Thursday, June 26, 2025

Unplanned Pregnancies and the Consequences Among the Garment Workers Around Dhaka City

 

Unplanned Pregnancies and the Consequences Among the Garment Workers Around Dhaka City

Introduction

Over the past 35 years, the growth of the garment industry has changed dramatically, and recent financial report shows that 80% as Bangladesh’s total foreign earning foundation. There are now 4,825 garment factories in Bangladesh and they are now creating job over three million people. The majority of the workers are women (85%), in which employees are able to give an amount of time and efforts to their work and also their personal life outside the work (Anna [1]). The Economist commented on this trend claiming, “Women’s empowerment in economic sector is debatably the biggest social change of times” (Anna, et al. [1]). Over the last decade, economic pressures have significantly raised the need for dual-earner families (Ford, et al. [2]). Additionally, into the paid work force, it has either directly or indirectly affected almost everyone in the society (Jenkins, et al. [3]). For every pregnant woman who dies during the childbirth, also around twenty more women suffer from injuries, infections or diseases which account to nearly 10 million morbidity in each year (WHO, 2013). Unsafe abortion is the major causes of deaths of mothers among other causes, and it accounts for nearly 13 percent of deaths (WHO, 2013). The decreased rate of Maternal Mortality Ratio (MMR) by half since 1990. The rate of MMR in developing countries is till 15 folds higher than the developed countries (UN, 2013).

Every year in the developing countries about 184 million child bearing mothers occur and among them 40% of these are unwanted (Bongaarts, et al. [4]). It is considered that about partly of the accidental pregnancies are mostly wrecked in termination, reason for maternal deaths at least one in seven globally (Singh, et al, [5]). Most of these deaths (approximately 95%) occur in developing worlds (Ciment, et al. [6,7]). It is designed to know pregnancy intention assessments of a woman’s plan before getting pregnant and also worried about the family planning issues. Accurate calculations that are valid for a diversified population is necessary (Gipson, et al. [7,8]). According to the National Survey of Family Growth (NSFG), unwanted pregnancies are whether “mistimed” or “unwanted” and it is calculated by retrospective questions which are assessed by the timing and intension for children. Diversification in pregnancy intention gauging between survey tools and continuing adjustment of assessments make contrasting results between surveys difficult if possible (Petersen and Moos, 1997, Fantahun, et al. [9,10]). Bangladesh is a developing country. It’s economy depend on the readymade garment industries. Majority of the workers in garment factories are 80-85% are women, they are not well educated and most of them are the victims of childhood marriage. So, they became pregnant at the very young age. Due to economic constrains they are forced to do jobs in garment industries. Their irregular use of contraceptives caused unplanned pregnancies in most of the time. In Bangladesh there are limited number of studies that were done on unintended pregnancy. Universally, 38 % of pregnancies are unwanted. At the international level, the rate of mortality of mothers (MMR) decreased by under 5.5 % to accomplish the aim of MDG (Siddhartha, et al. [11,12]). All the 8 goals of MDGs, nations have made the slightest improvement on the way to maternal mortality reduction (US Global Health Policy, [13- 25]).

Justification of the Study

Maternal benefits given by the Factory: The aim of this study was to determine the consequences of unplanned pregnancy among female garment workers in Dhaka city. For this study purposes, both pregnant and non-pregnant women who had history of previous abortion were included. This is the crucial factor that plays a great role in unintended pregnancy. As this benefit is maintained by the Bangladesh government so, the factory is compelled to maintain this. Therefore, this study was executed to determine the occurrence of unintended pregnancy and factors which are associated among randomly selected pregnant and non-pregnant women in readymade garment sector of Bangladesh.

Methods and Materials

Study Locale

The study was carried out in New Age Apparels Ltd. in Ashulia, Dhaka, Bangladesh. A cross-sectional descriptive research design study was conducted from September 2019 to November 2019. Basically, the study targeted all women who were having history of both intended and unintended pregnancy and also history of termination. Total 123 female garment workers were interviewed based upon a structured questionnaire. Among the study population, 100% of them were married and had the idea of family planning and methods were available for contraception. Their age average 24.3 years ranging from 18 years to 36 years. Total 123 female garment workers were interviewed based upon a structured questionnaire. Among the study population, 100% of them were married and had the idea of family planning and methods were available for contraception. Their age average 24.3 years ranging from 18 years to 36 years. Structural questionnaire was used for correlation of necessary information and medical record review were done for the assessment of the health of the female garment workers.

Ethical Considerations

It is a set of moral principles which maintain the integrity of the research and guide researchers how to deal with participants effectively (Mack, et al. [26-45]). Additionally, permission was taken from Institutional Review Board (IRB) of American International University-Bangladesh (AIUB), the committee on activities involving human subjects.

Results

Demographic Information of the Respondents

Most of the garment workers were experiencing at least 2 number of pregnancies. Minimum was 1 and maximum was 4. The female workers (52%) were on contraceptive methods and among them only 8% were regular and rest of them were irregular and thus they were witnessed unintended pregnancies, around 63% were having financial crisis and their job duration ranging from 1 year to maximum approximately 18 years (Table 1). The determination of the age at 1st birth of female workers were nearly 19 years and minimum age of 1st conception was 16 years and maximum was 27 years. Determination of intended pregnancy was around 32% and unintended pregnancy was 68% (Table 1). Among them the determination of keeping the baby was 59%. Those who were facing unintended pregnancy, the determination of termination of the pregnancy was 39% (Table 1). The total number of pregnancy was 75% among the population of the study. Rest of them were non-pregnant because they already did their abortion and came to medical room which was situated inside the factory. The determination of age of last child ranging from 0 to 15 years (Table 1).

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Table 1: Descriptive characteristics of the study population, (N=123).

Pregnant and Not-Pregnant Workers for Continuation of Pregnancy

Overall responsive behaviors regarding keeping the baby among female garment workers were satisfactory, 20 women who were pregnant, did not want to keep the baby and they went for abortion, not to keep the baby were 51 and 72 were interested in keeping the baby. Totally 92 female workers were pregnant. The Chi-square test value is significant at 1% level. Here the study showed that majority female workers were interested to keep the baby because they will get maternal benefit from the company as well as they will not lose the job (Table 2).

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Table 2: Significant difference between who wants to continue and abort the baby.

Different Methods of Contraceptives Used by Female Garment Workers

Approximately 47% female workers were on no methods and the frequency was 58, 29% women used contraceptive pills like shukhi, famicon, minipills and so on but they were not regular on their pills. Only 16% workers used injectable contraceptives , last only for 3 months and moreover and not regular on that method too. Only 8% women’s husbands used condoms as contraceptive but mostly failed to give full contraception because the failure rate was higher and the rupture of condom was common. The Female workers (52%) were on contraceptive methods and among them only 8% were regular and rest of them were irregular and thus they were victim of unintended pregnancies, around 63% were having financial crisis and their job duration ranging from 1 year to maximum approximately 18 years (Table 3).

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Table 3: Percentage and frequency of use of different types of contraceptive methods.

The Percentage of Children Ever Born

Majority (63%) of the female workers experiencing 1st pregnancy, 24% female workers reported that they had one alive child (Figure 1). Only 13% female workers had two alive children and their present pregnancy was third pregnancy.

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Figure 1: Percentage of children ever born.

Intention of Mother to Get Pregnant

Most of the female workers do not want to get pregnant as they think they might loose their job. So, nearly 68% of female garment workers were experiencing unintended pregnancy. On the other hand around 32% women were intentionally want baby and they continued their pregnancy.

Consequence of the Pregnancy

There were two consequences of unintended pregnancies, Either they terminate the child by using the different methods of abortions or they continued their pregnancy. This present study showed, almost 60% women continued their pregnancy and rest of the women (40%) terminated their pregnancy.

Causes of Termination of Unintended Pregnancy

About 55% female workers who wanted to keep the baby. Here both intended and unintended women were involved. Financial crisis played a major role in workers lives. Female workers who were facing economic crisis (about 26%), did not want to keep the baby. And they prefer to terminate the baby in the early stage of life. Another common issue not to keep the baby was domestic violence, like husband verbally and physically abuse the woman, to keep the wives salary. The least common cause of abortion was husband or his family members did not want the child to be born. Approximately 8% women abort their child by the pressure of her husband and in-laws. The reason behind that couples were newly married and also economic insolvency (Figure 2).

Complications and Hospital Admissions During the Termination of Pregnancies

It was observed that, approximately 60% (N= 74) female workers did not face any complications so, there was no need for hospital admission. The major reason for that was they were not terminated their baby. But nearly 38% workers who did not want to keep the baby they faced complication during the abortion. The number of women N=39 who were facing complications during abortion and majority faced bleeding problem. On the other hand, only 8% (N=10) female workers did not face any complications during that process so, they did not need any hospital admission (Table 4).

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Figure 2: Of termination of unintended pregnancy.

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Table 4: Complications and hospital admission ratio.

Methods of Termination of Unintended Pregnancy

Those who were used different methods for doing termination of pregnancy like menstruation regulation (MR), they were hospitalized. Also, those who were on herbal pills or took herbal method faced complications and thus admitted into the hospital. Among the study population admission during the study period. any hospital nearly 14% (N=17) female workers admitted into the hospital. Only 27% (N=33) did not require termination. Approximately 59% female workers who were not pregnant that time or primi gravida and wanted to keep the baby and also had unintended pregnancy. Another method used to abort the child was use of herbal products from some local kabiraj and from unskilled dhais. Herbal products used approximately 7% garments workers (Figure 3). This (Table 5) shows the correlation among the variables. The higher value shows that there is high correlation. The positive value shows that there is positive correlation between the variables. For example, the value -0.51 shows that there is negative relationship exist between keep the baby and number of unintended pregnancy and the correlation value is 0.51. So, it shows a good correlation. It also shows that the personal income is -0.10 and there is a negative relation with the number of unintended pregnancy and the correlation value is 0.15. So, if the personal income is high the tendency of continuation of pregnancy is lower. Again when the family income is good (correlation value 0.06) then the number of unintended pregnancy become lower (-0.13). Moreover, there is a negative relationship between financial crisis and continuation of the pregnancy. If financial crisis is present, the rate of continuation of pregnancy decreases (Table 6). Another good correlation is seen from the (Table 6) and that is the job duration and the continuation of the pregnancy. The correlation value of job duration is -0.04 and the continuation of the pregnancy is 0.07. Here shows a good correlation between them.

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Figure 3: Methods used for termination of unwanted pregnancy.

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Table 5: Relationship of different financial factors, no. children, unintended pregnancy and keeping the baby.

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Table 6: Multivariate logistic regression model.

Note: 1 failure and 0 successes completely determined

Logistic regression

Number of obs = 123

LR chi2(11) =54.17

Prob>chi2=0.0000

pseudo R2=0.3245

Log likelihood=-56.370247

Source: All calculation based on collected data

There is no relationship between the garment worker’s age and the unintended pregnancy. Both this group has the same age irrespective of their intended or unintended pregnancy status as the P-value is not significant. The mean value of ages of female workers both who wanted pregnancy and unwanted pregnancy are almost same and that is 24 and even the 95% coefficient interval value was same as 23 (Table 7). The regression equation is specified as keep the baby as a function of the other explanatory variables such as number of unintended pregnancy, age, education level, personal income, family income, years of marriage, financial crisis, number of surviving children, job duration and the age of last child. The dependent variable is binary (keep the baby: Yes=1, No=0). As the dependent variable is binary, so, need to apply logistic regression model and get the odds ratio (OR), have run log it regression model and got the odds ratio in STATA software (Table 6).

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Table 7: Relationship between age and unintended pregnancy.

Note: diff= mean(No)- mean(Yes)

Ho: diff=0; t=0.5965 degree of Freedom=121

Ha: diff<0

Pr(T < t)=0.7240;

Ha: diff !=0

Pr(|T| > t) =0.5520;

Ha: diff>0

Pr(T > t)= 0.2760

Discussion

The plan of this learning was to establish the frequency and factors linked with not deliberate pregnancy among women who are at this time working in garments factory. The cram was limited in one garment factory in Dhaka city. More than half of the respondents has their current pregnancy unintentional. Result indicates that age of women, educational status of women, economy of the household, children ever born, history of terminated pregnancy, maternal benefits given by the factory were significantly associated with unintended pregnancy.

Adult women were more to be expected to experience unintentional pregnancy and they were more wished-for continue the baby. The amount of money they got from company as maternal benefit was really high. Younger women who already had one baby, they were less interested to have second baby so early. Still financial constrain played a major role in case of keeping the baby or not, the amount of money they got from company as maternal benefit and also after returning from their maternal leave they still had their job in the same position. So, though it was an unintended pregnancy, they still wanted to keep the baby rather than terminate it. However, women who got high salary were less likely to have their second baby. Because they got high salary annually but the maternal benefit amount was really low in comparison to their salary.

Workers who were newly married, they were more prone to terminate their 1st pregnancy because their family did not want baby so early. An additional very vital issue was, every women knew about contraceptive methods and they mostly dependent on pills. Although they were not regular on their pills or other contraceptive methods like injections, implants and condoms etc. Hence consequences in unexpected pregnancies. Women who had history of termination or wanted to terminate the baby, they mostly used cytomis pills, iron pills or some other unknown pills which were taken from local pharmacy. Only a few number of women went to hospital and did menstruation regulation (MR). Some of them used herbal products for termination of pregnancy and when they faced problems , they got admitted into hospitals. They were not interested to go to hospitals for termination because of financial constrain. Wealth index was found to be significantly associated with unintended pregnancy in all models. However, there is difference in strength of association within different categories.

Conclusion

This revise is paying attention on the verdicts the prevalence of unintended pregnancy and factors associated with unintended pregnancy in garments sector in Dhaka. Results reveal that more than half of pregnancies are unintended, which is a very challenging issue. Age of women, economic condition of the family, educational status of women, numbers of previous births and history of terminated pregnancy and maternal benefits given by the factory were found to be significant associated with the pregnancy intention of women. In conclusion, from this study many factors contributed to the unintended pregnancy. It is understandable that the figure of earlier children a woman has had is a discrete determinant of whether or not the pregnancy is needed, or required at the time of conception. Further births enhance the possibility that a pregnancy will be useless and also amplify the probability that a pregnancy will be untimely. It may as a result of being effective to spotlight family setting up campaigns more intensively on those families that by now have two or more offspring. Overall, there is a substantial demand among women who are working in garments for effective contraceptive methods which are mentioned in this thesis. Women with additional children and women with abortion should be acknowledged and straightforward admittance of contraceptives information related to contraceptive use should be provided to them. In this way newborn and maternal death and morbidity as well as the need for abortion are decreased and the overall wellbeing of the family is maintained. In Bangladesh there is still carry out the early marriage whereas in some communities even child marriage is adept. Delay in age at matrimony shifts the time for sexual activities especially in the Bangladeshi context, therefore, government should address the issue of early marriage by investing in proper education and women empowerment.


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Bupropion Versus (+)OH-Bupropion Efficacy Upon Dopaminergic Activities in the Ventral Tegmental Area: An In Vivo Electrochemical Study in Rodents

 

Bupropion Versus (+)OH-Bupropion Efficacy Upon Dopaminergic Activities in the Ventral Tegmental Area: An In Vivo Electrochemical Study in Rodents

Introduction

The novel coronavirus SARS-COV-2 or COVID-19 was first found in Wuhan, China and is the cause of severe acute respiratory distress syndrome. Afterwards, this virus spread rapidly and became a global pandemic [1]. Although the fatality rate is low (reported to be 2.5% as of 12 February 2020), the accelerating transmission makes it a threat to mankind, and finding a curative treatment is a top priority. While no such treatment has been confirmed, many drugs and combinations are being suggested and some have even shown positive clinical results. On January 23, 2020, the first clinical trial for COVID-19 was registered, the number of trials then ascended to reach 125 registered trials by February 18, 2020 [2]. Common symptoms of Covid-19 include acute respiratory illness (cold-like disease), hyperthermia (fever>38 ºC), coughing, sore throat, and shortness of breath. Also, numerous sufferers may also experience digestive symptoms such as anorexia, diarrhea, and vomiting [3].

During the COVID-19 pandemic, people are facing major health care challenges, lockdowns, and stress, as there is no specific treatment and vaccination for this pandemic. Given the lack of specific therapy for and the rapid spread of this virus, vaccination would be a significant way in the fight against the SARS-CoV-2 pandemic [4,5].

Development of COVID-19 Vaccines

Pfizer-BioNTech vaccine (BNT162b2) is based on the mRNA technology to express the SARS-CoV-2 spike (S) gene and has shown a high efficacy rate against SARS-CoV-2 infection. Specifically, phase III trials showed that BNT162b2 has about 95% efficacy against laboratory-confirmed SARS-CoV-2 symptomatic infection, at least seven days after the second dose in the individual of 16 years and older without current or previous history of COVID-19. mRNA vaccines are a new type of vaccine that has been recently utilized. BNT162b2 mRNA vaccine has been developed to stimulate immune response against SARS-CoV-2 using mRNA coding SARSCoV- 2 spike protein. This vaccine was approved by the U.S. food and drug administration (FDA) on the 11th of December 2020 for EUA in individuals older than 16 years of age. On the other hand, two doses of Oxford-AstraZeneca adenovirus-vectored vaccine (ChAdOx1 nCoV-19) showed an overall 63% efficacy against symptomatic SARS-CoV-2 infection. This vaccine was authorized to be used in the age group of 18 years and older. Unlike BNT162b2, ChAdOx1 nCoV- 19 uses replication-deficient chimpanzees adenovirus as a viral vector to express the SARS-COV-2 spike protein [6].

During 2020, 58 vaccines against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) be developed and in clinical trials, with some vaccines reportedly having more than 90% efficacy against COVID-19 in clinical trials. This remarkable achievement is much-needed good news as COVID-19 cases are currently at their highest daily levels globally. New vaccine efficacy results are reported now in The Lancet: investigators of four randomized, controlled trials conducted in the UK, South Africa, and Brazil report pooled results of an interim analysis of safety and efficacy against COVID-19 of the Oxford–AstraZeneca chimpanzee adenovirus vectored vaccine ChAdOx1 nCoV-19 (AZD1222) in adults aged 18 years and older [7,8]. On December 11, 2020, and December 18, 2020, respectively, the US Food and Drug Administration (FDA), granted emergency authorization to the Pfizer/Bio N-Tech and Moderna COVID-19 vaccines. These two COVID-19 vaccines were developed quickly to benefit humanity and arrest the rise in the number of SARS-CoV-2 cases. From the time when the SARSCoV- 2 genome was released in early 2020 until these two vaccines received EUA status, less than one year passed.

The fastest any vaccine had previously been developed, from viral sampling to approval, was four years, for mumps in the 1960s. There have been some concerns about potential adverse effects of these vaccines. The present study aims to highlight evidence about the pharmacological characteristics, indications, contraindications, and adverse effects of Pfizer/BioNTech and Moderna vaccines [9]. The following Table 1 summarize the FDA approved COVID-19 vaccines with details on shoots number, efficacy, and side effects.

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Table 1: The FDA approved COVID-19 vaccines.

Side Effects of COVID-19 Vaccines

Clinical trials have shown that both Pfizer-BioNTech and Oxford-AstraZeneca vaccines were associated with various mild to moderate side effects, such as pain, redness or swelling at the site of injection, tiredness, headaches, chills, muscle, and joint aches, and fever. According to a Saudi study, the participants who received the Oxford-AstraZeneca vaccine reported a significantly higher frequency of fatigue and headache than those who received the Pfizer-BioNTech vaccine [6]. Significant differences were observed between the side effect profiles of mRNA versus viral vector vaccines (predominantly Pfizer versus AstraZeneca). Overall, the recipients of mRNA vaccines reported a higher incidence of any selfreported side effects, which were, however, of significantly milder severity compared with those who received viral vector vaccines. While mRNA vaccines were associated with an increased incidence of local reactions, they were associated with a considerably lower incidence of systemic side effects including anaphylaxis, fever, swelling in the face or mouth or generalized swelling, flu-like illness, breathlessness and fatigue. Most importantly, mRNA vaccines were associated with a significantly lower incidence of severe side effects (requiring hospital care) [10].

On the other hand, another study conducted in Japan showed that individuals vaccinated with the mRNA-1273 vaccine were more likely to experience systemic reactions than those vaccinated with the BNT162b2 vaccine. Delayed injection site reaction was reported most frequently in middle-aged females after receiving the first dose of the mRNA-1273 vaccine [11]. The most common side effects of Sputnik V (adenovirus vector) are injection site pain, fever, headache, fatigue, and muscle and joint pain. Moreover, unusual thrombotic cases have rarely been reported during the use of vector vaccines. The most important reasons involved in causing this rare complication are platelets and PF4 (platelet factor 4). The mechanisms that may be behind thrombotic thrombocytopenia after COVID-19 vaccination are

1. Antibodies against PF4.

2. The cross-reactivity of anti-spike antibodies and PF4.

3. Cross-reactivity of antibodies against adenovirus with PF4.

4. Interaction between spike protein and platelets.

5. The direct interaction between adenoviral vector and platelets [12].

Conclusion

The efficacy of FDA-approved vaccines against COVID-19 ranged from 70-95% with the highest efficacy of Pfizer-BioNTech vaccine. mRNA based vaccines (Pfizer and Moderna) may have lower systematic side effects compared with vector-based vaccines (Sputnik V and AstraZeneca), but mRNA vaccines have higher incidence of local reactions and may be associated with myocarditis and pericarditis according to thousand reports. Further studies on vaccine safety are recommended to strengthen public confidence in COVID-19 vaccines.


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Wednesday, June 25, 2025

Uncovering the Saga of Bangladesh Paradox and its Relevance in Global Health Care Systems: Taking Inspiration from a Resilient Positive Deviant

 

Uncovering the Saga of Bangladesh Paradox and its Relevance in Global Health Care Systems: Taking Inspiration from a Resilient Positive Deviant

Introduction

While many nations across the world still continue to struggle to achieve near optimum and desirable health outcomes in various areas including public health, education and so on and despite being economically well-off and bestowed with robust resources; Bangladesh as a so-called “one of the poorest nations” has set an example in redefining its position on the world map by achieving some outstanding achievements in the health sector [1,2]. With a current population of over 153 million, ranking eighth on the list of most populated nations globally and despite once being labeled as “the country without hope” after its independence in 1971, Bangladesh has strived to overcome various odds in the health sector which go in parallel with other endeavors [3,4]. It is commendable that only after four decades of its independence, in the year 2010, UN acknowledged Bangladesh as a country for setting milestones in achieving extraordinary progress in Millennium Developmental Goal (MDG 4) in combating child motility [2].

While on the other hand, this goal has not been achieved in most of the neighboring countries in Asia, even with much higher GDP than Bangladesh. Moreover, Bangladesh has also achieved its goal of being parallel in the direction of significantly reducing maternal mortalities (MDG5) [5]. In this report we will uncover the extraordinary journey of this budding nation and its remarkable achievements in ten points, especially in the health sector, and how other nations could employ these strategies to achieve their national health care goals, and simultaneously its implications in the global health arena. Moreover, the implications of its achievements which go in parallel with current and future challenges, in combination with the national and international stakeholder involvement, the changing dynamics of the health and other priorities, not only put Bangladesh at the forefront of the global health arena but prepares a diverse global audience of international leaders, policymakers, health advocates, other stakeholders and its future generations to mark not only on how these new challenges are conquered but also on how the existing milestones are sustained.

Objective

In this report, I will discuss some of the incredible achievements of Bangladesh in enhancing its health care system and its relevance in global health. Secondly, this report presents an evidence-based window to the nations in the West and across the globe to consider strategies, planning, and implementation mechanisms in their governance, thereby focusing on achieving and enhancing their goals in health care. Finally, while I discuss these achievements, the paradox behind the reason that this nation is called a “Positive Deviant”will become more clear, thereby confirming the interplay of its visionary leadership, timely intervention and navigation and investment of adequate resources amid a low resource setting.

Rationale for Choosing Bangladesh as a Country in Focus

Before India got its liberation from British Rule in 1947, Bangladesh and Pakistan were still part of India. However, with a new Muslim majority Pakistan formed its own independent country on August 14, 1947, and huge part Bangladesh was part of it. However, clashes began when Bangla was scrapped as the national language of Pakistan, and Urdu was announced to be the new official language in the region. After years of oppression, Bangladesh became an independent nation in the year 1971, late in comparison with both India and Pakistan. However, Bangladesh with its persistence, resilience, smart planning, strategy, and implementation of tailor-made policy and mobilizing its national human resources by seeking bilateral and international support made it a real achiever in health gains, which are some of the main points to discuss in this report. Because of these inspiring facts, Bangladesh has achieved some incredible milestones in the sector of health, which countries like India and Pakistan have still not yet achieved. Moreover, in the global health arena, narrating the success story of the neighbor who has done incredibly great in achieving these milestones could open new insights to get inspiration not in only changing the perception in bi-lateral information and exchange on employing sustainable methodologies in a country for example, India, Nepal, Pakistan and so on, but also the nations across the globe, who have not a higher GDP (please see appendix) but are also bestowed with better health infrastructure, resources (including human resources), technology, innovation and so on.

The saga of Bangladesh’s success story is summarized in following ten points:

a. Health at low cost: Bangladesh is the first country in the region of Southeast Asia and East Asia to have an economic and user-friendly health policy, which is not implemented timely but is accessible to the wider subjects including the poorest in this nation. For this landmark achievement, Bangladesh was acknowledged and praised for its innovation for “Health at low cost” [6].

b. Prioritizing Health issues and mobilizing resources: After its independence in 1971, Bangladesh started its nationwide developmental process characterized by factors such as social mobilization, institutional pluralism, and civil dynamism, which set up a forging ground for various stakeholders, government, non-governmental organizations (NGOs), informal providers, international donors, and commercial enterprises. All the stakeholders involved worked for a common goal of providing health-service delivery with the foundation of equity and inclusion. This was achieved by focusing on the high-priority issues in health, which included family planning, immunization, oral rehydration therapy, tuberculosis, vitamin A supplementation, and so on [7].

c. Integration of women empowerment, gender equity, and health targets together: Another exceptional feature of Bangladesh’s success story in the health sector is that these health strategies, actions, and endeavors emphasized the importance of women’s empowerment and gender equity and its implication on sustainable achievement of health goals. Both these targets were achieved by smartly integrating them. This was acknowledged and implemented at the very early stages of the nation’s history as an independent country. Therefore, Bangladesh despite having a low gross domestic product (GDP), was still able to enter the medium range of the UNDP Human Development Index category in 2003 [8].

d. Timely development, adoption, and dissemination of health policies: Bangladesh under her ambitious governance, visionary leaders, and strategic policymakers not only pushed its health sector goals by introducing pioneering innovations for new policies, products, and processes but were also timely developed, rapidly adopted and widely disseminated among masses making sure that the benefits are reached to even most vulnerable. All the prioritized health actions were scaled-up to the entire country through the huge and remarkable deployment of diverse stakeholder involvement, the key to which is involving mostly its female frontline health workers who reached out to every household even in the most unreachable and infrastructurally inaccessible geographic areas [9-11].

e. Endorsement of active family planning initiative: Bangladesh is one of the first developing countries in the region to strongly endorse a national family planning program. This has resulted in an outstanding reduction in fertility rates among women aged 15 to 49 years from 6.6 births per woman in 1994 to 2.7 in 2007 among the same age group in the nation. Although inequalities among birth rates still exist, where poorer women still have approximately one child more (3.2) than well-off women (2.1). However, this indicator is far better than the other neighboring countries in the region, despite its lower per capita income [12,13].

f. Involvement of NGOs and foreign assistance: Bangladesh consists of some of the world’s biggest NGOs working in the country including BRAC and Bangladesh Diabetic Samity (BADAS) For example the network of hospitals and clinics associated with BADAS provide low-cost healthcare services to people suffering from diabetes and other disorders throughout the country. Moreover, these NGOs work in different sectors to address issues of poverty, unemployment, health, education, the environment, and so on. The leadership of this country has not only created a sound space for such agencies to work on the ground, but work in collaboration to achieve the common goal [14-16]. This goal has greatly been achieved by foreign assistance and aid, which has seen significant peaks since its independence. For example, external financial investment was up to 70% in 1970 (which was reduced up to less than 10% in 2005). Yet, foreign aid has proven to be fruitful to accelerate the work of the NGOs, which grabbed up to 18% of total aid commitment to the country in 2003 [17]. This is because foreign donors wanted to make sure that their money is reached the people in need therefore NGOs were involved as an effective channel, rather than the country depending only on government aid and assistance. In this way, developmental assistance from foreign stakeholders had a significant impact on the nation’s stride.

g. Outreach on innovation and facility to most vulnerable: Another smart approach towards disseminating and reaching out to people belonging to the most remote areas in the nation in terms of providing health care, was the government move (in collaborating with NGOs) which included creating a sustainable approach which increased the outreach through the creation of new facilities up to the union and lower levels, by recruiting thousands of new workers. These workers were mostly women from the community (called informal providers), who were given basic training and took over the most important program of immunization program by reaching out to almost all parts of the country, even the most remote, thereby increasing the coverage from 2% in 1986 to 59% in 1993–94, to nearly 82% in 2007 [18]. These programs included oral rehydration therapy, which enabled mothers to prepare homemade oral rehydration saline to combat their children’s diarrhea [19,20].

h. Acknowledging the essence of research and evidencebased approach: Since the establishment of Bangladesh as an independent nation, great emphasis has been given to investing in research, especially in the sector of health. This became the backbone of the nation’s program and policy development; efficient monitoring and evaluation thereby leading to their successful implementation and returns. It is noteworthy to mention that this nation hosts some world-class research institutions like the International Centre for Diarrhoeal Disease Research. This nation also developed oral rehydration therapy and pioneered much in health policy and systems research within its national boundaries and across the globe. Simultaneously, The Bangladesh Institute of Development Studies pioneered the basic research that clarified the role of health during increasing poverty. Also, The Lancet commission has shown its deep interest in undertaking a series of studies, which is a testimony of the nation’s research capacity [21,22].

i. Preparedness and resilience towards natural disasters: Bangladesh’s remarkable achievements in the health sector must also acknowledge the contributions made due to its success in mitigating the effects of and showing strong resilience after multiple natural disasters. It is well documented how nations’ innovations in alleviating the effects of natural disasters changed over time and have inspired nations across the globe to follow in their footsteps. For example, the cyclone in 1970, killed more than 500 000 people in the country, in comparison with recent cyclones which on the one hand are of equal force and severity but killed only a few thousand people. This is because the nation developed a smart and sustainable, system of timely and emergency warning, evacuation, and resilience systems in case of such events [23].

j. Education: Non-health parameter with direct impact on health: Bangladesh has shown a phenomenal increase in its primary education enrolment which has increased from 74% in 1991 to 87% in 2005. A larger percentage (almost 80%) of young girls and women in the age group of 15 to 19 years have completed their primary education than boys and men (68.6%) in the same age group. This could be credited to the mass education campaign launched in the mid-1980s to enroll all girls in primary school. This has greatly led to the empowerment of women by high literacy rates, thereby contributing to higher uptake and success in health programs which have led to increased success of health parameters. BRAC is a great example of such a program that emphasized providing primary and secondary education to girls for free including free books and monetary assistance. This reinforced parents to send their daughters to school to receive an education.

The nation of Bangladesh has showcased an inspiring fighting spirit to conquer odds, vigor, and willingness to adapt and endorse innovative policies, pathways, and mechanisms in challenging situations in health care versus a challenging economy. This attitude has not only been witnessed but is being followed by many nations in the world. However, despite its great achievements, this nation is still facing some pressing issues in healthcare and other sectors. The paradox however is, how these challenges will be solved in the coming years? Will this vigor continue to achieve better and more in health and other sectors, given the changing dynamics of its current leadership? How will this nation cope with epidemiological transition and its double burden on health care and population? How will this nation fill the economic and social gaps among its subjects and its implications on health and social parameters? How will Bangladesh continue this path of resilience and positive deviance in the crisis of climate change, global warming, resource scarcity, competition, and increasing national, increasing incidences of NCDs while meeting national and international demands? The answer might still be found by just looking at the achievements of this nation, which started with realistic hope, despite being labeled as “The Nation without hope”. If this nation continues to believe in the manpower, intellect, and passion of its leadership and its proactive approach of openly accepting its vulnerability and achievements, there is no doubt that the future holds a strong hope for this nation to achieve, thrive, and inspire global health systems in future, despite may odds and challenges, but how these hopes are achieved is worthwhile to witness in the global health arena [24,25].


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