Health equities imperative for UHC in Bangladesh

On 12th December 2012, the United Nations General Assembly adopted a landmark resolution emphasising health as a critical element in international development, urging all countries to provide universal access to healthcare to their citizens without suffering the consequences of financial hardship.

To commemorate this significant step, the date was declared as Universal Health Coverage (UHC) day, to be observed every year as reiteration of every country’s commitment to its people.

WHO recommends at least four antenatal care (ANC) visits during pregnancy. Photo: Shehzad Noorani/ icddr,b

UHC has become a central element in the adoption of the Sustainable Development Goals (SDGs) as good health underlies all aspects of development and this is reflected in Goal 3.8 which aspires to. More than 400 million people across the world currently lack access to one or more of seven lifesaving health services, including childhood immunisation, malaria control, HIV/AIDS treatment or family planning,and 150 million are impoverished by the healthcare costs every year. There has been mounting pressure on governments to take responsibility for financing and improving their health systems while simultaneously recognising the necessity for the availability, accessibility, and capacity of health workers to deliver quality people-centred integrated care”.

Even prior to the United Nations (UN) declaration, the Prime Minister of Bangladesh affirmed the country’s pledge to achieve universal health coverage by 2032 at the 64th World Health Assembly in 2011. In spite of the weak health system and inadequate access to services, Bangladesh has made gains to reform health service delivery, reduce the burden of diseases, and improve the overall health outcomes of its citizens. There has been remarkable progress in reducing maternal mortality ratio (MMR), addressing the first part of Goal 5 of the Millennium Development Goals. In the 25 years from 1990 - 2015, the rate tumbled from 569 per 100,000 to 176 - a 69 per cent decline.

Despite these gains, inequity remains and hinders progress in the other target for Goal 5 - universal access to reproductive health services.

The World Health Organization recommends at least four antenatal care (ANC) visits during pregnancy to ensure adequate care is provided to both the mother and child; in Bangladesh only 31 per cent of women take advantage of the recommended number of visits. Researchers at icddr,b conducted a study charting the trends in four or more (4+) antenatal care over 22 years (from 1994 - 2014) and exploring the determinants of utilisation and inequity in 4+ ANC services as published in the last two Bangladesh Demographic and Health surveys (BDHS) in 2011 and 2014.

In Bangladesh, 4+ ANC services for the marginalised might help achieve UHC. Photo: GMB Akash / icddr,b

Availability, accessibility, quality of ANC, women’s socio-economic status, demographic factors, women’s education, perceived knowledge, cultural beliefs, and previous obstetric history were all identified as predictors for ANC utilisation, along with the efficiency of the health system. The research found a steady increase in 4+ antenatal care during the 22 year period, rising from 5.5 per cent in 1994 to 31.2 per cent in 2014 but it is far behind the desired level of 50 per cent by 2015. Moreover, women residing in urban settings were twice as likely to seek ANC services as their rural counterparts and those who had higher education were four to seven times more likely to utilise 4+ care than those with no formal education. These findings are consistent with studies conducted in countries with a similar context.

Socio-economic inequities were observed as the biggest predictor of 4+ antenatal care utilisation, as women who were more economically stable were more likely to engage these services than those who are in more financially precarious situations. Although overall inequity of ANC utilisation decreased between 1994-2011, the study observed a slight increase in wealth-related inequity from the data collected in 2011 and in 2014, though further studies are required to determine the causes behind this rise.

Given the results from the study, the authors conclude that focused interventions need to be developed and implemented targeting women with less formal education, women living in lower economic strata and in rural areas and especially Sylhet should get most priority to understand its low utilisation of 4+ ANC. Dr Aminur Rahman Shaheen, an author of the publication and project coordinator at icddr,b, states that “4+ ANC services with ensured quality can bring underprivileged and marginalised groups under coverage that might facilitate to achieve UHC in Bangladesh”.

Furthermore, the successful application of these interventions will not only promote greater access and utilisation of maternal healthcare services, but it can also be a contributing factor in  improving  overall socioeconomic equity in access to services, thereby taking the country one step further towards achieving the UN Sustainable Development Goals.