Almost all global challenges like food, nutrition, water and sanitation, flood, cyclone, air pollution, excessive rain or draught, warming, sea level rise, deforestation and greenhouse effect ends in health issues. Covid-19, an outcome of global climate change issue, took the opportunity to test the preparedness and ability of all the countries in health issues and economic strength where almost all the countries especially some developed countries failed miserably. Lower middle-income country Bangladesh is frequently visited by different natural calamity along with some permanent and increasing climate change effects. Covid-19 is the opportunity in disguise for us to revisit the whole health sector and understand where we stand, what are the strengths and weakness, what the challenges are and what to do to ensure universal health coverage.
SDG 3 deals with specific health agenda; health for all by 2030 and more specifically, considers health with high priority and during Covid-19 it draws much more attention of the global community. SDG 3 has a very high ambitious goal for ensuring healthy life and promoting wellbeing for all at all ages having 13 targets and 27 indicators. Health and well-being are related with SDG targets like maternal mortality, child mortality, HIV/AIDS, tuberculosis, malaria, hepatitis, neglected tropical disease, pre mature death, non-communicable disease like heart disease, cancer, diabetic etc., suicide, use of drug and alcohol, death due to road accident, access to sexual reproduction and Family Planning facilities, universal health coverage, accessible and affordable health care, medicine and vaccine, out of pocket health expenditure, death for hazardous chemical, air, water and soil pollution, death due to unhygienic water and sanitation, unintentional poisoning and so many. Major means of implementation of SDG targets are to reduce the use of tobacco, research on medicine and vaccine, vaccine coverage, development assistance in research and basic health, core health facility and sustainability, human resource in health sector; doctor, nurse and paramedics ratio and finally emergency preparedness.Globally maternal mortality reduced substantially in between 2000 and 2017. Since 1990, maternal mortality fell by 45 per cent, and there has been an over 50 per cent decline in preventable child deaths globally. In 2000 it was 342 per 100 thousand live birth which reduced by 38% to 211 in 2017. Annual reduction globally 2.9%, but to achieve SDG in terms of maternal mortality 70 in 2030 the globe needs to reduce yearly 6.4%. South Asia in this period reduced from 395 to 163 maternal mortality per 100 thousand births, which is 59% reduction. Only in 2017 south Asia saw 57 thousand maternal deaths. Sub-Saharan Africa changed a lot; there is also 39% which is global average. In 2017, in high income country one mother died out of 5400 during delivery. In low income country it is substantially very high; that is 1 mother dies out of 240, in LDC countries 1 mother dies out of 56 deliveries. In the last 17 years global achievement in maternal mortality reduced to almost half; in 2000 one mother globally died during 100 deliveries and in 2017, 1 mother died in 190 deliveries. Though in terms of achievement it is substantial but the globe needs to double the reduction of maternal mortality rate to achieve SDG as it is mentioned above.
In Bangladesh maternal mortality with a target to reach 105 by 2020, 85 by 2025 and 70 by 2030 from the base year 2015 figure of 181 per 100,000 live births up to 2019 we could reach only 165 which is about 4%. To reduce maternal mortality and child mortality rate, the government is piloting stipend for the expecting poor mothers for about two years to reduce maternal mortality, child mortality and to address malnutrition to be scaled up on the success report of the project. In the field of maternal mortality, we need to give much more attention to double the reduction.
The main causes of death during delivery are haemorrhage, eclampsia, sepsis, embolism and unsafe abortion. Most of these deaths can be prevented by skill birth attendance. Birth attended by skilled health personnel, we targeted to reach 65 by 2020. Here we reached in 2009 to 59, achieved well ahead of time. As the skill birth attendant in terms of doctor, nurse, paramedics, midwives, in 2014, 42% delivery in Bangladesh were attended by skilled birth attendant but again regional difference is very high. In a research it was found, in the same year in Khulna 58% delivery was with skill birth attendant, but in Sylhet it was only 27%. From 1990 to 2015 estimated annual rate of reduction of maternal mortality rate and neonatal mortality rate were 4.5% and 3.5% respectively and these to be increased to 6% and 4.5% to achieve SDG.
Let us turn to infant mortality; globally in 2019 per 1000 birth 25.788 children died; in 2020 it was 24.73, highest infant mortality was in Nigeria which is 117.2 per 1 thousand. Global infant mortality in 2020 reduced by 4.1% in comparison to 2019. Among all the infant mortality, one prominent cause is child marriage, that is, the mother is not healthy enough to deliver child. Everyday, globally 14,722 and total 5.3million children died in 2018. Bangladesh had a very good track record of below 5 mortality from MDG period and in SDG era, achievement is remarkable; in 2019 it is 28 for 1000 births down from 36 in 2015. The ultimate target is to reduce below 5 mortalities to 25 per thousand by 2030 which we will achieve easily. Likewise, in neo-natal mortality ultimate target is 12 per thousand in 2030 with an interim target to reach 18 by 2020. But in the meantime, in 2019 we reached 16. So, we are well ahead of SDG target in below 5 mortality, skilled birth attendant and neo-natal mortality.
It is well understood that due to Covid-19 this year expecting mothers refrained from antenatal care, visit of health and family planning workers was not possible for a few months. Child birth with skilled birth attendant and post-natal care were hampered significantly. A good number of hospitals were declared designated Covid-19 hospital and physicians and surgeons refrained from attending regular duty both in hospital and private chambers that caused general deterioration of health services not in Bangladesh only but this was a global problem during first few months of Covid-19. Protocol for antenatal care, birth attendance and post-natal care during unusual period of Covid-19 needs to be developed quickly to reduce maternal mortality, infant and under-five mortality. Overall health sector has an unusual human resource structure in opposite ratio in our country; nurses are more in number than the health technicians and number of doctors is much higher than nurses. We need to bring doctor, nurse and technician ratio from 1:0.5:0.2 in 2015 to the right proportion of 1:3:5 in 2030 which is a huge shift from the present structure. But health infrastructure, especially about 13,000 Community Clinics all over the country, each for 6,000 people run under a Foundation with both Government and local resources played a very positive role in all primary healthcare issues during the Covid-19 also.
The writer is a former Principal
Secretary and Principal SDG