# Bangladesh’s unlikely attainment of the 4th Millennium Development Goal

## Abstract

This study centres on the 2015 “Millennium Development Goals,” (MDGs) a historic United Nations (UN) initiative aimed at bridging many of the world’s inequalities. Since its conclusion, the success of the project has been hotly debated, as progress at the international level was markedly uneven. In order to ensure the success of future initiatives, it is necessary to determine why these goals failed so decisively in some contexts but succeeded in others. Given the innumerable nations involved in the project, the scope of the essay was narrowed to focus on a single country and MDG goal. This study centers on the improbable attainment of the fourth development goal (pertaining to neonatal and newborn health) in Bangladesh, one of the world’s poorest countries. Using official UN documents, seminal literature, and consultation with crucial UN actor Uzma Syed herself, this study demonstrates that Bangladesh’s success was a result of efficient programming, data acquisition, and transnational, individual, and domestic cooperation. This allowed a small nation like Bangladesh to significantly reduce its under-five and infant mortality rates, illustrating that it is, in fact, possible to enact meaningful change in difficult circumstances. Following the conclusion of the initiative, the country has decided to maintain child survival as a government health priority, as inequalities between populations persist. According to former secretary general Ban Ki-Moon, a continued, strategic focus on under-fives is imperative, with a particular emphasis on the structural and social determinants of health. Looking, now, toward the Sustainable Development Goals (SDGs), Bangladesh’s triumph can be used to build a framework for continued progress in the realms of child and neonatal health.

## Introduction

One of the most significant proposals aimed at bridging the Global North-South divide was the 2015 UN Millennium Project, more commonly known as the Millennium Development Goals (MDGs). Initiated by then-Secretary-General Kofi Annan in September 2000, the project proposed eight ambitious developmental priorities to be achieved worldwide by 2015: (1) the eradication of extreme poverty and hunger; (2) the establishment of universal primary education; (3) the promotion of gender equality and the empowerment of women; (4) the reduction of child mortality; (5) the improvement of maternal health; (6) the control and suppression of HIV/AIDS, malaria, and other diseases; (7) a commitment to environmental sustainability; and (8) the development of a worldwide partnership for aid and development. These time-bound targets held global significance, as they were agreed upon by many of the world’s countries and developmental organizations (Ojcius and Wallander, 2010). But were they ‘adequate’ in bridging the North-South divide? The simple answer is yes, and no. According to the final Millennium Development Goals report, the project has gone down in history as the most successful anti-poverty movement ever created. The progress made was astounding but uneven; inequalities persist.

Years after the conclusion of the initiative, the success of the project continues to be debated in academic and humanitarian circles alike. Initially a sceptic, Microsoft Corporation founder and philanthropist Bill Gates expressed that the targets were “picked arbitrarily,” but later acknowledged that “without them, the world would not have made such progress in reducing … child and infant mortality” (Gulland, 2013). MDG 4 was created to address this need, and stressed that mortality rates of children under five be reduced by two-thirds by 2015. In the years leading up to the deadline, this goal was one of the furthest from being realized (Motluk 2010) with just six countries on track to achieve it—Laos, Cambodia, Nepal, Egypt, China, and Bangladesh (Gulland, 2013). It is necessary to determine why this particular goal was attained in some countries but failed in others. Given the numerous nations involved, the scope of this study will be narrowed to focus solely on the improbable attainment of MDG 4 by Bangladesh. Given that it is the poorest of the nations listed above, Bangladesh’s success is that much more extraordinary. Bangladeshi techniques and approaches aimed at improving neonatal health were particularly impressive given the initial lack of resources. Bangladesh’s achievement of MDG 4 in spite of extreme poverty levels will be analysed, highlighting the importance of the accountability and strategic co-operation of domestic governments, non-governmental organizations (NGOs), and individual actors. Firstly, the methods of this study will be outlined, followed by an overview of existing literature, a presentation of the results, a brief discussion and contextualization of the findings, and lastly, conclusions and implications.

## Methods

In order to ensure the success of the Sustainable Development Goals (SDGs)—direct successor to the MDGs—it is crucial that the triumphs of the MDGs be thoroughly investigated; it would be impractical to forge ahead into the next initiative without adequate exploration of the successes of its predecessor. A focus on a single case study will allow for an in-depth analysis of the Bangladeshi context. Similarly, only MDG 4 will be explored, as opposed to all of the goals, because it was the goal Bangladesh was able to achieve thoroughly and completely, and in fairly short order. While it is beyond the purview of this work to compare Bangladesh’s progress to that of all other high-performing, low-income countries and their respective circumstances, the aim is not to focus solely on Bangladesh, as the MDGs are geared toward a collective rather than individual good. Bangladesh will therefore act as a case study and will be positioned within the broader framework of the Millennium and Sustainable Development Projects as it pertains to child and neonatal health. In the paragraphs that follow, Bangladeshi techniques and approaches will be investigated so that they may be applied to future initiatives, most notably the SDGs.

### Existing literature

The importance of neonatal health cannot be overstated. The first 28 days of life, the ‘neonatal’ period, is the most vulnerable time in a child’s life (“The neonatal period,” 2016). A nation’s under-five survival rate is generally a good indicator of the strength of that nation’s health care system and standard of living overall, as it demonstrates the attention paid to the most vulnerable members of the society—young mothers and their children. The existing literature on the attainment of MDG 4 in Bangladesh is generally quantitative and macro-level in nature, such as Halder and Kabir (2008), which discusses reforms that could be made in order to bridge health inequality gaps, such as standardizing the quality of health coverage. A ten-year overview of health developments in Bangladesh echoes this, stating that future initiatives need to focus on the quality and consistency of care (Rubayet, 2012). Such analyses are useful in understanding trends at the national level, but say little about action that can be taken at the community level. Similarly, Minnery et al. (2015) provides a quantitative, high-level analysis, comparing national and sub-national rates of neonatal mortality in order to compute relative and absolute inequalities between groups. In spite of inequalities and limited resources, the concluding United Nations Millennium Development Report (2015) posits that low income does not need to be an impediment to progress, as evidenced by the strong reductions in under-five mortality rates in a number of low-income countries, Bangladesh included. Bangladeshi success can be partially attributed to “intermestic development circles,” (Stiles, 2002) which bring together international donor agencies, the domestic community, and private organizations.

While Bangladesh was successful in reducing under-five mortality rates, the progress across all the Least Developed Countries (LDCs) was mediocre (Akanda, 2015). Martín et al. provides an overview of the performance of MDGs 4 and 5 in the least developed nations in Asia, highlighting the programmes that contributed to Bangladesh’s performance, as well as the role of political stability in affecting change. Even in Bangladesh, however, there is still progress to be made in terms of bridging inequalities between communities, reducing ‘growth stunting’ among under-fives, and universal access to reproductive health (“Bangladesh Progress Report 2015,” 2015; Chowdhury, S. et al., 2011).

Seminal articles with MDG 4 as a focus tend to take a quantitative, macro-level approach, giving little attention to the individual actors and bodies which made possible Bangladesh’s attainment of MDG 4. Qualitative metrics are an equally important measure of success, as they provide a more holistic view of health across populations. Assessments of neonatal and under-five health cannot only rely on numbers; there needs to be a human face applied to the data. This study will work to address these gaps in the literature. While quantitative analyses are useful, a qualitative, micro-level approach will be taken instead, focusing on individual actors and initiatives that allowed Bangladesh, in particular, to surpass the other LDCs in its attainment of MDG 4.

## Results

To begin, this study will discuss Bangladesh’s economic position within the international arena. In today’s world, around 60 per cent of the world’s one billion extremely poor people live in just five countries: India, Nigeria, China, the Democratic Republic of the Congo, and Bangladesh (“The Millennium Development Goals Report 2015,” 2015). As the most populous of Asian LDCs, Bangladesh is home to many of the world’s poorest people (Martín et al., 2016). A critical link has been drawn between a country’s GDP and its child mortality rates, which serves to explain, at least partially, Bangladesh’s high initial neonatal mortality rate of 151 per 1000 live births, of which two-thirds of all deaths were children younger than one year. Prior to the MDGs, little emphasis was placed on essential newborn care in Bangladesh, as it was only one of eight elements of reproductive health and was not among the indicators used to measure health sector performance (Shiffman and Sultana, 2013).

### Agenda setting

The creation of the MDGs was the first step toward placing neonatal care on health agendas worldwide, as it pressured nation-states to act and provided them with specific targets toward which to strive. Upon their introduction, the MDGs were immediately integrated into Bangladesh’s long- and mid-term development plans and were placed at the forefront of government health policy. While it was customary for lower-income countries to designate child health a low priority, Bangladesh quickly became “an exception to this inattention” (Shiffman and Sultana, 2013, p. 623). By 2011, four years shy of the deadline, the country had made progress far ahead of that of the other LDCs and had already achieved the MDG 4 goal of a two-thirds neonatal mortality rate reduction (Martín et al., 2016). While “low income need not be an impediment to saving children’s lives,” as stated in their culminating 2015 MDG report, Bangladesh’s success was not achieved without the focussed commitment of multiple actors (UN, 2015).

The range of organizations present in Bangladesh—from domestic, to international, to non-governmental, to governmental—played a vital role in the reduction of neonatal and child mortality rates. The United States Agency for International Development (USAID), The United Nations International Children’s Emergency Fund (UNICEF), and the Gates foundation were just a few of the organizations that provided financial support, as well as programme establishment and maintenance (Shiffman and Sultana, 2013). For example, the domestic NGO Bangladesh Rural Advancement Committee (BRAC) spearheaded a maternal, neonatal, and child health project that positively impacted eight million residents of urban slums, supported by $25 million in funding from the Gates Foundation. The United Kingdom, Australia, and the European Commission provided$71.5 million to fund three governmental programmes pertaining to maternal, newborn, and child survival in fifteen of Bangladesh’s sixty-four districts (Shiffman and Sultana, 2013). Saving Newborn Lives (SNL)—a programme of Save the Children USA—had by far the most meaningful impact on Bangladesh’s transformation. Soon after its creation, SNL sought to create a global alliance of organizations aimed at the promotion of newborn survival, and selected Bangladesh as one of its six focal countries. Company officials moved quickly to establish a presence in Bangladesh, providing the impetus for the first large-scale child health movement in the country.

### The power of the individual

As director of SNL (Syed, 2017) Dr. Syed proceeded to “cultivate ownership for the issue among multiple organizations and individuals—especially those in the government (Shiffman and Sultana, 2013). The existence of SNL and Syed’s persistence allowed for the creation of a ‘policy community,’ a network of organizations and individuals collaborating and sharing a keen interest in the issue. Elsewhere referred to as ‘development circles,’ these networks involve collaboration between foreign donors—private and public, bilateral and multilateral—and local non-state actors. The groups often experience a “disassociation from traditional loyalties,” and a “new sense of identity as a member of the development circle first and foremost” (Stiles, 2002). The MDG 4 policy community linked the Bangladeshi government, SNL, UN agencies, a Bangladeshi research institution, and several medical associations with a commitment to neonatal health. Working together, they were able to identify several core causes of the slow rate of neonatal mortality reduction, including a lack of skills among community health workers, lack of nurse midwives, and low postnatal care coverage (Stiles, 2012). They also organized attention-generating ‘focusing events’ that served the dual purpose of making the issue visible to government officials and influencing policy. The importance of generating such interest and awareness around a pertinent issue like child mortality cannot be understated, especially in a country like Bangladesh, where it was historically considered a low health priority.

The policy community in Bangladesh continually assessed relevant data in order to track progress and therefore ensure accountability (Shiffman and Sultana, 2013). The necessity of such ‘checks and balances’ has been highlighted by Joy Phumaphi, co-chair of a UN group tasked with analyzing the connection between accountability and the MDGs. She points out that the “few countries that that were due to meet targets on both infant and maternal mortality had all introduced strong oversight and accountability mechanisms” (Gulland, 2013). Bangladesh’s continued publication of credible data allowed policymakers to reach evidence-based consensuses on the interventions and policy alternatives needed to make progress. From this, it becomes clear that information, national oversight, and accountability are all critical components in achieving large-scale policy goals and ultimately accomplishing change.

### Effective programming

Programmes pertaining to immunization, the control of diarrheal diseases, and the supplementation of Vitamin A have aided not only in the decline of child deaths in Bangladesh but have also contributed to economic and social growth. In the post-MDG era, the country has emerged as global leader in the development of low-cost interventions such as oral rehydration solution, the use of zinc to counteract childhood diarrhoea, and tetanus vaccinations for pregnant women. These interventions have been introduced locally and then scaled-up (“Bangladesh Progress Report 2015,” 2015). This, combined with larger-scale initiatives like family-planning, and more targetted reforms such as increased human resources in underserved areas, have contributed considerably to overall progress (Minnery et al., 2015). As cost-effective and targetted initiatives, these programmes were well-suited to the Bangladeshi context, and are indicative of the benefits of smart, effective programming.

## Discussion

The Bangladeshi attainment of MDG 4 will now be positioned within the broader context of the UN Millennium Development Project and future developmental goals. In the culminating MDG report, UN Secretary-General Ban Ki-Moon stated that while progress had been uneven and inequalities persisted, the UN Millennium Development Project was by far the most successful anti-poverty movement in history, according to the final MDG report. With regard to MDG 4, the international child mortality rate was cut in half, declining from 90 to 43 deaths per 1000 live births, while the number of deaths of children under five had declined from 12.7 million to almost six million globally. Given that MDG 4 was not achieved on the global scale, Ki-Moon emphasized that continued, strategic focus on newborn and child health was imperative, and that structural and social determinants such as poverty, illiteracy, and female disempowerment should not be overlooked (“The Millennium Report 2015,” 2015). The direct successor of MDG 4 is now Sustainable Development Goal 3, which aims to “end preventable deaths of newborns and children under 5 years of age … reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births” (“Sustainable Development Goal 3,” 2017).

Looking now to the SDGs, Bangladesh’s success should be used to create a framework to ensure future progress in the realms of neonatal and child health. Given that the socio-economic contexts of the LDCs vary widely, the inequalities within them being nearly as significant as the inequalities between them, adjustments will need to be made (Halder and Kabir, 2008). Bangladesh itself was a very specific case, given its complex health system with innumerable actors. But while specific plans must be developed for each country, there are some commonalities to success. In a comparative report co-authored by individuals from a number of non-profit organizations, including Dr. Syed, researchers found that overarching drivers of progress include elements such as “local ownership and involvement, [a] broad representation of all stakeholders in formulating national-level technical oversight of research and associated politics […] community involvement, locally-generated data, and site visits by policy makers in-country in order to effectively implement and maintain policy and programme innovations (Rubayet et al., 2012). From this, it becomes clear that Bangladesh’s success is not solely to its own benefit; there is much to be gained by the international community as well.

## Conclusion and implications

As one of the world’s poorest countries, with “widespread poverty, low levels of female literacy” and “more than two-thirds of births occurring without … skilled assistance,” Bangladesh has demonstrated that it is possible to enact change in even the unlikeliest of circumstances (Rubayet et al., 2012). Progress required a combined effort and targetted attempts to bring the issue to the forefront of the national imagination. As demonstrated by the Bangladeshi context, an effective framework might feature the participation of determined political entrepreneurs, the persistence of an organized and accountable policy community, the ongoing publication of credible data, evidence-based consensuses on policy decisions, as well as the availability of funding from international and domestic donors. Most importantly, substantial progress requires global agreements such as the UN Millennium Development Project, which encourage accountability and push states to act.

Bearing in mind that MDG 4 was not globally attained, this analysis of Bangladesh’s success is aimed at encouraging a dialogue and further research. Future analysis may address: (1) the societal transitions—economic, political, and social—that occurred in Bangladesh throughout the 1990s and early 2000s, which may have assisted or inhibited their developmental progress; and (2) Bangladeshi advancements not only in child health, but in decreasing poverty, supporting gender equality in primary and secondary education, combatting HIV and tuberculosis, among others. Bangladeshi strategies should be put toward the creation of a developmental framework applicable to other LDCs, which would ensure continued advances not only in the Sustainable Development Goals, but in future global health initiatives.

## Acknowledgements

The author would like to thank Uzma Syed for her feedback on the initial draft of this article.

## References

1. Akanda, A. M. (2015). Has Bangladesh really come ahead of the LDCs? Journal of economic and Social Development, 17(2), 223-40.
2. Alam, S. (2015). MDG achievement – a story of success. The Financial Express, Bangladesh. Retrieved from https://dailyasianage.com/news/6356/mdg-achievement–a-story-of-success.
4. Chowdhury, S. et al. (2011). Achieving Millennium Development Goals 4 and 5 in Bangladesh. BJOG: An International Journal of Obstetrics and Gynaecology, 188 (suppl. 2), 36-46.
5. Gulland, A. (2013). Strong government accountability is crucial to meeting millennium development goals, UN assembly is told. The British Medical Journal, 347.
6. Halder, A. K., and Kabir, M (2008). Child Mortality Inequalities and Linkage with Sanitation Facilities in Bangladesh. Journal of Health, Population and Nutrition, 26(1), 64-73.
7. Martín, J. A. R., et al. (2016). Millennium Development Goals 4 and 5: Progress in the Least Developed Countries of Asia. Social Indicators Research, 129 (2), 489-504.
8. Minnery, M., et al. (2015). Neonatal Mortality and Inequalities in Bangladesh: Differential Progress and Sub-national Developments. Maternal Child Health, 19(9), 2038-47.
9. Motluk, A. (2010). G8 revisits maternal and child deaths: more funds pledged at summit for the two UN Millennium Development Goals farthest from their targets. Nature, 466(7302), 18.
10. Ojcius, D. and Wallander, J (2011). Addressing the UN Millennium Development Goals. Field actions science reports, 3-19. Retrieved from http://factsreports.revues.org/611.
11. Rubayet, Sayed et al., “Newborn survival in Bangladesh: a decade of change and future implications.” Health Policy and Planning, 27, no. 3 (July 2012): iii40-56.
12. Shiffman, Jeremy and Sharmina Sultana, “Generating Political Priority for Neonatal Mortality Reduction in Bangladesh,” Framing Health Matters, 103, no. 4 (April 2013): 623-31.
13. Stiles, Kendall W. Civil Society by Design: Donors, NGOs and the Intermestic Development Circle in Bangladesh. Westport, CT: Praeger Publishers, 2002. Print.
14. Syed, Uzma. [E-mail correspondence. April 3, 2017.]
15. “Sustainable Development Goal 3 – Progress,” United Nations Department of Economic and Social Affairs, https://sustainabledevelopment.un.org/sdg3.
16. “The Millennium Development Goals Report 2015,” The United Nations, 2015, http://www.un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf.
17. “The neonatal period is the most vulnerable time for a child,” UNICEF, January 2016, https://data.unicef.org/topic/child-survival/neonatal-mortality/.
18. “World Prematurity Day.” The Daily Star, Bangladesh, http://www.thedailystar.net/world-prematurity-day-57804.