13 Dec Bangladesh: Case Study of Innovation in Addressing the Treatment and Prevention of Diarrheal Disease
Article posted on December 13, 2016.
Prioritizing equity to develop treatment approaches that reach the poorest communities
- The coverage of oral rehydration salts (ORS) improved by 1% between 2007 and 2011.
- A closer look at the ORS coverage increase shows a concentrated effort to reach the poorest communities in Bangladesh.
- Bangladesh innovatively used a combination of health and economic development approaches to reach the most vulnerable groups.
Beginning in November, Stop Pneumonia is featuring a series of excerpts from the 2016 Pneumonia and Diarrhea Progress Report: Reaching Goals Through Action and Innovation. The annual report identifies the 15 countries with the greatest number of deaths from pneumonia and diarrhea among children under the age of five. In addition, the country profiles, Q&As, and essays focus on how to save children’s lives through action and innovation. The report is produced by the International Vaccine Access Center, at the Johns Hopkins Bloomberg School of Public Health.
2016 Pneumonia and Diarrhea Progress Report:
Bangladesh: Case Study of Innovation in Addressing the Treatment and Prevention of Diarrheal Disease
Prioritizing Equity to Develop Treatment Approaches that Reach the Poorest Communities
How is it possible for Bangladesh to substantially reduce diarrheal deaths without changing oral rehydration salts (ORS) coverage? ORS, an effective treatment that helps prevent most childhood deaths from diarrhea, has been called by a leading medical journal the “most important medical advance of the century.”42, 43 On first glance at the national ORS coverage data in Bangladesh between 2007 to 2011, the change in population coverage appears stable, even stagnant. The casual observer, noting just a 1% increase in coverage from 77% to 78% over that period, might assume a shift away from the country’s initial disease treatment and prevention efforts. An observer who looks more deeply into the data will indeed notice a shift—but a shift of intensified, rather than diluted, effort. That 1% increase in coverage occurred during a time period when the country was making precisely targeted investments in distributing ORS to the poorest communities, with the highest burden of diarrheal disease and the worst economic and health outcomes. UNICEF data for the period between 2008-2012 shows that the poorest 20% of children in Bangladesh had the same access to ORS treatment as the richest 20% of children (81.2 versus 82.3, for a ratio of 1.0).44
In fact, Bangladesh made impressive decreases in under-5 death rate from 55.9 to 44.0 per 1000 live births over this period, meeting the MDG 4 target.45, 46 International donor organizations and national officials of health and finance ministries have asked how they might replicate this effect.
The effect is not tied to one policy; most people attribute it to the country’s comprehensive, pro-poor strategy for the prevention of diarrheal deaths using both health and economic development approaches, such as those used by the Bangladesh Rural Advancement Committee, a global development and microfinance non-governmental organization working to empower poor communities with a focus on Bangladesh.47 Innovation can be defined as doing the thing that was so simple or obvious that nobody thought to do it. This example illustrates an innovation in service delivery.
The success of this case example lies in the innovative incorporation of an equity approach into a comprehensive multi-sector disease prevention strategy. By following a strategy focused on providing coverage to the most vulnerable first, Bangladesh has held steady in ORS coverage and shown continued decreases in under-5 mortality rate, with the most recent rate at 37.6 deaths per 1000 live births, with 2 per 1000 live births attributed to diarrhea.2, 45
2 UNICEF. (2015, December). Estimates of child cause of death, diarrhoea 2015. [Data file]. Retrieved from https://data.unicef.org/wp-content/uploads/2015/12/CoD_Diarrhoea_Dec-2015_WHO_MCEE_234.xlsx
42 Water with Sugar and Salt. (1978). Lancet, 312(8084), 300-1. doi:10.1016/S0140-6736(78)91698-7
43 UNICEF. (1996). ORS: the medical advance of the century. The State of the World’s Children 1996: 50th Anniversary Edition. Retrieved from http://www.unicef.org/sowc96/joral.htm
44 UNICEF. (2013, December). Bangladesh Statistics: Disparities by Household Wealth. Retrieved from http://www.unicef.org/infobycountry/bangladesh_bangladesh_statistics.html
45 UNICEF. (2015, September). Child Mortality Estimates [Data file]. Retrieved from https://data.unicef.org/wp-content/uploads/2015/12/U5MR_mortality_rate_39.xlsx
46 You, D., Hug, L., Ejdemyr, S., Idele, P., Hogan, D., Mathers, C., … Alkema, L. (2015). Global regional, and national levels and trends in under-5 mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Inter-agency Group for Child Mortality Estimation. Lancet, 386(10010), 2275-86. doi:10.1016/S0140-6736(15)00120-8
47 BRAC. (2016). Retrieved from http://www.brac.net/