Commentary: Sustaining progress towards comprehensive reproductive health services in Bangladesh

Bangladesh has made major shifts in health policy and programme initiatives since the 1994 International Conference on Population and Development (ICPD). The lead author of this commentary has previously described the pivotal post-ICPD change in ‘health policy priorities and investments, from a narrow focus on family planning to comprehensive services for sexual and reproductive health (SRH)’ (Jahan & Germain, 2004). Where is Bangladesh today? What have we learned, and what is the way forward? With 157 million people and a current per capita income of only US$1044, Bangladesh has made remarkable, unexpected progress towards the health Millennium Development Goals (MDGs). After independence in 1971 until the mid-1990s, Bangladesh invested primarily in child survival and vertical family planning services, mainly for women. Notable innovations included recruitment of thousands of women outreach-workers to deliver contraceptives to the recipient’s doorstep, and wide provision of ‘menstrual regulation’ services in primary health centres (Johnston, Oliveras, Akhter, &Walker, 2010). The contraceptive prevalence rate (CPR) increased from 8% to 45%, and the total fertility rate (TFR) declined from 6.3 to 3.3 in this period (National Institute of Population Research and Training [NIPORT], Mitra and Associates, MEASURE DHS, & ICR, 2013). Maternity care drew little attention, however. Thousands of traditional birth attendants (TBAs) were trained from 1978 and 1979 through the global ‘Safe Motherhood Initiative’ until 1997. While TBAs can play useful roles, a failure to integrate them into the health system and lack of investment in essential obstetric care meant that the maternal mortality ratio (MMR) declined slowly, from 620 per 1,00,000 live births in 1980, to 574 in 1990 (General Economics Division Planning Commission Government of the People’s Republic of Bangladesh, 2010; Khan, Jahan, & Begum, 1986). Bangladeshi activists advocated nationally and internationally in the 1990s to promote more comprehensive reproductive health services. Following the ICPD, in 1995 civil society and women’s organisations were invited for the first time by the government and development partners to help design a new national health strategy and programme. These groups significantly influenced the content and adoption of the first Health and Population Sector strategy (HPSS) in 1996, and the five-year health and population sector