RESEARCH PAPER
ON
DEVELOPMENT OF HEALTH IN BANGLADESH

Introduction:
Bangladesh is a developing country with a population of 152,518,015 (approx.) Since our war of independence we have face numerous amount of health and nutrition issues in our country. Although Bangladesh has seen impressive progress in health and nutrition in the last few decades. Despite still low social indicators and continuing prevalence of poverty (40% of the population lives below the poverty line), the health sector in Bangladesh has shown impressive progress. We improved in sectors such as pharmaceuticals, increasing number of doctors, increasing number of hospitals and medical colleges. ICDDR’B etc. The government of Bangladesh has shown policy continuity and commitment to improving health conditions, placing particular emphasis on improving the health conditions of its citizens and targeting the poor, women and children. Where as many of the problems still remains unsolved. The ministry of health and family planning is responsible for the health service of the country should take necessary steps to solve those problems.

Objective:
The main objective of this whole research is to evaluate the health condition of Bangladesh. From 1971 to 2013 health condition of Bangladesh has radically changed. We are here to present that the number of health centers, hospitals, medicals colleges and other institutions related to health development of our country. We have also seen numerous amount of development in since 1971 regarding heath. Inspire of those development we still face a lot of challenges. It is our failure that we still have numerous problem related to health. We are here to focus our objective of our research paper is to show the number of institutions engaged in the health service of our country, mortality rate, development of pharmaceuticals, number of doctors present in our country, condition of maternal health, condition of combat diseases, family planning condition, life expectancy of the people of our country and international recognition of ICDDR, B. We are also going to the most important role played by Government and NGO’s. The goals that Millennium Development Goal (MDG) related to health are also one of our objectives. We are also going to show the sectors where we are facing challenges in and some relevant solutions to those problems.

Methodology:
The research paper is an exploratory one by nature and is based on mainly secondary data sources available from libraries, information available from different websites in internet and survey’s by different institutions. Data collected were then analyzed, sorted and represented to represent findings and arrive at a conclusion. Four Decade of Health Condition of Bangladesh (1971-2013):
From 1971 till 2013 the health condition of Bangladesh has changed drastically. There has been a lot of improvement in health sector of our country. People no more die due to diseases like cholera, diarrhea, fever, flu etc. The condition of the health service sector is shown in the following time line:
1971-1980:
* 1971: War of Independence—time of reconstruction with high aid dependence * 1974-1975: Low point of economical and political condition. Devastating famine * 1979: Following Alma Ata Declaration a decentralized health sector started emphasizing access to primary education, strong family planning with recruitment of outreach services. * Grameen Bank, BRAC and a handful of other NGOs begin work on a very small scale
1981-1990:
* Continued to emphasis on family planning and health sector policies included a strong health policy that regulated doctors and drug sales through enforcement of an essential drug list * Mandatory rural services for doctors. * Gradual growth of the NGO sector which remained small scale in terms of national impact. * Fertility rate declined rapidly * 1985: launching of the Expanded Program of Immunization (EPI) * Aggressive family planning program with doorstep delivery of services. * Widespread malnutrition, inadequate sewage disposal, and inadequate supplies of safe drinking water. * fertility rate was also extremely high * Morbidity and mortality rates for women and children were high * 1986: the Universal Immunization Program was initiated * 1982: adapted National Drug Policy (National Drug Control Ordinance 1982)

1991-2000: * 1994 Cairo agenda argued for reform in fp towards broader emphasis on Reproductive Health. * National immunization days were instituted, to deliver two doses of polio vaccine a year * 1997: Health and Population Sector Strategy (HPSS) was adopted * 1998: Health and Population Sector Programme (HPSP) was launched for duration of five years * 2000: first National Health Policy * Fertility decline stagnant for most of the decade, but contraceptive use continued to increase. * Micro-finance grows from about 12% membership of all reproductive age women to 30% membership.

2001-2010: * Increased funding for HIV-AIDs prevention despite low prevalence. * 2003: launched its successor the Health, Nutrition, and Population Sector Programme (HNPSP), conceived within the sector-wide approach * 2004: National Nutrition Programme (NNP) was launched * Newborn survival has evolved as a national health priority * The water flow from upstream rivers has been reduced * Fertility decline resumes in 2004. Low emphasis on family planning and primary health care services. Government’s Role in Development of Health Service:
Health Care System of Bangladesh is governed by Ministry of Health and Family Planning. The government is responsible for building health facilities in urban and rural areas. For example, in the late 1980’s in Bangladesh, the rural health facilities that existed in the rural areas were mostly sub-district health centers, rural dispensaries and family welfare centers. Urban health centers also had problems with inadequate medical supplies. The scenario has changed now. The Government of Bangladesh’s vision is “to see the people healthier, happier, and economically productive to make Bangladesh a middle-income country by 2021” (Vision 2021). The government finances 70 percent of the $4.2-billion five-year Population, Health, and Nutrition Sector Strategic Program. The goal of the next sector program, covering 2011-2016, is to ensure quality and equitable health care for the citizens of Bangladesh. Revitalizing social services is a core focus of the Bangladeshi government, including a commitment to: rebuild the health system at the community and district levels; improve access to services for the most disadvantaged, including women; and increase governance, accountability, and credibility in addressing the country’s remaining health challenges.
NGO’s Role in Development of Health Service:
As Bangladesh is still a developing country there are a good number of NGO’s in our country. There are 2209 NGO’s in our country among them BRAC, ASHA, Proshikha, Swanirvar Bangladesh etc are leading. NGO’s of Bangladesh are providing training and education service in field of health and nutrition. In some specific area of primary health care sector like diarrhea control, vaccination against six hazardous diseases, campaigning for health consciousness, expansion of water and sanitation services , reproductive health care and family planning services etc. the NGO’s have achieved extensive success. In order to develop the health and nutrition situation, around 350 brought in sanitary toilets for 14 lakh people and safe water for 1.5 crore people through establishment of 1.5 lakh tube-well, 186 rural sanitation centers and 2.5 lakh latrine. NGOs are playing notable role in changing poverty state by bringing in primary and other health and nutrition care services within the reach of poor people.

Millennium Development Goal (MDG):
Globally agreed all eight Millennium Development Goals (MDGs): eradicate extreme poverty and hunger, achieve universal primary education, promote gender equality and empower women, reduce child mortality rate, improve maternal health, combat HIV/AIDS, malaria, and other diseases, ensure environmental sustainability and develop a global partnership for development by 2015, are closely connected and all the targets might be achieved if the targets of the health related Millennium Development Goals are achieved. By reviewing literature related to health related Millennium Development Goals in Bangladesh issue this paper finds that progress made by Bangladesh on the MDGs, especially those related to health, has been extremely slow. With only five years left, it might be quite difficult to achieve the health related Millennium Development Goals as in most of cases the progress is not on track rather far away from the desired target.

MDG-4: Reduce Child Mortality Rate
If the current trend continues, the Unnayan Onneshan projection reveals that under-five mortality might stand at 53 deaths per thousand live births in 2015 against the targeted rate of 48 in 2015. Under-five mortality rates steadily declined from 146 deaths per thousand live births in 1990 to 67 per thousand in 2009 (GoB’s progress report 2010). Projected infant mortality rate might reach to 43 deaths per thousand live births by 2015, which is higher by 12 deaths per thousand live births against the target. Infant mortality rate was 45 live births per thousand in 2009 (Bangladesh Progress Report, 2010). The average annual reduction between 1991 and 2009 was 2.84 percent against a target of 2.76 percent. Estimated one-year-old children immunized against measles might not reach to 100% by
2015 rather only 75% might be attained. The rate of improvement of immunization coverage increased from 54 percent in 1991 to 88 percent in 2006(GoB’s progress report 2010). In that period, the average increase in the coverage of child immunization between 1991 and 2006 was 3.25 percent: 0.65 percent above the targets annual rate of 2.6 percent.

MDG-5: Improve Maternal Health
Unnayan Onneshan’s projection on health related MDGs indicates that Bangladesh may possibly reach to 280 deaths per 100,000 live births by 2015 while the target is to reduce to 143. In 2006 the estimated maternal mortality ratio was 290 per 100,000 live births (BDHS, 2007). It was 348 in 2008 (Bangladesh Progress report 2010). Proportion of births attended by skilled health personnel might increase to 23% against the target of 50% by 2015. Between 2002 and 2006 the proportion of assistance during delivery by medically trained providers increased to 18 percent, at an annual average of 16.25 percent. Due to pregnancy and childbirth-related causes, principally because of skilled birth attendants, 21,000 mothers die annually. If this trend is maintained, Bangladesh may be far behind to achieve the MDG targets by 2015.

MDG-6: Combat HIV/AIDS, malaria, and other diseases
HIV/AIDS-positive individuals have increased steadily since 1994 to approximately 7,500 people in 2005 (ICDDR, B). UNAIDS estimate the number to be slightly higher at 11,000 people. At the end of February 2010, 12,000 people in Bangladesh had HIV/AIDS and 500 deaths occurred due to the fatal disease (CIA World Fact book). But this is a strong apprehension that the actual figure would be far higher as HIV/AIDS-infected people are afraid to disclose that they have the disease. Over 98 percent of all malaria cases in the country are concentrated in 13 districts out of total 64 that belong to the high-risk malaria zone. It is said that from 1955 to 1958, 47,500 people died of malaria each year, while 1.5 million were affected. In 2007 there were 50634 reported cases of malaria and 239 deaths. Bangladesh has made significant progress in preventing and reversing the spread of tuberculosis (TB) during the last two decades. The TB prevalence rate has reduced from 406 per 100,000 per year in 2006 to 391 in 2007. TB mortality rate also reduced in this period from 47 to 45 per 100,000 per year. To further decrease incidence and prevalence of TB, the momentum must be maintained to reach the MDG target.

It is pertinent to mention that theoretically many of the strategic documents and policy papers are sound and seems to be implementable. Though, the government of Bangladesh and some several other organizations are very much hopeful to achieve the MDG targets by 2015. However, the foregoing discussion indicates that it may be quite difficult for Bangladesh to achieve the health related MDGs, if the government does not give top priority on the MDG 4, 5, 6, and if the compliance and accountability of the developed world are not ensured.
MDG- 4
Reduce Child Mortality
Target for Bangladesh
To achieve the goal, Bangladesh must reduce under-five mortality from 146 deaths per thousand in 1990 to 48 by 2015, infant mortality rate from 92 deaths per thousand live births in 1990 to 31 by 2015. Another target is to enhance the proportion of immunized one-years-olds for measles from 54% in 1990 to 100% by 2015.
Current Situation and Future Projection
Under-Five Mortality
If the current trend continues, the estimated under-five mortality might stand at 53 deaths per thousand live births in 2015 against the targeted rate of 48 in 2015, which is higher by 5 deaths per thousand per year. Under-five mortality rates steadily declined from 146 deaths per thousand live births in 1990 to 67 per thousand in 2009 (GoB’s progress report 2010). Current situation demands under-five mortality rates to be reduced annually by three deaths per thousand between 2000 and 2015 (Figure 1) to achieve the target. The report highlighted the need to focus attention on neonatal and prenatal causes of death, deaths due to pneumonia, diarrhea, injuries, poor care-seeking practices, malnutrition and low birth-weight (LBW). However, the decline was about 10 percent among 1-4 years old children and about 2.4% annually among post neonates (1-11 months) and also 2.2 percent in neonates (Bangladesh Demographic and Health Survey, 2007). It is obvious that if substantial reductions in post neonatal and neonatal mortality are not achieved, Bangladesh may not achieve MDG 4.
Infant Mortality Rate
Unnayan Onneshan projection reveals that the projected infant mortality rate might possibly reach to 43 deaths per thousand live births by 2015, which is higher by 12 deaths per thousand live births against the target. In 2009, the rate was 45 per thousand live births must be reduced annually by at least four deaths per thousand between 1999 and 2015. Infant mortality rate in Bangladesh, like under-five mortality rate, has also decreased impressively from 1990 to 2009 (Figure 4). The average annual reduction between 1991 and 2009 was 2.84 percent against a target of 2.76 percent.
Major Causes of Infant Mortality
The major causes of infant deaths are acute respiratory infections, neonatal and prenatal problems, diarrhoea, pneumonia etc. Neonatal and prenatal causes amount one-half or two-thirds of under-five mortality or infant mortality (GoB and UN, 2005). According to the Bangladesh Demographic and Health Survey (BDHS) 2007, each year 1.2 lakh newborn babies died within 28 days. Neonatal deaths now substantially amount 57 percent to overall mortality of children aged less than five years (BDHS, 2007). So, neonatal and prenatal care for the mother is very important. Around four in ten women receive no antenatal care. In rural areas, about 90 percent natal practices occur at home; while in urban areas, little over one-fourth of this practice is done at health care center (BDHS, 2007). Only 24.4 percent of births are delivered by skilled health personnel (MICS, 2009). There is a strong association between under-five mortality and mother’s education.
It ranges from 32 deaths per 1,000 live births among children of women with secondary complete or higher education to 93 deaths per 1,000 live births among children of women with no education (BDHS, 2007). Birth spacing is another variable associated with under-five mortality. As the birth interval becomes shorter, infant mortality chances rise sharply. Both infant and under-five mortality rate are lower for those in the highest wealth quintile.

Malnutrition
After the first month of birth, malnutrition becomes an important contributing factor to infant and child mortality. But in Bangladesh, it often occurs early because of improper feeding practices which play a pivotal role in determining the optimal development of infant. Poor breastfeeding and infant feeding practices have adverse consequence for the health and nutritional status of children. Only two-thirds among the infants, less than 2 months old, (64 percent) are exclusively breastfed. The remainders are given water, other milk and liquids in addition to breast milk, and 6 percent even receive complementary foods. From about six months of age, the introduction of complementary foods is critical for meeting the protein, energy and micronutrient needs of children. Among children age 6-9 months, only three in four children receive complementary food (BDHS, 2007). Malnutrition passes from one generation to the next because malnourished mothers give birth to malnourished infant. If they are girls, these children often become malnourished mothers themselves and the vicious cycle continues. Health experts disclose that Bangladesh has one of the highest rates of child and maternal malnutrition in the world. State of World’s Children (SOWC) Report 2008, issued by UNICEF, indicated that 48 percent of all the children under-five are under-weight. New born deaths make up nearly half of all under-five deaths (57 percent) and 71 percent of infant mortality. One neonate dies every year, according to UNICEF (IRIN, November 19, 2008).

Immunization against Measles
The current trend of one-year-old children immunized against measles suggests that it might not reach to 100% by 2015 rather only 75% might be attained. The rate of improvement in immunization coverage was 88 percent in 2006 (Millennium Development Goals Progress Report of Bangladesh, 2010). If the immunization coverage rate from 1991 is maintained, it will not achieve the target within 2015. However, the rate of improvements from 2000 in the immunization coverage explore different scenario, i.e. if this can be continued it will reach the target within 2015 years (Figure 5). In that time, the average increase in the coverage of child immunization between 1991 and 2006 was 3.25 percent that is 0.65 percent above the target annual rate of 2.6 percent. Figure 6 is a fluctuated figure. However Bangladesh is on the track to achieve MDG 4, the government should give top priority to achieve MDG 4 within 2015, otherwise not.

MDG 5 Improve Maternal Health
The global target under this goal is to reduce the maternal mortality ratio by three-quarters between 1990 and 2015. This goal has one target and two indictors; i) maternal mortality ratio; and birth attended by skilled health personnel.

Target for Bangladesh
To achieve the goal, the targets of Bangladesh are: i) reduce maternal mortality from 574 deaths per 100,000 live births in 1990 to 143 by 2015; and ii) increase the proportion of birth attended by skilled personnel to 50 percent by 2015.

Current Situation and Future Projection
Maternal Mortality Ratio
Unnayan Onneshan’s projection on health related MDGs indicates that Bangladesh might reach to 280 deaths per 100,000 live births by 2015 while the target is to reduce to 143. In 2008, the rate was 348 (Millennium Development Goals, Bangladesh Progress report 2010). The estimated maternal mortality ratio in 2006 was 290 per 100,000 live births (BDHS, 2007). Bangladesh’s estimated maternal mortality rate between 320 and 400 per 100,000 live births (GoB and UN, 2005), in 2002 was the highest in the world at that time and is still high relative to many developing countries. Government claims the decline rate is on track for achieving the goal, however the rate of reduction from 1999 does not indicate so (Figure 7). In Bangladesh maternal mortality ratio has decreased from 574 per 100,000 live births in 1990 to 315 live births in 2001

Causes of Maternal Mortality
Most maternal deaths occur due to hemorrhage, unsafe abortion and natal problems. Over half of all pregnant women do not receive any institutional health service during childbirth, while significantly fewer received institutional post-natal health care (BDHS, 2007). About four in every ten women receive no antenatal care. Eighty percent of the deliveries still take place at home. The percentage of deliveries with assistance from qualified professionals is also very low, 18 percent deliveries are attended by medically trained personnel while 10.8 percent births are attained by trained birth attendants. Only 15 percent births take place at health facility. Malnutrition, particularly chronic energy deficiency (CED) and anemia, contribute to poor maternal health and pregnancy outcomes for both the mother and her children. Severe anemia increases the risk of maternal mortality, which accounts for over one-thirds of maternal deaths. Recent data indicates that 40 percent of adolescent girls, 46 percent of non-pregnant and 39 percent of pregnant women are chronically malnourished (BDHS, 2007). MDG- 6
Combat HIV/AIDS, Malaria and Other Diseases
Target for Bangladesh
Bangladesh’s target for achieving the goal is also to stop and reverse the spread of HIV/AIDS, malaria and other diseases by 2015.

Current Situation
HIV/AIDS Prevalence Rate
AIDS is caused by infection of a virus named Human Immunodeficiency Virus (HIV). This virus is transmitted through blood and sexual contact. In addition, infected pregnant women can pass HIV to their offspring during pregnancy and deliver as well as through breastfeeding.
Overall HIV/AIDS prevalence in Bangladesh is expected to be extremely low and insignificant. In reality, HIV/AIDS-positive individuals have increased steadily since 1994 to approximately 7,500 people in 2005 (ICDDR,B). UNAIDS estimated the number to be slightly higher at 11,000 people while CIA World Fact book anticipated 12,000 people in Bangladesh had HIV/AIDS at the end of February 2010 and 500 died due to the pandemic. A strong apprehension is that the actual figure would be far higher as the infected people are afraid to disclose their status.
The level of knowledge on HIV/AIDS and its prevention among the people is increasing but 85 percent of men and only 67 percent of women have heard of it (BDHS, 2007). Though, there is a variation of estimated figure of HIV/AIDS-positive people among different sources, the increasing trend of HIV/AIDS positively indicates that country is on the brink of a nationwide crisis.
Government Initiatives
Bangladesh’s HIV/AIDS prevention program started in 1985 with the establishment of the National AIDS and Sexually Transmitted Disease Program under the overall policy support of the National AIDS Council (NAC). The national AIDS/STD Program has set guidelines on key issues including testing, care blood safety, sexually transmitted infections, and prevention among youth, women, migrant population, and sex workers. In 2004, a six-year National Strategic Plan (2004-2010) was approved. The country’s HIV policies and strategies are based on other successful family planning programs which include participation from schools, as well as religious and community organizations. The AIDS Initiative Organization was launched in 2007 in order to combat the virus. But the government has yet to show any good success. The activities of various organizations of UN and NGOs working on this issue are limited. The government is expected to produce and market cheap sterile syringes and needles that will automatically be damaged after one use. But it has not been implemented yet. In addition, blood screening facilities are not developed by the public or the private sector until now.

Condom Use Rate
The Bangladesh Demographic and Health Survey data 2007 indicate that overall 55.8 percent of currently married women are using a contraceptive method, with only 4.5 percent of men are using condom. Use of condom increased slowly from 3 percent in 1989 to 4.5 percent in 2006 (Figure 12). There is no data available on the contraceptive prevalence rate among the HIV/AIDS high-risk groups. UNAIDS estimate consistent condom use is only 2 percent and 4 percent for brothels and street based sex workers. Among their clients 75 percent of truck drivers reported that they did not use condoms the last time they purchased sex, and only 2 percent of rickshaw-pullers reported using condoms consistently while having sex with sex workers (GoB and UN, 2005).
Contraceptive Prevalence Rate
The contraceptive prevalence rate in Bangladesh increased from 44.6 percent in 1989-93 to 55.8 percent in 2006 at an annual average rate of 1.56 percent. However, the contraceptive prevalence according to BDHS was 58.1 percent in 2004 and it reduced to 55.8 percent in 2007 (Figure 13). Deeper analysis shows that there was no decline in use of modern methods but use of traditional methods reduced in this period without adversely affecting the TFR, which declined from 3.0 in 2004 to 2.7 in 2007.

Prevalence and Prevention of Malaria Bangladesh’s target for achieving the goal is to stop and reverse the spread of Malaria which is one of the major public health problems in Bangladesh because 13 out of total 64 districts belong to the high-risk malaria zone. Over 98 percent of all malaria cases in the country are concentrated in these districts. It is said that between 1955 and 1958, 47,500 people died of malaria each year while 1.5 million were affected. In 2007 there were 50634 reported cases of malaria and 239 deaths. The case fatality ratio was 472 per 100,000 in the same year (Table 1). The trend of malaria cases per 100,000 population shows that the prevalence of the disease increased from 43 in 2000 to 47 in 2002. After 2002 it reduced to 42 percent and remained almost same in 2003 and 2004. Then the prevalence of malaria reduced drastically in 2005 to 34 percent per 100,000 populations (Figure 14). Changes in the malarial death rate per 100,000 population show similar trend as the trend in reported cases of malaria.
Prevalence and Prevention of Tuberculosis
Reports from various sources indicate that Bangladesh has made significant progress in halting and reversing the spread of tuberculosis (TB) during the last two decades on route to reaching the goal of MDG. Though about 70,000 patients die of TB each year (GoB and UN, 2005) the TB prevalence rate has reduced from 406 per 100,000 per year in 2006 to 391 in 2007. TB mortality rate has also reduced from 47 to 45 per 100,000 per year (NTCP and WHO, Bangladesh). The momentum must be maintained for further decrease incidence and prevalence of TB to reach the MDG target.
The TB detection rate under DOTS, show that the country has been highly successful in identifying the TB cases from 21 percent in 1994 to 71 percent in 2006 and well on the track towards 100 percent detection rate by the year 2015. Tuberculosis treatment under DOTS also made a good progress. The tuberculosis treatment success rate under DOTS gradually increased from 73 percent in 1994 to 92 percent in 2006 (Table 3). Given this phenomenon, Bangladesh is well on the track towards achieving the MDG target which percent in 1994 to 92 percent in 2006 (Table 3). Given this phenomenon, Bangladesh is well on the track towards achieving the MDG target which is 100 percent treatment success rate.
Mother and Child Mortality Rate:
Bangladesh Maternal Mortality and Health Care Survey (BMMS-2010):
The Government of Bangladesh is committed to achieving its targets for Millennium Development Goal 5: reducing the maternal mortality ratio (MMR) to 143 deaths per 100,000 live births by 2015 and increasing skilled attendance at birth to 50 percent by 2010. The 2010 Bangladesh Maternal Mortality and Health Care Survey (BMMS2010) was carried out to assess how well the country is progressing toward these targets.

Pharmaceuticals:
The Drug Act of 1940 and its rules formed the basis of the country's drug legislation. Following the Drug Control Ordinance of 1982, some of the local pharmaceutical companies improved range and quality of their products considerably. The pharmaceutical industry, however, like all other sectors in Bangladesh, was much neglected during Pakistan regime. Most multinational companies had their production facilities in West Pakistan. With the emergence of Bangladesh in 1971, the country inherited a poor base of pharmaceutical industry. For several years after liberation, the government could not increase budgetary allocations for the health sector. Millions of people had little access to essential lifesaving medicines.

Top pharmaceutical company: * Square Pharmaceuticals Ltd. * Incepta Pharmaceuticals Ltd. * Beximco Pharma ltd. * Bio-pharma Ltd. * Opsonin Pharma Ltd. * Eskayef * Renata Pharmaceuticals * Acme Pharmaceuticals * Aci Pharmaceuticals * Aristopharma * Drug International * Sanofi Aventis * Glaxosmithkline * Orion pharma bangladesh * Novo Nordisk * Healthcare Pharmacy * Ibn Sina * Sandoz * Popular Pharmaceutical Ltd. * Novartis * General Pharmaceuticals * Zenith Pharmaceuticals Ltd. * Edruc Limited

Doctor and Patient Ratio:
The availability of health personnel is critical for health service delivery and, despite considerable expansion in recent years; this still remains a problem today. The number of registered doctors has increased five-fold in the last three decades— rising from just about 10,000 in 1980 to close to 50,000 by 2009. During the same period, the number of registered nurses has increased about eight-fold—from 3,000 to over 24,000; and the number of registered midwives has increased even faster— almost 16-fold, going up from nearly 1,350 in 1980 to close to 22,000 by 2009. At present the ratio of doctor and patient is 1:4000.
Family Planning:
The following are the steps taken by the Ministry of Health and Family Planning of Bangladesh:
(a) Population and (b) Family Planning Services
• Promoting delay in marriage and childbearing, use of post-partum FP, post abortion FP and FP for appropriate segments of the population.
• Strengthening FP awareness building efforts through mass communication and IEC activities and considering local specificities.
• Using different service delivery approaches for different geographical regions and segments of the population.
• Maintaining focus on commodity security and ensuring uninterrupted availability of quality FP services closer to the people (at the CC level).
• Registering eligible couples with particular emphasis on urban areas to establish effective communication and counseling.
• Compensating for lost wages (reimbursement for opportunity costs) for long acting and permanent method contraceptive performance.
• Strengthening FP services especially post-partum and post abortion FP and demand generation through effective coordination of services with DGHS utilizing appropriate opportunities.

Achievement of ICDDR,B (International Centre for Diarrheal Disease Research, Bangladesh):
ICDDR, B is a health research institution in Bangladesh which dedicated to save lives through research and treatment. ICDDR, B was established as a Cholera Research Laboratory in 1960 in Bangladesh before independence. When Bangladesh became independent from Pakistan in 1971, activities were diminished. In 1978 a proposal by an international group of scientists was put forward to elevate the organization to an international research center. The organization was established in its current form via an act of parliament in 1979. The Centre is credited, among other accomplishments, with the discovery of oral rehydration therapy for the treatment of diarrhea and cholera. Oral rehydration therapy is thought to have saved over 40 million people worldwide.
Awards and recognitions
In May 2001, ICDDR’B received the first Gates Award for Global Health from the Bill & Melinda Gates Foundation. The director of ICDDR,B during the time of the discovery of oral rehydration therapy, Dr Dilip Mahalanabis, received the Pollin Prize for 2002 and Mahidol Award for 2005. In 2007, ICDDR,B received the Leadership Award from the Alliance for the Prudent Use of Antibiotics.
Challenges regarding health in Bangladesh: 1. Food adulteration: Adulteration of food in Bangladesh with toxic chemicals has reached to an alarming level. It is very difficult to find a food industry in Bangladesh which is free of adulteration.

Product | Harmful elements mixed with | Fish | Formalin | Tea and coffee powder | Reused | Fruits, vegetables | Formalin, CaC, acid etc. | Dairy products | Textile color, melamine, CaCO3 | Rice and the related items | Urea | Snacks | Excessive burning oil, color, chemicals etc. | Masala | Color, brick powder | Sauce and Juice | Rotten Pumpkin, tomato, carrot, Textile color, harmful chemicals, saccharin etc. | Flour | Chalk powder | Cow, Goat, Chicken etc | Injected and fed with harmful growth medicines |

Moreover, in almost every hotel and every restaurant, dead and rotten meat and fish are served. So, proper steps should be taken immediately.

2. Lack of modern equipments and research work: Still now Bangladesh is lagging behind in the case of research works and modern equipments. Most of the government hospitals outside Dhaka, are the real examples. There is no modern machine such as city scan machine, muga scan machine, MRI machine, endoscopy machine etc. For this reason, still a lot of people who have enough money, can go abroad each year for better treatment and the poor and middle class people are deprived. There is also lack of research work in Bangladesh regarding health. Although there are some research institutes, the research works are not enough to fulfill the demands of people. There is also lack of modern equipments for research work.

3. Prize hike: Prize hike is also another big problem in Bangladesh which indirectly affects the health condition of the people of Bangladesh. The prize of daily commodities in Bangladesh, especially the prize of food items has increased over the years and still it is increasing day by day and for which the poor people are finding it difficult to buy nutritious and high quality food which causes malnutrition, for example the prize of milk has been being increased over the years for which poor people are finding it difficult to buy milk for their babies and their babies are suffering from malnutrition.

4. Water pollution: Water pollution is another problem regarding health in Bangladesh. The sources of pure and sweet water are getting polluted day by day. So the people especially the poor people in Bangladesh are facing a lot of trouble to find it. Besides, they are not enough conscious about health. As a consequence, they have to take the polluted water which causes a lot of sufferings from various water born diseases like diarrhea, cholera, dysentery, typhoid fever, E. coli Infection etc. Recommendation about health:
Till we discuss 4 about health condition in Bangladesh. Now to improve the health situation in Bangladesh in we need to take some steps. Those steps are discussed Bellow: 1. Improving education rate: The University of New Castle found that 62% farmers of Bangladesh don’t know about the rate of comical mixing in the field. On the other hand the primary educational rate 63.2% and 72% for the girls and boys whose age more than seven. However in coastal, chaor, drought, the educational rate is less than 20% as well as they do not have any idea about health. Only to build primary school in that area and confirm their participation can increase the educational as well as health knowledge. 2. Decreasing the child mortality rate: 60 million children live in Bangladesh. 47.8% children out of 1000 die every year by infection, ARI, diarrhea, asphyxia whose age bellow five. So by improving awareness, ensuring proper caring of pregnant ladies by giving proper training to the persons who take proper care of them. 3. Health after natural calamities: Every year natural calamities occur in Bangladesh which is a cause cause for diarrhea, typhoid, malaria, TB, dysentery.
By giving training and improving the awareness can solve the affects of these diseases. NGOs (BRAC, ASA, and PROSHIKHA) can give them training easily because they already have already gone and can go in rural Ares. 4. Food adulteration rate: Carbide, Formalin, Textile colors are mixing with food and vegetable those are dangerous for our health. Food adulteration is cause for kidney failure and cancer. We have BSTI as well as law like Ordinance 1985 and ordinance 2005. BSTI and law enforcement team can solve by proper observation about launce and food quality. 5. Arsenic problem: Arsenic is a serious problem for Bangladesh. By taking long time as well as short time vision. Long time vision is like pipe line water supply from long distance. Collecting rain water, establishing deep tube well as well as emergency water and medicine supply by medical care can reduce it problem. 6. Critical issue about medicine use: More than 15% medicine in Bangladesh is unqualified and people get medicine without prescription. Law enforcement team and government can reduce this rate by proper law enforcement. 7. Establishing the proper committee by participation of public servant and general people. By working together it health problem can be reduced. 8. Improving health service and living condition: In rural area 36.3% and urban area 12.3% people are living under poverty line.. As a result people cannot take food. Price hike is a big issue for poor living condition. Government as well as big fishes can come forward for helping them. Government takes steps to give basic food with in low price but it is not enough as well as not in proper way. By reducing corruption and reducing the price can be a solution for poor living condition. 9. HIV and maternal health: HIV effected condition is good in Bangladesh. However, to increase awareness about use condom, take blood by testing can reduce it. On the other hand, to improve maternal health, we need give proper medical care as well as improving awareness among us by seminar, movie and teaching in educational institutions. 10. Modern equipments: All the hospital especially the government hospitals should use more modern equipments so that people can get good treatment. The government should take more steps to improve the condition of all the govt. and non govt. hospitals that lack modern facilities. 11. Preventing prize hike: Prize hike is a big problem in Bangladesh that indirectly affects the health of poor people in Bangladesh. To prevent prize hike any syndicate activities are to be suppressed boldly and inflation of money should be controlled. The government should also emphasize on the increase of production by applying scientific agricultural methods. Agricultural sector should be given priority in annual budget. Law and order system should be made more strick to punish those people who increase the prize of necessary things illegaly. At the same time public awareness should be created among people against prize hike.
Therefore we need to take all-out efforts to come out of this serious crisis.

Conclusion:
In conclusion we can say that previously the health condition of the people of our country was not enough good but through the decades we have made significant improvements in the sector of health in spite of having limited capacity. Although we have made significant improvement, we still have some problems like lack of modern equipments, food adulteration, prize hike, HIV, water pollution etc. If we can solve these problems we can hope to achieve more improvement in health sector.

Reference:
1. http://paa2011.princeton.edu/papers/111771
2. http://pdf.usaid.gov/pdf_docs/PDABT333.pdf
3. www.wikipedia.com
4. www.unicef.org/bangladesh/ 5. U.S. Library of Congress
6. Towards Achieving the Right to Health:
The Case of Bangladesh: OMAR HAIDER CHOWDHURY and S. R. OSMANI
7. www.mohfw.gov.bd/
8. httpwww.healthreformasia.comresourcesdownloadspresentationsEl-Saharty_O065.pdf
9. http://www.unnayan.org/reports/Health_MDG.pdf