How Bangladesh handled its baby boom

How Bangladesh handled its baby boom
SWAPNA MAJUMDAR

While India was heralding the birth of its billionth baby, celebrations of adifferent kind were on in a neighbouring country Bangladesh. The tinycountry confounded all gloomy prognostications by bringing about aremarkable decline in its fertility rates. Bangladesh has, in its shorthistory, brought down the number of children from 6.3 per woman to 3.3.Attainment of this seemingly impossible task has buoyed planners to set up amore ambitious goal of stopping population growth altogether by the year2045.

Bangladesh was born in 1971 with a population of 73 million. Burdened withthe dubious distinction of being one of the most densely populated countriesin the world, planners were faced with the daunting task of slowing down thepopulation growth, which was at an annual rate of 2.5 per cent. Liberationpopulation as its biggest problem and set in motion an extensive familyplanning programme.

Even through the throes of political disturbances and military coups, theprogramme never got derailed. ``Political commitment has been one of themost important factors behind our success,'' says Dr Jahir Uddin Ahmed,director, Directorate of Family Planning, Ministry of Health and FamilyWelfare. ``It didn't matter which government came to power. They allunderstood the importance of this programme.''

Although it could be argued that much of this political commitment wasprompted by the high influx of financial aid from foreign donors, the factremains that population programmes were given top priority. Strategies forfamily planning incorporating the maternal and child health (MCH)programme, adopting a cafeteria approach by broadening the choice ofcontraceptives and making domiciliary services backed by clinical methodsavailable were boosted by the policy decision to focus on a communityparticipation-based multi-sectoral approach.

This had a major impact. Between 1972 and 1996, the proportion of currentlymarried women using contraception rose from 4 per cent to 49 per cent. Thisin turn reduced fertility rates from 6.3 to 3.3 children per woman.

This steep drop has become more pronounced since the mid-1980s. ``One of themain reasons for this was the introduction of primary health care servicesand making family planning workers responsible for distribution of vitaminsand ensuring immunisation,'' contends Dr Ahmad Neaz, director general,Family Planning Association Of Bangladesh (FPAB). ``Another significantfactor was the introduction of the family welfare assistant (FWA) register.This helped keep a record of acceptors and monitor the performance of theprogrammes,''he said.

The decision brought about positive results because it facilitated planningat the local level in accordance with the individual needs and theirpriorities. It also led to greater participation of non-governmentorganizations (NGOs). A recent UNFPA survey found some 40,000 familyplanning field workers, both from government and NGOs, providing healthservices at the grass-root level.

NGOs, in fact, have played a crucial role in disseminating information andservices. BRAC, the country's largest organisation of this kind, led theway. It mobilised the community into fighting against diarrhoea, the singlelargest killer of young children. It pioneered a lobon-gur saline(salt-sugar solution), a simple yet effective treatment to combat diarrhoeaand used its female workers to educate rural women. By 1990, 1,200 BRACoral- rehydration therapy workers had introduced the saline o 13 millionhouseholds. This tremendous success led to a fall in infant mortality ratesfrom 117 to 77 per thousand live births.

``This success prompted us to venture into other health and populationprogrammes like reproductive health and disease control, family planningfacilitation programme and nutrition facilitation programme. Our goal is toattain a sustained health impact through the reduction of maternal, infantand child mortality and morbidity as well as improving the nutritionalstatus of women and children,'' says Purabi Dutta, director, Health andPopulation Programme, BRAC. ``In certain areas we are in direct partnershipwith the government and other NGOs. In areas where gaps in service deliveryexist, our programmes have been designed to implement the national familyplanning programme.''

Says M. Tajul Islam, director, public affairs and communications, BRAC, ``Weare not competing with the government. Our aim is to enhance the quality oflife of the people by improving their family health. This is why we have noego problems in facilitating government efforts.''

Statistics reveal that more women are achieving primary education thanbefore and there has been a jump in the number working outside the homethanks to the booming garment export industry. This has helped in raisingthe age of marriage. Fall in infant mortality rates has meant that parentscan afford to reduce the number of births. In addition, virtually allparents know about family planning thanks to the Grameen Bank'swell-entrenched micro-credit programme. The Bank's decision to tie credit toacceptance of family planning has brought over two million women under thefamily planning umbrella. Population strategists therefore feel thatBangladesh should have no problem in further reducing the fertility rate to2.2 children by 2005. But will it be able to do so?

The answer is yet not clear. This is because the population programme hasreached a critical stage in the country. Sustaining the acceptance of familyplanning methods is becoming increasingly difficult. There has been a shiftin family planning methods accepted so far, from clinical to reversible.The numbers discontinuing family planning altogether is also on the risebecause of the lack of confidence in the quality of services and poor adviceon possible side effects and how to manage them. Many women who have beensterilised complained of side effects. When women see their friendssuffering, they want to avoid the experience especially if sterilisationshave been forced. Therefore, a structural and behavioural change in FPprogrammes is inevitable.

Bangladesh must make the environment for acceptance of family planning moreconducive. It has two major factors in its favour. Firstly, surveys suggestthat women want to space their next birth or to limit childbearingaltogether and secondly, there is a clear need not met with. An estimated 16per cent of women want to plan their families but are not usingcontraceptive methods. The Bangladesh government has also recognised thatmen have been neglected so far, although their participation is crucial.Efforts are being made to design programmes for them.

A great deal also depends on the performance of the economy. ``The morechildren, more income earners' belief may come into play and negate theachievements of the programme if the economy turns sluggish. Officially,therefore, Bangladesh has prioritised greater socio-economic developmentalong with population control.

Readers can send feedback to focus@expressindia.com. Swapna Majumdar is afreelance journalist who was recenlty in Dhaka