Health and development: missing social determinants of health?

In recent years Bangladesh has performed exceptionally well in delivering ‘Good health at low cost’ despite a weak, low-performing and pluralistic health system suffering from ‘shortage, inappropriate skill-mix and inequitable distribution’ of health workforce’. Bangladesh’s basic health indicators are equal to or better than its neighbours who have higher per capita income. For example, the life expectancy has increased by 23 years in the past 40 years compared to 16 years in India, 10 years in Afghanistan and 18 years in Iran. Various explanations have been made for this achievement, including the benefits of targeted public health interventions e.g., immunization, family planning, and nutrition supplementation which were broadly pro-poor (Mahmud 2008).

However, this is not the end of the story because health is also a factor of ‘conditions in which people are born, grow, live, work, and age – conditions that together provide the freedom people need to live lives they value’. Underpinning Bangladesh’s spectacular performances in health are other contextual factors in the socio-economic sector including enabling social environment for women. While giving due credit to the health system for its part, we should not loss site of the fact that health is contingent upon broader socio-economic development.

First of all, the economic growth. It is very interesting to note that Bangladesh, despite all odds in the form of natural and man-made disasters and the adverse effects of economic ups and downs in the international arena, made a steady growth above 5.5% in the last few decades. There has been a steady decline in poverty (from 53% in 1995 to 40% in 2005 to 32% in 2010), and ultra-poverty  (from 41 to 18% during 1991/92-2010) and thus mitigation of ‘income-erosion’ effect of poverty. With this came slow but definitely increasing public investment in health over the years, which has been largely pro-poor. One of the critical developments has been the improvement of infrastructure, especially the roads, which reduced not only the distance to the economic hubs in the urban/peri-urban areas but also to health facilities with associated benefits for health.

The other most important factor has been the spectacular march of the women in Bangladesh! Academically termed as ‘empowerment of women’, this has been achieved through micro-credit based income generation, labour-force participation especially in the garments sector, and state-facilitated and state sponsored female literacy. The age-old notion of ‘men as the bread-winner’is challenged by the changing role of women as ‘income-earners’ in Bangladesh. Income and education has given women freedom to choose a meaningful life and redefined their relation vis-a-vis the society and the state.

Education has increased their ability of women to access necessary health information and make better use of available health services. They can now take informed decisions which are critical for the well-being of their children, exemplified in radical improvement in child survival since the ‘90s. Compared to past, they have more autonomy to take and implement decisions regarding their reproductive health e.g., whether and where to seek contraception care, pregnancy care and delivery care. The results have been drastic reduction of maternal mortality in recent times (see overview paper). However, a lots remain to be done in engineering the social determinants for better health and development.

The global countdown to design the new development agenda beyond 2015 has begun. The health system needs radical realignment to address health issues beyond 2015, based on influencing and modulating social determinants of health, and strengthening the heath system. Universal Health Coverage through risk sharing and resource pooling (insurance or tax revenue) may be one approach, but is not the panacea for all problems since ‘better health requires much more than UHC’.