Economic trends
There has been a slow and steady increase in GDP per capita from US $217 in 1991 to $254 in 1995. The annual growth rate of the GNP at constant market prices increased from 3.56% in 1991 to 4.86% in 1995. With the increase in population, the overall public financing for health remains the same.
About one-half of the total population is poor, with the same picture seen in both urban and rural areas. Income generating schemes are being financed by the Government to make the poor more self-reliant .

Demographic trends
The annual population growth rate has declined from 2.04% in 1991 to 1.81% in 1995. Similar declining trends are seen over the same period for the crude birth rate (31.6 to 26.9), crude death rate (11.2 to 8.5) and total fertility rate (4.24 to 3.45). A survey in 1995 revealed that those in the 20-29 year age group are in need of information on health and family planning, as well as of family planning services.

Social trends
The adult literacy rate in the population over 15 years has shown a gradual increase between 1981 (males 39.7% and females 18.0%) and 1995 (males 50.5% and females 35.9%). Whether this increase has resulted in better utilization of health services is difficult to ascertain.

Food supply and nutritional status
About 50% of newborn infants have a low birth weight (DGHS 1993-95). The percentage of children whose weight-for-age is below international standards ranges from 6% to 8% and that of height-for-age between 43% and 48% (1995). About 69% of the population suffers from iodine deficiency disorders (IDDs) as estimated by the urinary excretion of iodine. Among the population, the total goitre rate is 47.1%, of which 8.8% have visible goitre. The presence of cretinism is 0.5% (1993). The IDD control programme now targets hyperendemic areas with lipiodol injections as a short term measure and universal iodization of salt as the long term intervention.
The prevalence of anaemia among adult women was estimated at 74% and that of children under five years at 73% (1982/83). Studies conducted in 1990 and 1995 found the situation unchanged.
The prevalence of vitamin A deficiency (night blindness) among 1-6 year old children was found to be 1.78% (1993). Supplementation with liquid vitamin A for children under one year is linked to infant contacts for immunization and children 1-6 are administered high potency vitamin A capsules at six-monthly intervals. As a long term measure, health education is used to encourage the production and intake of vitamin A rich vegetables. With NGO collaboration, a major nutrition project is currently being implemented. Some constraints faced at improving nutrition are inadequate food supplies including micronutrients, economic and sociocultural factors, and the prevalence of diseases.

Lifestyle
The percentage of the male population aged 15 years and over who are regular smokers has steadily increased over the last five years. Data for 1995 show that the proportions of adult males and females who are regular smokers are 41% and 4.6% respectively. The Government and NGOs are making efforts to counter this trend by creating more awareness of the adverse effects of smoking, warning messages on cigarette packets, anti-smoking schemes among doctors, banning advertizements on radio, creation of smoke free zones, etc. There is a need to also address issues relating to substance abuse, drug trafficking and juvenile delinquency.

General protection of the environment
There are many legislative enactments pertaining to the environment that need to be modified and updated. In 1989 a new Ministry of Environment and Forests was created. In May 1992 a national environmental policy was approved and a national environmental action plan developed. In 1995 the Bangladesh Environment Protection Ordinance was enacted. Environmental objectives are also contained in the government's Fourth Five Year Plan (1990-1995) and the Perspective Plan (1996-2010). Monitoring and regulatory mechanisms for air pollutants mainly caused by vehicular emissions are operational only in four major cities. A standard for per capita water availability has yet to be set. A national monitoring system for contamination of drinking water has not yet been established. The regular collection of solid waste is only in municipal towns but handling and disposal is questionable. Bangladesh has no national food safety policy. A plan of action for food safety and an inter-ministerial committee for coordinating and monitoring food safety are operational. The incidence of food-borne diseases is high.
With regard to housing, the key issues identified are unplanned and unregulated urban growth, high population density, often with poor provision for sanitation causing a high incidence of disease, and inadequate facilities for disposal of waste, sewage treatment and management. In 1993 the government adopted a National Housing Policy with provision to address the above issues. In 1991 for the first time, protection of the environment and environmental pollution were included in the industrial policy.
The main constraints include delay in the approval of national policy and work plans, lack of a monitoring system for environmental health concerns, insufficient budget, and insufficient trained manpower.

Water supply and sanitation
The availability of safe drinking water in urban areas has increased from 44.9% in 1991 to 49.1% in 1995 and in the rural sector from 88% in 1991 to 96% in 1995. Over 96% of the rural population use tube well water (safe water) for drinking purposes, but only about 16% use it for other domestic purposes due to the distance from the water source.
The proportion of the population with adequate excreta disposal facilities has also increased, from 38% (1991) to 41.1% (1995) in the urban sector and from 10% (1991) to 36% (1995) in the rural sector.
The main constraints are the shortage of trained manpower, limited funds, poor community awareness, and a weak information system.

Human resources for health
Significant changes in human resources for health have taken place in recent years leading to overall improvement in the coverage of health services. These include production and deployment of more health and health-related personnel, refresher training for health personnel in service, and greater use of health volunteers. In 1997 the distribution of health personnel per 10,000 population was as follows: physicians 2.034, nurses 1.126, pharmacists 0.57, dentists 0.98, and other health providers 4.93. The main constraints were inadequate attention being paid to quality standards in basic and in-service training, inappropriate placement of personnel, lack of a good training institute for health workers, inadequate supervision, and poor accountability on the part of health personnel. Remedial actions are being considered which include the establishment of a permanent health institute, formulation of a human resource development plan, and enhancing the quality of medical education.

Financial resources for health
In 1993-94 the national health expenditure by both public and private sectors amounted to 3.04% of the GNP. The total government health expenditure as a percentage of the GNP was 1.22%. In 1995-96, the government health expenditure as a percentage of the total government expenditure was 7.54%. In 1996-97 the total government health expenditure per capita was Taka 142.72. Constraints to mobilizing financial resources for health and their efficient use are the inability of communities to finance health services due to poverty, unwillingness of donors to support infrastructure development, and lack of coordination in financial mobilization. The government now gives priority to cost sharing, decentralization of authority, decision making and programme implementation at the peripheral level, promotion of community participation, delivery of a package of essential services to the poor, and mobilization of financial resources by negotiating with donors such as the World Bank.

Physical infrastructure
Since the mid 1980's the government has sought to improve its health services and teaching institutions. The explicit goal was to build one union subcentre (USC) or health and family welfare centre (HFWC) in every union (4415); one health complex in every thana (397); and one general hospital or tertiary facility in every district (59). As of 1996, there were 4200 USC's/ HFWC's, 379 health complexes and 59 district hospitals. There were also 10 medical colleges and 7 postgraduate/ specialized hospitals. Government hospital beds and private hospital beds number 29,106 and 8025 respectively To overcome many of the local constraints in the construction and maintenance of health facilities, the government is considering introducing a more need-based health planning process that will involve all stakeholders and the community.

Essential drugs and other supplies
As early as the 1980s Bangladesh had a national essential drugs policy and a list of essential drugs to be procured and used in health services. These have been maintained to date. Most of the essential drugs were known by their generic name and were less costly than brand name drugs. Production and distribution facilities, both in the private sector and public limited companies, are adequate. Despite these advantages, government run health facilities did not have sufficient essential drugs to meet their actual needs, since the budgetary allocation for the procurement of drugs was very small. In 1997 a sample of remote health facilities revealed that only 8% of essential drugs needed at those levels were available. Over the period 1990-1995, however, the investment (public and private) in essential drugs, vaccines and ORS increased from 4.31 million to 75.29 million taka. The government also launched an education programme for providers and users on the rational use of drugs. The government is considering implementation of a new cost sharing scheme based on a sliding scale which would benefit the poor.

International partnerships for health
Bangladesh willingly shares experiences and expertise with other countries, particularly in training, research and disease surveillance. WHO has played a major role in gradually building up the national capacity through regional collaboration. SAARC is another forum used to address regional issues including health. Partnership arrangements for health have been established with bilateral agencies, with funds usually channelled through nongovernmental organizations. An NGO bureau regulates and monitors the funding. There is a need to further strengthen coordination between NGOs and government activities/programmes.

Health policies and strategies
Though there is no formal national health policy, a set of guiding principles committed to HFA using a PHC approach has been adopted. Priority is given to ensuring universal accessibility to and equity in health care, with particular attention to the rural population. MCH receives priority in the public sector and reproductive health has recently been a priority concern. There has been improvement in the government financial allocation for health. Efforts are being made to develop a package of essential services based on the priority needs of clients, to be delivered from a static service point, rather than providing door to door visits by community health workers. This is a major shift in strategy and will require complete reorganization of the existing service structure. This is expected to reduce costs and increase efficiency as well as meet "peoples' demand". Privatization of medical care at the tertiary level, on a selective basis, is also being considered.

Intersectoral cooperation
Intersectoral committees at the different levels from the national level to the periphery are formed whenever the need for cooperation exists. At national level for example, nutrition and population councils are chaired by the prime minister. At the district and thana levels intersectoral coordination committees also exist, while at the lowest administrative level (union), similar committees are formed, e.g. for water and sanitation projects. There is, however, a need to revitalize this process to make it more effective.

Organization of the health system
Committees have been formed, including an interministerial committee, to integrate/merge the health and the family planning departments. Functionally, health and family planning personnel work closely at thana, union and outreach levels, but a dichotomy exists at the district and national levels. An obstacle to this process is the resistance shown by certain agencies and officers. More decentralization of management is also being considered.

Managerial process
The government decided to formulate a national health policy during 1997, for which a health policy committee and five subcommittees were formed. Commencing about two years ago, there was a change from a top-down planning process for health to a participatory approach involving the stakeholders in the health sector. The first product that was formulated utilizing this approach was the health sector perspective plan. A health sector strategy document has also been prepared following the same process.
A new approach to programme implementation, which is product oriented and emphasizes outputs rather than inputs, is being tried out with WHO assistance. Decentralization of the management process is also being considered. The major constraints have been the excessive centralization in the planning and implementation process and the non-utilization of the health management information system (HMIS) that has already been developed.

Health information system
A weekly epidemiological surveillance and outbreak control reporting system for selected communicable diseases have been initiated throughout the country. The routine HMIS is not functioning satisfactorily, though activities have been undertaken to strengthen it. Information support is not yet adequate. Use of data remains limited. Strengthening of the HMIS through training, use of data collection tools already designed, and the establishment of information networks with computer support have been planned.

Community action
The roles of the individual, family and community are emphasized in the intensified action programme for PHC implementation, which involves decentralized planning at thana and union level. A total of 12 districts (86 thanas) are now in the intensified PHC programme. Through intersectoral collaboration and community participation, a joint action plan has been implemented involving 60,000 village health volunteers (one for 50 households). The participation of teachers and religious leaders is encouraged. The information department and mass media inputs are also utilized to support IEC activities.

Emergency preparedness
Bangladesh is a densely populated delta whose land mass is sandwiched between the Bay of Bengal and the high Himalayan mountains. Throughout the centuries the country has suffered natural disasters such as cyclones, tornadoes and floods. During 1993-1996, two major floods, one cyclone and one tornado, with catastrophic effects, have affected millions of people.
Currently there is no legislation in the country that underpins the management of natural disasters at national and subnational levels. In the absence of any legislation, the Ministry of Disaster Management and Relief in 1997 issued revised "standing orders for disasters". These provide guidelines and instructions to various line departments and ministries. There are separate standing orders for different hierarchical levels of the health sector which include coordination committees, contingency plans for manpower deployment, essential medical relief supplies and maintaining a database, training in emergency preparedness and response, a communication network, and budgetary allocation for emergency management. A draft "Disaster Management Act" is currently under review.

Health research and technology
Three organizations [the Bangladesh Medical Research Council (BMRC), the Institute for Cholera and Diarrhoea Disease Research, Bangladesh (ICDDRB), and Essential National Health Research (ENHK)] spearhead biomedical and operational research. They undertake training and provide research grants. Many of the research findings are helpful in making policy decisions. Research units have also been opened by BMRC in medical colleges. Field study stations have been established by BMRC and ICDDRB. BMRC has reorganized itself internally to cope with the growing demands of young researchers. Literature search systems in BMRC and ICDDRB have been modernized.
Health systems research (HSR) is not handled as a separate, independent entity. Individual faculty members and other relevant people have been trained in HSR, but there is no coordination among researchers. Health training institutions have yet to include HSR in their curricula. The research culture has not yet fully developed in Bangladesh, and there is no effective critical mass of researchers to form a strong advocacy group. Coordination and networking among researchers and funding agencies have still to be developed.