Box 4.3The Bangladesh Success Story

In the mid 1970s, an average Bangladeshi woman had more than six children, which—in combination with poor nutrition and lack of access to quality health services—jeopardized the health of both the woman and her children. Beyond the health impact of this situation, high fertility and rapid population growth represented major constraints to the country's economic development and social progress.

The Bangladeshi family planning program, initiated to reach demographic goals, had four elements. The first element was the deployment of young, married women who were hired as outreach workers and trained to conduct home visits with women, offering contraceptive services and information. The number of these outreach workers, referred to as family welfare assistants, eventually reached about 25,000 in the public sector and another 12,000 in NGOs. The program also recruited 4,500 male outreach workers.

Each family welfare assistant was expected to cover three to five villages, or 850 rural women, visiting each household once every two months (Hossain and Phillips 1996). The program's reach was dramatic: family welfare assistants contacted virtually all Bangladeshi women at least once and reached more than one-third every six months. The family welfare assistants were well-recognized village visitors and constituted the main link between the government program and rural women.

A second element of the program was the provision of as wide a range of methods as possible to meet a variety of reproductive needs. This so-called cafeteria approach offered temporary methods as well as sterilization services for individuals with two living children where the youngest child was at least two years old (Rob and Cernada 1992). A well-managed distribution system provided family planning commodities to outreach workers to support their work.

A third element of the program was the family planning clinics established in rural areas to which outreach workers could refer clients who wished to use long-term or permanent methods such as sterilization. Eventually, about 4,000 government facilities and 200 NGO clinics were established.

A fourth element was the information, education, and communication activities that were intended to change norms about family size and provide information about contraceptive options. State-of-the-art use of mass media proved to be particularly effective.

As a result of the program, virtually all women in Bangladesh are aware of modern family planning methods. Contraceptive use by married women increased from 8 percent in the mid 1970s to about 50 percent in 2000, and fertility decreased from more than 6.0 children per woman in 1975 to about 3.3 in 2000. Even though social and economic improvements have played a major role in increasing the demand for contraception, investigators have shown that the provision of services and information has had an independent effect on attitudes and behavior.

The program is estimated to cost about US$100 million to US$150 million per year, with about one-half to two-thirds of the funding coming from external donors. Cost-effectiveness has been estimated at about US$13 to US$18 per birth averted, a standard measure for family planning programs.

Despite its achievements, the Bangladesh family planning program is far from perfect. Since about 1995, declines in fertility have slowed greatly. Many observers have noted opportunities to increase the program's efficiency, to respond more effectively to women's needs, and to better link family planning and health. Nevertheless, Bangladesh has done something few other countries at its level of social and economic development have been able to accomplish: it has complemented efforts to change attitudes about family size with the provision of family planning services to realize a sustained and dramatic decrease in fertility. Although the original motivation for the program was to achieve demographic aims, the government was able to create a program that responded to couples' needs rather than employing coercive measures.

Source: Authors.

From: Chapter 4, Cost-Effective Strategies for the Excess Burden of Disease in Developing Countries

Cover of Priorities in Health
Priorities in Health.
Jamison DT, Breman JG, Measham AR, et al., editors.
Washington (DC): World Bank; 2006.
Copyright © 2006, The International Bank for Reconstruction and Development/The World Bank Group.

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