The University Press Limited (UPL), in association with Bangladesh Health Watch, James P Grant School of Public Health of Brac University, and the Embassy of Sweden, has just published a monumental book of great importance, titled 50 Years of Bangladesh: Advances in Health, edited by Ahmed Mushtaque Raza Chowdhury, Yasmin Ahmed, Khairul Islam, and Shishir Moral. It describes the progress that Bangladesh has made since independence in improving the health of its citizens. In global terms, compared to other countries at a similar level of development in 1971, Bangladesh's achievements are astonishing – the collective result of (1) inspired dynamic leadership from thousands of individuals who have worked with communities, government, and non-governmental organisations; (2) government leadership and international support from donors and technical experts; (3) communities striving for the collective common good; and (4) millions of people giving their all for a better life for themselves and their families.

Among the many noteworthy achievements highlighted in this book since independence, several stand out: i) the improvement in life expectancy at birth to 72 years; ii) the reduction in under-five child mortality from 251 to 31 per 1,000 live births; iii) the reduction in the total fertility rate from 6.6 births per woman to 2.0; iv) the expansion of childhood immunisations to 86 percent and the elimination of polio; and v) the decline in the percentage of deaths from diarrhoea among children from 25 percent in 1970 to two percent in 2000 and since.

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Capacity enhancement is the need of the hour

Progress in women's empowerment, elimination of illiteracy, increases in the level of education (especially for girls), formation of women's groups and microcredit and other poverty alleviation programmes, expansion of agricultural output, and improvement in roads, communications and other infrastructure have all helped to make the health achievements possible. The book concludes that "[c]reating a cadre of female health workers…, demystifying (healthcare) and making it more understandable for the general public have been found to be critical factors for success of Bangladesh's health sector."

Given Bangladesh's projected economic growth over the next two decades, the overarching question is not whether there will be the money to reach "Health for All," but whether this money will be used in a way that will bring the greatest benefits possible for the health of the population and particularly for the poorest members of society.

The way forward

There are eight key priorities for the next 50 years that arise from this remarkable book:

Support for bold innovations from "outside the box"

What has worked in the past is not necessarily going to work in the future. Bangladesh has picked much of the "low-hanging fruit" in its success in reducing child mortality and fertility, but picking the "high-hanging fruit" by creating a strong and effective primary healthcare system for all citizens will require a bold and innovative commitment of the government together with civil society.

Major expansion of funding for the health sector, with priority given to expansion of coverage at the lower levels of the health system

This new book informs us that, at present, the government's health expenditure as a percentage of the GDP is the lowest in the world – 0.7 percent. Major expansions of funding for the health sector will be required together with large increase of the health workforce. This will require a tripling of the portion of the GDP for health to two percent.

Over the past five decades, Bangladesh has inspired the rest of the world because of its achievements in the implementation of health programmes, saving lives, and overcoming poverty, thereby bringing dignity and hope to millions of people.

Development of a strong primary health care system with continued outreach to every home

Bangladesh needs a strong, effective, and affordable primary healthcare system that gives emphasis on the prevention, early identification, and ongoing treatment of non-communicable diseases. The dangers of "hospital centrism" in which hospitals and specialty care capture a disproportionate share of public sector financing must be overcome by careful and transparent monitoring of government expenses for health and a political commitment to give priority to expanding the budget for the lower levels of healthcare delivery.

Creation of a strong professionalised cadre of community health workers

Bangladesh also needs to build on its strong tradition of CHWs by upgrading them to a strong professionalised cadre of well-trained, full-time workers who are well-supervised and supported, and well-integrated into the primary healthcare system. Globally, CHWs are at the dawn of a new era and, in fact, in many countries, they are leading the way to "Health for All" as their potential for achieving high levels of population coverage of evidence-based interventions that would not be otherwise achievable.

Decentralisation of funding and authority for primary healthcare

The decentralisation of funds for primary healthcare and the decentralisation of authority over the use of those funds will be required in order to revitalise the primary healthcare system and to ensure that every locality has the funds it needs to provide essential services. The local entities that receive these funds will need to have the capacity to speak and act on behalf of the communities they serve.

Provision of health coverage to all citizens

Bangladesh has the highest rate of out-of-pocket expenditures as a percentage of total health expenditure in the world – 67 percent. In 2016, 11 million people fell into poverty because of health expenditures. The global goal established by the United Nations of Universal Health Coverage by 2030 require in Bangladesh, among other things, the creation of a safety net to protect families from these tragedies.

Continuation and further enhancement of the culture of research and evidence in healthcare

Brac and icddr,b, among many others, have made enormous contributions by conducting field research related to health services implementation and effectiveness, with the learnings applied through iterative implementation. As Bangladesh has done so well already, innovations need to begin at the local level and gradually scale up with monitoring and evaluation at each level of scaling up.

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Bangladesh’s journey with health in the past 50 years

Strengthening of civil society watchdogs and civil society leadership

A vibrant, informed civil society (that includes, of course, the NGO community) will be essential for Bangladesh to make progress on all these fronts. This calls for a strong role for Bangladesh Health Watch and other similar organisations that can take a dispassionate view of the health needs of the country and the steps that need to be taken to address them. This will also require the emergence of strong leaders who can inspire others in these efforts. Making government expenditures transparent and holding the government accountable for how it uses its money will be critical.

The 1978 Declaration of Alma-Ata, affirmed by representatives of 134 countries including Bangladesh, called for the achievement of "Health for All" – "a level of health that will permit them to lead a socially and economically productive life." The declaration also reminds us that "[t]he people have the right and duty to participate individually and collectively in the planning and implementation of their healthcare."

Over the past five decades, Bangladesh has inspired the rest of the world because of its achievements in the implementation of health programmes, saving lives, and overcoming poverty, thereby bringing dignity and hope to millions of people. The closing remarks of 50 Years of Bangladesh: Advances in Health proclaims, "The government must play a bold role and lend a hand towards the transformation of the health system. That is, the government needs to have courage and full commitment." Only through this, but within a pluralistic health system that incorporates the full spirit and participation of civil society and local communities, will such efforts succeed in providing "Health for All."

This is an abridged version of the author's keynote address at the launch of the book, Bangladesh at 50: Advances in Health, held in Dhaka in May 2023.

Dr Henry B Perry is a senior scientist at the Johns Hopkins Bloomberg School of Public Health in the US.