For a better future

Improved child health means improved productivity of adults, and improved productivity leads to development of an economy. Healthy children have better cognitive development which enhances their ability to learn, and enhanced learning will add to human capital – an important determinant of economic growth. 

Both domestic and foreign employers are interested in employing healthier workforce. Initiatives for better child health can reduce healthcare burden on families and the state. Moreover, healthy and productive individuals can contribute to government's earning from tax. Bangladesh has laid high emphasis on child health as reflected in the government's plan and Poverty Reduction Strategy Paper (PRSP). Investment in child health is extremely important for a country aspiring for rapid development. 

The worthiness of this investment is very high if we take into account its positive "externality" occurring in a particular period as well as over time and generations. Investment Case Analysis (ICA), which is based on the Marginal Budgeting for Bottleneck (MBB) tool, appears to be very promising in the context of difficult areas of the country. 

Bangladesh has made substantial progress in improving the child health scenario, especially in neonatal health, over time. The Millennium Report: Countdown to 2015 placed Bangladesh among the only 16 countries in the world that are on track to achieve MDG 4 with regard to child mortality. Under-five mortality has reduced from 116 in 1996-97 to 46 in 2014. Similarly, infant mortality rate has decreased by more than half in the same period (38 per 1000 live births in 2014). The proportion of one-year-old children immunised against measles has also increased by more than 80 percent compared to the status during 1990-91.

In Bangladesh, the aggregate level of achievement in child health is satisfactory, although it is still lagging behind in terms of accomplishment at disaggregate level. Bangladesh cannot develop at the desired pace, unless regional disparities can be reduced and need-based resource allocation is ensured.

The results of the MDG needs assessment and costing study showed that the estimated per capita resource requirement was more than 2.5 times for child health (US$ 4.38), compared to that of the maternal health (US$ 1.72). The total per capita investment needed was US$ 19 to achieve the health related MDGs from 2009-15 (GoB 2009). The total health expenditure in the country was US$ 27 in 2012, including both private and public health care financing (MoH&FW 2015).

The above estimates of the required investment for maternal, newborn and child health (MNCH) services appertains to the aggregate level only; it does not explicate the resource needs at the level of specific areas and specific segments of population. But the situation widely varies from upazila (sub-district) to upazila as well as within upazilas. The obstacles, which stand in the way of rapid increase of the use rate of MNCH services and the needed strategies, will differ in the difficult areas from the general obstacles and strategies. The strength of the ICA is that it first identifies the obstacles specific to areas and formulates strategies needed, and then calculates the required amount of investment and selects the most cost effective interventions. To do this investment case analysis (ICA) exercise, there exist many tools, among which the MBB tool is a competent one. 

Recently, a study on ICA has been carried out in two selected districts, Chittagong and Sylhet, by the Institute of Health Economics, University of Dhaka, with the support of the UNICEF Bangladesh in close collaboration with the Directorate General of Health Services (DGHS) and Health Economics Unit of the MoH&FW. Three investment scenarios were developed for each district using the validated data, identified bottlenecks and proposed strategies in district and central workshops. 

The major bottlenecks included inadequate provision of emergency supplies, vacant posts of Community Health Workers (CHWs), absenteeism of providers, high travel cost, insufficient transport facility, lack of trained medical persons, and lack of knowledge of the clients. 

Implementation of the basic scenario in Chittagong is expected to reduce the under-five mortality, infant mortality, and neonatal mortality by more than 22 percent at an additional cost of only US$ 0.45 per capita. The implementation of expanded scenario shall increase the reduction in the under-five mortality, infant mortality, and neonatal mortality marginally compared to the basic scenario. The additional cost of implementing this is $1.20. A comprehensive scenario is expected to reduce the under-five mortality, infant mortality, and neonatal mortality by more than 30 percent at an additional cost of $2.27 per capita. 

Implementation of the basic scenario in Sylhet will help to reduce the under-five mortality by 15.6 percent, infant mortality by 13.0 percent, and neonatal mortality by 6.8 percent at an additional cost of $0.55 per capita. Implementation of the expanded scenario shall further reduce the under-five mortality, infant mortality, and neonatal mortality slightly. The additional cost of $0.93 per capita is needed to implement the expanded scenario. A comprehensive scenario shall reduce the under-five mortality, infant mortality, and neonatal mortality by around 30 percent at a cost of $2.33 per capita. 

In Chittagong, the incremental cost effectiveness ratio for averting under-five deaths is lowest, under a basic scenario compared to that of expanded and comprehensive scenarios. This implies that the health service delivery will be most cost effective if full utilisation of the existing resources can be ensured. Under the basic scenario, US $516 is required to avert one under-five death. In Sylhet, the increase in the number of human resources and infrastructure is expected to reduce child mortality in a cost effective way and the incremental cost effectiveness ratio to avert one child death (US $723) is lowest under comprehensive scenario.

It is extremely important to improve maternal and child health status in Bangladesh, both for attaining the targeted health status of the population as well as pacing up socio-economic development. Investment in child health is highly return-generating and use of the ICA for choosing investment options in the local level planning for MNCH services will be greatly effective for the formulation and implementation of the plan. 

The writer is the Director of the Institute of Health Economics, University of Dhaka. email: najahan.ihe@gmail.com