neonatal Care. Adolescent Health Care, Prevention and
control of RTIs / STDs, HIV/AIDS and infertility.
Child Health Care : Acute Respiratory Infection (ARI), control of Vaccine
Preventable Diseases (EPI), Prevention of Vitamin A deficiency, Diarrhoeal Diseases,
Hepatitais B vaccination for inclusion in the EPI programme, Prevention of lodine
Deficiency Manutrition, and Intergrated Management of Childhood Illness (IMCI).
Communicable Disease Control : TB, Leprosy, Malaria, Filariasis, Kala-azar,
Intestinal parasites and Other Emerging and Re-emerging diseases including dengue
fever and arsenic poisoning.
Limited Curative Care: Basic First Aid, Treatment of Medical and Surgical
Emergencics, Pain Relief and Advice, Asthma, Skin Diseases, Eye, Dental and Ear
Diseases.
Behavior Change Communication (BCC) : Changing attitudes and behavior of
the people to improve their health status. Changing attitudes and behavior of service
providers to provide client- oriented services.
Reproductive Health Service Facilities :
Bangladesh has a very well designed grassroot based service delivery infrastructure all
over the country. At national level there are one Institute of Post Graduate Medicine
and Research, one Maternal and Child Health Institute (MCHTI), one Institute of Child
& Mother Health (ICMH) and 13 Government Medical College Hospitals in the country.
The Services available are antenatal, perinatal (delivery) including comprehensive EOC
services and postanal care for mother and childcare. At District level 57 District hospitals
provides antenatal. delivery care including comprehensive EOC services postnatal care,
EPI and child care services.
There are 90 Mother and Child Welfare Centers (MCWC) in the country situated at the
District, Upazila and Union level which provide antenatal care, normal deliveries,
postnatal care; EPI, childcare etc. Out of them 64 MCWCs also provide comprehensive
EOC services. There are 397 Upazila health complexes in the country. The major
services provided are antenatal care, normal delivery: postnatal care EPI, FP, health
education, childcare etc. Out of them 40 Upazila Health Complexs (UHCs) also provide
comprehensive EOC services.
There are 3,200 Constructed Union Health and Family Welfare Centers (UH & FWC) in
the country. The services provided here are: antenatal (Sereening for “at risk”
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pregnancies and referral), safe deliverics through domiciliary follow up, postnatal care,
health education and child care. Present Government has planned to post graduate doctors
in all Union Health and Family Welfare Centers by phases.
Every month about 30,000 “satellite clinics” are organized at ward and community levels
in all over the country to aim at to bring the service facility at the door step of the people
to deliver antenatal care, Family Planning, health education and EPI services.
About 23 thousand Family Welfare Assistants and 15 thousand Health Assistants are
working at the grass root level for basic health & family planning service delivery.
NGO and Private sector Services : NGO and private sectors are also involved to
provide Reproductive Health services. At present many NGOs have special program and
facilities for providing antenatal care and safe delivery care. Beside this, there are private
physicians and increasing number of service sites, specially in urban areas. There is an
active social marketing company in Bangladesh which sales contraceptives through a
network of pharmacies and shops.
Reproductive Health Initiatives:
Safe Motherhood : To reduce the maternal mortality and improve the overall
reproductive health status of women, Bangladesh government has taken an extensive
program, The major activities aimed at maternal health focus on awareness about and
access to contraceptive methods; antenatal care (Tetanus immunization, iron folic acid
supplementation, nutrition education); promotion of safe delivery practices by skilled
birth attendants, Emergency Obstetric Care (EOC) and post natal care. The focus will be
on increasing utilization of EOC services by addressing the “ Three Delyas and Five
Danger Signs Model” through increassing coverage and decentralizing EOC services
together with mobilizing the communities. The vision is to create a socio-cultural
momentum that reduces maternal mortality and morbidity as women’s right.
Emergency Obstetric Care (EOC) : Emergency obstetric care (EOC) is an important
element of safe motherhood component. Government has taken initiatives to strengthen
proper medical attention and hygienic conditions during delivery. This can reduce the
risk of infections and facilitate management of complication for the mother and the
newborn. At present 57 district hospitals, 64 MCWCs and 40 (Upa-Zila Health
Complexes (UHC) are functioning as providing comprehensive EOC services. By the
year 2003, 120 UHCs will be converted as comprehensive EOC service centers and then
there will be one comprehensive EOC center for about 500,000 population as per WHO
guideline.
To further strengthen the program for better coverage Bangladesh Government has also
devised a detail plan to provide safe delivery at community level. It is planned that all
FWAs (23,000) and all female HAs (4,000) will be imparted training on midwifery
practices for six months, by phases. So, they will be able to provide the obstetric first aid
along with normal delivery care at the country level.
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Antenatal Care services : Antenatal Care promotion is one of the major services to
protect women’s reproductive health Antenatal care services by all service centers and
service providers to facilitate detection and treatment of pregnancy related problem. The
package of antenatal care are immunization of Tetnaus toxoid, risk assessment,
assessment of pregnancy status, physical checkup including basic urine and blood test,
blood pressure checkup, advice on nutrition, safe delivery and breast feeding.
Family Planning Services : Family Planning is an important component of reproductive
health Family Planning can help to reduce the incidence of high risk birth of the mothers
by spacing and limiting the number of children. The contraceptive prevalence rate has
increased significantly in Bangladesh during last two decades from 7.7 percent in 1975 to
53.8 percent in 2000, with an average 2 percent increase every year. All service centers
and field workers are responsible for providing FP services. In the presnt program
emphasis has been given on reduction of discontinuation of short acting FP methods and
increase of long acting and permanent F.P methods.
Prevention and Control of RTIs, STDs and HIV / AIDS:
Bangladesh Government has given emphasis on RTI and STD case management and
treatment and prevention of HIV and AIDs. The govenment has taken a country wide
program with the aim of creating awareness among the people on HIV / AIDs and
imparted training to all level of service providers. In addition, Government has identified
syndrome management at peripheral facilities for men and women with appropriate
referral services.
Adolescent Care : The ICPD, Cairo program of action has for the first time recognized
formally adolescent reproductive health care. After ICPD, Bangladesh Government has
given special attention on adolescent reproductive health. In the 1998-2003 period
specific behavioral change massages and program have been undertaken to address the
adolescents. The program focuses on adolescents, puberty, safe sexual behavior and how
to avoid health risk including STD / HIV / AIDS, proper nutrition and hygience. Beside,
the unmarried adolescents have little access to heath care fcilities in Bangladesh. Since
the national family Planning program targets eligible couples especially married women
between 15 to 49 years, many of these adolescents are not receiving education and
services of their reproductive health. All the service centers have been declared as
adolescents friendly. Some drugs are given to the adolescents for prevention of anemia
and pain during menstruation. NGOs also have program to address the adolescents
Development partners are also giving importance to this issue. UNICEF, UNFPA and
WHO are the front runners in helping government to formulate a well planned policy
regarding Adolescent Health.
Infertility Care : At present the investigation services and treatment of infertile
couples are inadequate in our program. The infertile couple takes services and treatment
by their own interest and initiative from private doctors and clinics. In the present
program some interventions gave been undertaken such as educate both husband and
wives about the factors contributing to infertility; orienting field workers and service
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providers about the causes of infertility and prevention of secondary infertility by treating
STDs and RTI cases.
Promotion of Maternal Nutrition : The traditional biological demands due to
menstruation, pregnancy and lactation have made nutritional deficiency most widespread
among the girls and women. The Government has given strong emphasis on maternal
nutrition. Program has been initiated for providing counseling, supplementation with iron
/ folic acid and vitamin A capsule during the lactating period. GOB is also implementing
a project entitled Bangladesh Integrated Nutrition Project (BINP) / National Nutrition
Program (NNP).
Neo Natal Care Service : The Neonatal care is an important component of the
present program. the services are health education for mother on cleanliness, umbilical
cord care, breast feeding, thermal control management of asphyxia, routine eye
prophylaxis and special care of pre term and low birth weight babies, prevention and
treatment of Acute Respiratory Infection.
Gender Issues : As the recommendation made by the ICPD, Caro’94 the important
issues where attention should be needed for ensuring reproductive health is elimination of
discrimination on gender. As women constitute almost half of the Bangladesh population,
have little opportunity to enjoy equality. Less participation in the economic activities
carry a disproportion burden of poverty, illiteracy, malnutrition and ill health. So, to
accelerate the total socio economic development and promote the reproductive health of
women Bangladesh have already given importance on gender issue aspect. Gender
differentials in present program considered a major challenge. To face the challenge the
present program has given importance on gender issues. Gender equity strategy has been
developed and already incorporated in the main stream of the program. MOHFW has
established a gender issue cell in the Ministry and nominated focal point in each program
unit for effective functioning of gender related activities.
Program constraints : Bangladesh Government is firmly committed to implement
the reproductive health program efficiently, but there are some constraints for effective
implementation of reproductive health care program, Such as inadequacy of quality care,
unmet need of FP, Discontinuation of FP methods. decrease of long acting and permanent
methods, under utilization of facility, lack of side effect management of FP methods,
inappropriate counseling, lack of promotion of condom use for preventing STD,
HIV/AIDS, ineffective procedure for diagnosis of high risk pregnancy, low accessibility
of services and traditional health beliefs and practice and very low percent of births by
trained personnel. To date there has been insufficient attention given to maternal care and
although the physical infrastructure is in place, concept of the Safe Motherhood Initiative
and the provision of Emergency Obstetric Care (EOC) have only been implemented in a
limited scale, though the activities of MCWCs and some other EOC centers are
considered satisfactory.
Present Program Focus : The Government is fully aware about these constraints. To
over come the situation, present program has given emphasize on reproductive health
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care: safe motherhood including EOC, male involvement in reproductive health,
increased acceptance of clinical methods, increased acceptors of FP method among low
parity couples special program for low performance area, improve nutritional status
especially for women and children, decrease discontinuation rate of FP methods care for
adolescents encourage delayed marriage, ensure empowerment of women and gender
equity, preventing RTIs / STDs & HIV/ AIDs and ensuring quality of care services.
Targets for the coming years :
 To reach the replacement level of fertility NRR = 1 by the year 2005.
 To reduce Total Fertility Rate (TFR) from 3.3 to 2.2 by the year 2005.
 To increase Contraceptive Pre Rate (CPR) from 53.8% to around 70% by the year
2005.
 To reduce Infant Mortality Rate (IMR) From 66.4 to 50 per 1000 live birth by the
year 2005.
 To reduce Maternal Mortality Rate (MMR) from 4.0 to 2.6 per 1000 live birth by the
year 2005.
Program Areas, Strategies and Interventions to Share:
Some effective interventions “Best practices” in the field of Bangladesh population
program which the member countries can share.
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Political commitment in the success of family planning and EPI program.
EOC services incorporated in all level service facilities (UH & FWCs UHCs.
MCWCs, District Hospital).
Reproductive health program is well recognized and well institutionalized.
Advocacy program for religius leaders for promotion of family Planning, MCH and
other reproductive health.
Advocacy program for local and field level elected leaders for promotion of family
planing MCH and other reproductive health.
Advocacy program for National and district level Journalists for promotion of family
planning, MCH and other reproductive health.
Multisectoral approach involve other ministries and sector for promotion of family
planning, MCH and other reproductive health .
Government and NGOs collaboration in family planning and immunization program.
Women empowerment through micro credit and skill development.
women empowerment through female secondary education stipend program.
As an instance the strategy to involve religious leaders for promotion of immunization
and family planning can be replicated in the countries that are facing the religious
orthodox regarding the reproductive health. Similarly following the Bangladesh micro
credit program for women can benefit all developing countries. It is not possible for any
Government alone to do everything for the betterment of the people. NGOs involvement
increases the strength of the government to bring success in mass program. Bangladesh is
the unique example of GO-NGO collaboration.
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The Challenges and further lessons to be learnt :
The very first challenge of Bangladesh, that all attempt to transform human
development concept into reality, the “population size” itself is very big one and not easy
to ensure proper balancing between human numbers and their needs and the resources.
Thus in the field of population and health sector development which form the basis for
human development, among various other challenges the most significant and critical
ones are:
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The Population Program itself
Maternal Health Care.
Adolescent Health
Nutritional Status.
Program Sustainability.
Other challenges include poverty eradication, environment urbanization education
(especially need for female education) and the Gender agenda.
Challenges for the Population Program
There are some challenges of future population growth, and at the same time ensure
accelerated human development in the context of a poverty stricken economy The
population imperative for the acceleration of sustainable human development is evident
from the following salient features of the Bangladesh population.
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Young age structure of the population,
Married women in the reproductive ages (15-49) account for 40 percent of the total
female population.
Rate of early marriage of girls is still high.
Urban population accounts for about 27 percent of the total population of the country.
Neo-natal, infant, child, and maternal mortality rates are still very high.
Increasing (relative) size of the elderly population.
The large size of the slum population and higher fertility rate in the slum dwellers.
The long term goal of government is to achieve a “two-child-norm” by the year 2005
(NRR=1 or TFR = 2.2). Though the family planning program has achieved a considerable
success but still it has remained below the desired level, total fertility rate of 3.3 is still
too high and remain constant for about last 7-8 years.
Need to be addressed to mitigate the challenges :
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To motive current non-users to become family planning users.
To strengthen the delivery system to provide quality services,
to improve the quality of care for increasing number of users,
To use limited resources efficiently and effectively.
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5.
6.
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To increase the permanent and long active FP methods in the method mix.
To reduce drop out / discontinuation rate of FP methods.
To increase male participation in FP methods.
Motivate newly weds, low parity and young couples to adopt FP methods.
Challenges for reducing maternal mortality and morbidity.
Maternal mortality and morbidity is a serious concern in Bangladesh. Within the
current maternal mortality ratio of 4.0 per 1000 live births. around 16,000 mothers die
each year due to causes related to pregnancy and childbirth. It is estimated that
complication develop in about 600,000 pregnancies of the 4 million women who become
pregnant every year. In Bangladesh there are about 9 million women who have survived
the rigors of pregnancy and childbirth and suffer from lasting complications.
According to the most recent Demographic and Health Survey only 8 percent of
all deliveries are conducted in health facilities. Assuming a 15 percent rate of obstetric
complications in the process of pregnancy and birth the physical demands for EOC
service should be around 600,000 cases annually, Among them only 27 percent are able
to avail the life saving services. In full compliance with the ICPD spirit, Bangladesh is
committed to reduce maternal mortality to 2.6 per thousand live births by the year 2005.
Challenge of Adolescent Health :
Adolescent Health has been recognized as a priority program in Bangladesh. The
adolescent population categorized by those between ages 10 and 19 years constitute about
23 percent of the total population in Bangladesh. The absolute size is about 30 million.
Adolescent Reproductive Health situation in Bangladesh is yet to be improved.
Challenge of the sustainability of Population and Health Program :
The disadvantaged “ resource – population” equation in Bangladesh prompts us to
conclude that sustainable development cannot be achieved without targeted efforts . in
the field of population. The hard fact of our life is that the population pressure has
already created additional demand on the already scarce land, water and other non
renewable resources thereby making it increasingly difficult to support the increasing
number of human beings. Even with the assumption that there will be some improvement
in program efficiency and therefore cost reduction. the total financial resources required
supporting the expanded family planning program will increase the cost in future.
These are the challenges for Bangladesh, but many developing countries haven a better
success story in the area of population, adolescent health and maternal health program,
Bangladesh may have the opportunity to learn from member countries best practices and
replicate those in our county.
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Demographic Data Sheet
Indicator
Total Population
Population density (Per Sq. Km.)
Population Growth Rate
Crude Birth Rate (CBR) per 1000 live
births
Crude Death Rate (CDR) per 1000 live
births
Total Fertility Rate (TFR)
Maternal Mortality Rate (MMR) per 1000
live births
Infant Mortality Rate (IMR) per 1000 live
births
Child Mortality Rate <5 per 1000 live
births
Number of Eligible Couples
No. of Women in Reproductive age group
(15-49 years)
Average Age at First Marriage
Male
Female
Contraceptive Prevalence Rate (CPR)
Life Expectancy at Birth
Male
Female
Number / Rates / Rations
130 million (Census 2001)
867 persons.
1.4%
22.4 (BBS-2000)
8.2 (BBS-2000)
3.3 (BDHS 2000)
4.0 (BMMS-2001)
66.4 (BDHS-2000)
94 (BDHS-2000)
25.84 million (MIS 2000)
31.2 million (BBS-2000)
27.8 years (BBS-1999)
20.2 years (BBS-1999)
53.8 percent (BDS-2000)
61 years (BBS-1999)
61 years (BBS-1999)
61 years (BBS-1999)
Reference :
1. Summary findings 1994, 1995, 1996 & 1999 Health & Demographic Survey (HDS).
BBS.
2. Contraceptive Prevalence Rate, November’ 1995. (Provisional, HDS, BBS).
3. The 1993-94, 1996-97, 1999-2000 Bangladesh Demographic & Health Survey
(BDHS).
4. Morbidity Health & Household Environment Statistics BBS 1997.
5. Bangladesh Maternal Mortality Survey –2001
6. Census Report –2001
7. Statistical Pocket Book of Bangladesh, 1999, 2000.
8. HPSP Programme Implementation Plan. Part-I, Part-II.
9. MIS Report 2000, Directorate of Health Services.
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