By Professor Rumana Huque & Abdullah M. Rafi
Bangladesh today stands as a shining example in global health sector. Two decades ago, more than 400 mothers died for every 100,000 live births; that figure has now fallen by more than half. Similarly, neonatal mortality has dropped from 44 per thousand to 20. This achievement is not the result of any single project; the foundation for such progress was laid in the 1970s with the launch of the family planning programme. Continuous and coordinated efforts — from family planning, emergency care during child birth, expansion of female education, rural development and the near-universal coverage of child vaccine — have driven this remarkable journey.
According to the Bangladesh Demographic and Health Survey (BDHS), between 2000 and 2022, the rate of child marriage decreased from 65 per cent to 51 per cent, while care during pregnancy (at least one visit during pregnancy) rose from 34 per cent to 88 per cent. During the same period, deliveries in healthcare centre increased from 8 per cent to 65 per cent and adolescent pregnancies dropped from 35 per cent to 23 per cent. The rise in education levels and improved communication networks have also contributed to this success. Female literacy has climbed from 54 per cent to 86 per cent and most households now have access to electricity and mobile phones.
Bangladesh’s economic growth has likewise been remarkable. According to government data, poverty has declined from 49 per cent to 19 per cent, while women’s participation in the labour force has risen from 23 per cent to 32 per cent. This integrated social progress has strengthened the health system and reduced maternal and neonatal mortality. However, research indicates that this progress has slowed since 2010, with inequality identified as a key factor.
Economist Amartya Sen, a Nobel Prize achiever once remarked, “I believe that at the root of almost every problem in the world lies some form of inequality.”
Health inequality is not simply a matter of who is healthy and who is not. It is about who has the opportunity to live and who does not. Some people have access to treatment nearby, while others must travel miles for the same care. Some give birth under the supervision of a doctor, while others lose their children before birth due to the lack of medical attention.
While Bangladesh’s health sector has achieved impressive progress, it also carries serious warnings. Without improvements in service quality and without addressing poverty, education gaps, geographic disparities and weak regulation in the private sector, sustaining the current pace of progress will be difficult. The State has expanded healthcare access to many, yet the quality and equity of that care remain far from assured.
Women, men and others
Although reproductive health services in Bangladesh are primarily focused on women, their limited decision-making power, social and familial restrictions and financial dependency significantly hinder their access to care. This inequality is not only a loss for individual women but also affects the next generation. When a mother is deprived of proper care during childbirth, the first month of her newborn’s life becomes the most perilous.
In terms of antenatal care, safe delivery and the management of non-communicable diseases, women continue to face discrimination. Statistics show that 36 per cent of women aged 35 and above suffer from hypertension, compared to 23 per cent of men.
Meanwhile, the third gender community remains largely invisible within the national health system. Although officially recognised in government records as Hijra, they are almost absent from healthcare centres, hospitals and public programmes. Social stigma, discrimination and fear deter many from seeking medical care, leaving them excluded from reproductive and mental health services, HIV prevention and hormone therapy.
A 2019 survey by the NGO, Bandhu Social Welfare Society found that around 73 per cent of respondents reported having no access to government healthcare. Bangladesh’s health sector thus faces a multi-dimensional inequality: not only do men and women still lack full equality in healthcare, but the third gender citizens remain almost entirely outside the system.
Urban vs rural disparities
Like gender inequality, rural citizens also experience considerable health disparities compared to their urban counterparts. While hospitals, clinics and pharmacies are increasingly available in cities, many villages still rely solely on community clinics as their only source of care. As a result, healthcare remains a distant promise for many rural residents.
According to the 2022 BDHS, 76 per cent of urban births occur in health facilities, compared to only 61 per cent in rural areas. In urban settings, access to doctors, hospitals and ambulances is readily available. By contrast, rural women often have to give birth at home due to distance, cost, and social constraints. Urban women can quickly consult physicians or obtain emergency care, while rural women still face a long, expensive and uncertain path to such services.
From medicine procurement to hospital construction and from recruitment to service delivery, a lack of accountability at every step harms ordinary citizens, especially the poor and marginalised
Economic inequality
Economic status creates the widest divide in healthcare access. An individual’s income, housing and occupation largely determine their access to care, quality of service and even their likelihood of survival.
The 2022 BDHS reports that while, on average, 65 per cent of births occur in health facilities, the rate is 87 per cent among wealthy families but only 42 per cent among the poorest. In other words, safe motherhood remains highly dependent on a woman’s economic standing.
A similar pattern appears in neonatal mortality. Although the national average stands at 20 deaths per 1,000 live births, the rate is 12 among affluent families and nearly 31 among the poorest, almost three times higher. The only area where economic inequality is relatively less evident is in vaccine work.
Geographical disparities
Access to healthcare in Bangladesh varies widely not only between urban and rural areas but also across regions. Hospitals, doctors and medicines are more readily available in the capital and its surrounding districts. In contrast, people in the northern, hilly, coastal and haor regions still struggle to obtain even basic medical services.
According to the BDHS, neonatal mortality rates in Mymensingh, Sylhet and Rangpur divisions are significantly higher than the national average, while Barishal, Rajshahi and Khulna fare comparatively better. Institutional delivery rates follow a similar pattern: over 70 per cent in Dhaka and Khulna, but barely half in Mymensingh, Barishal and Sylhet.
Lack of awareness and corruption-induced inequality
Beyond unintentional social and structural inequalities, corruption has institutionalised disparity in Bangladesh’s healthcare system. According to Transparency International’s 2023 report, nearly half of all households experienced some form of corruption while seeking government healthcare services. Syndicates also reportedly control emergency services such as ambulances, depriving the poor of free services and forcing them to spend from their own pockets.
From medicine procurement to hospital construction and from recruitment to service delivery, a lack of accountability at every step harms ordinary citizens, especially the poor and marginalised. Due to the shortage of free medicines and low-cost diagnostic services in public hospitals, patients are often compelled to seek treatment in private facilities at much higher costs, effectively denying the poor their basic right to healthcare.
The path to reducing inequality
How can this inequality be addressed? The answer lies in ensuring equity and fairness in healthcare services and policies. The first step is to identify lagging regions and communities, followed by targeted investment, adequate staffing, medicine supply and infrastructure development.
At the same time, the quality and effectiveness of healthcare must be ensured by bringing every district, upazila and household under the umbrella of health equity. Health indicators must also be analysed through the lens of inequality.
For an effective health system, regular district and upazila-level data review and analysis are essential, supported by the availability of reliable data and evidence-based decision-making.
A person’s place of residence, social standing or financial capacity should never determine their right to live or die. True progress in our health sector will come only when every citizen – rich or poor, urban or rural, male or female everyone can enjoy equal access to a healthy life.
May our journey in the health sector continue in that direction.
