Poor, packed, flat, watery, and full of rickshaws--the common images of Bangladesh for most people. But, through new innovative and comprehensive approaches, Bangladesh is making remarkable progress in tackling healthcare needs and reducing the growth rate of the population.

With 129 million people crammed into 133 910 km2, Bangladesh is the most densely populated country in the world.1 This is equivalent to twice the UK population in half the land, with a population growing at a rate of 2.2% each year.2 During monsoon, up to two thirds of the country is flooded with recurrent cyclones destroying property, agriculture, and thousands of lives.

REX/RICHARD SOWERSBY

Health indicators paint an even bleaker picture. Half of Bangladeshis are estimated to live below the poverty line and less than 40% have access to modern primary health care beyond immunisation and family planning.3 Nutritional deficiencies, overcrowding, poor water and sanitation, violence against women, and inequality all contribute to serious health problems. Rates of malnutrition and maternal mortality are among the highest in the world; about 1 in 40 women die of causes related to maternity.4

A sixth of children die before their fifth birthday, mainly from readily preventable causes such as pneumonia and diarrhoea.5 A sad reflection of the sex inequalities throughout Bangladesh is that, unlike almost all other countries, life expectancy at birth is lower for girls than for boys.2

Battling to overcome these never ending constraints is a health system largely funded by a consortium of donors and aid agencies or by out of pocket payments, inevitably casting doubt on both the sustainability and equity of health care in Bangladesh. The limited resources are based in large towns and cities and are inaccessible to most of the urban population.

How is it possible then that Bangladesh is hailed by many as "remarkable" and a "health success"? As desperate as things are now, they were a lot worse. A report on Bangladesh in 2000 highlighted, "Taking into account the limited financial resources, the persistence of its traditional cultural values, and high levels of illiteracy, Bangladesh has made remarkable progress during the past three decades."3 Since the 1970s the birth rate has halved,6 infant and under 5 mortality has decreased by 25%,7 the health of the population has improved, and primary healthcare services have been strengthened. To its credit, Bangladesh is one of the few countries on track to achieve the millennium development goal of reducing mortality in under 5 year olds by two thirds between 1990 and 2015, though it will inevitably fall short of other goals.

In July 1998, a new comprehensive national policy for health, population, and nutrition was formulated, heavily influenced and funded by the World Bank, non-governmental organisations, and health professionals. The policy aims to provide an "essential package of services" which focuses on reproductive and maternal health, health care for children, communicable disease control, and limited curative care. Continued government commitment and implementation of this for the entire population are key if Bangladesh is to support the gains already made and make any real progress towards providing health care for all.