Sunday, November 24, 2013
Dr Amartya Sen: What's happening in Bangladesh?
Self-assured commentators who saw
as a “basket case” not many years ago could not have expected that the country
would jump out of the basket and start sprinting ahead even as expressions of
sympathy and pity were pouring in. This informative Lancet Series
on Bangladesh helps
to explain what happened—and why. It is important to understand how a country
that was extremely poor a few decades ago, and is still very poor, can make
such remarkable accomplishments particularly in the field of health, but also
in social transformation in general.
The lessons are important for
own future, and for what The Lancet Bangladesh Team describe
as the construction of “a second generation of health systems”. But the
messages from Bangladesh's
experience are also of great relevance for many other countries in the world
that suffer from debilitating poverty. It might not be good manners for Bangladesh to
start lecturing the world on what to do, so soon after jumping out of the
basket to which it had been relegated, but the country's experience has
important lessons for other developing countries across the globe.
These lucid and helpful papers discuss the main avenues of change on which
Bangladesh has travelled. I will
not summarise the findings: this has been nicely done in the introductory paper
by Mushtaque Chowdhury and colleagues. Instead I will concentrate on a
small number of striking features of the strategy followed by Bangladesh in
moving rapidly towards health transition.
One direction of change is the emphasis that the country has placed on reducing gender inequality in some crucially important respects. The impetus for the change was linked in many different ways with the politics of liberation that made the issue of freedom, including the liberation of women, a part of the progressive agenda of what people wanted and were ready to fight for. There are inescapably complex issues to be addressed in order to explain more fully how exactly that happened. It can be argued that there were historical elements in the culture of
Bengal, and particularly in the emergence
of radical movements in various forms in that province throughout the first
half of the 20th century, that leant them to include a serious concern for
gender equity. But it was the nature of the struggle for independence of Bangladesh, particularly in focusing on the
contrast with West Pakistan, that made it
possible to make an effective political translation towards empowering women.
The causation of this move towards gender equity cannot but remain somewhat speculative, but its consequences are clear enough. Schools focused particularly on expanding the education of girls:
is one of the few countries in the world where the number of girls in school
now exceeds the number of boys. Public services, including school teaching, health
care, and family planning, employ a much higher proportion of women workers
than is the case in most developing economies, including in Bangladesh's
neighbouring countries. Women have also entered the economic workforce in
plentiful numbers, led by such industries as garment making that provided easy
entry to female labourers, even though the neglect of safety at work has been a
huge blot in the record of that industry, a serious deficiency that is only
belatedly being addressed, and perhaps not yet strongly enough.
Women have also received special attention from Bangladesh's powerful non-governmental organisations (NGOs)—from large initiatives like BRAC and Grameen Bank to smaller organisations—and the mobilisation of the active agency of women has been a distinctive feature of the vision that has moved Bangladesh forward. And there has been a general determination in post-independence
target the elimination of female disadvantage in different fields of action,
including maternal and child survival.
The removal of female disadvantage and the use of female agency have raised
record of achievement even on its own, but it is in fact the case that women's
agency has also contributed greatly to the advancement of the lives and
freedoms of all—men, women, and children. The unlocking of the power of women's
active role in the society and in the economy has been an extremely productive
move for Bangladesh and
contrasts with what has happened in much of India. Bangladesh's
powerful achievement in making much greater use of women's agency is a remarkable
affirmation of the importance of what Mary Wollstonecraft called, in 1792, “the
vindication of the rights of woman”. Indeed it turns out that the removal
of the social shackles that restrain women has a crucial part to play in the
progress of all people—of both sexes and of all ages.
A second striking feature of the
story is the general acceptance of a multiplicity of instruments in the public
and private sectors for rapid social advancement. Just as state initiatives
have been seriously undertaken, NGOs and private enterprises have been
forcefully supplementing the efforts of the public sector. As Syed Masud Ahmed
and colleagues argue, the use of pluralism has allowed Bangladesh to
get off to a quick start bringing the country a little closer to a health transition.
This is not to deny that the mixture of instruments that characterise
Bangladesh's path of development
will demand critical examination over time, since substantial overall
advancement can coexist with persistent inefficiency and inequalities in the
sharing of the benefits of health transition. These evaluative issues remain
open to scrutiny and critical examination, but what has to be immediately—and
firmly—recognised is that Bangladesh has been, in its own way, going ahead
rapidly, rather than remaining paralysed by the slowness that is often entailed
by the pursuit of “purity” in more ideologically oriented initiatives which
favour either exclusive reliance on private enterprise or exclusive use of
state-based programmes. The pragmatism that Bangladesh came to accept through a
complex political and social process has yielded noticeable success, which has
impressed—and to a considerable extent surprised—the world.
A third feature, closely related to the second, is the intelligent use of community-based approaches in the delivery of health services and medical care. As Shams El Arifeen and his coauthors outline, the mobilisation of community-based participation has many advantages, not only for the fostering of social cooperation, but also for extending the reach of the health initiatives and their impact. The innovations in health-service delivery from which Bangladeshis have benefited have been possible partly because of these participatory features in the process of social change. The importance of innovations is also discussed in the context of equity in the paper by Alayne Adams and colleagues.
A fourth feature, which demands particular attention in Bangladesh, is the country's improved ability to face natural disasters, such as storms, cyclones, floods, and droughts. These natural calamities have acted as a persistent drag on the country's progress. As the contributions by the Richard Cash and colleagues highlight, the deep vulnerability of the disaster-prone country to unruly forces of nature, which needed to be subdued, has indeed been, to a considerable extent, reduced. The elimination of these problems would, however, demand much more security-oriented progress in future years, especially if the threats for climate change become stronger.
I have pointed to a few of the special features in
progress towards a health transition, and many other features have been
explored in this valuable Lancet Series. One very important
aspect of this compendium of investigations is the continued focus on a call to
action that nicely
supplements the appreciation of what has been accomplished. Bangladesh has
still a long way to go. This Lancet Series shows how Bangladesh has
firmly placed itself on the way to that long journey (and has made an excellent
beginning), but also points to further problems that have to be tackled as the
journey proceeds. The key to Bangladesh's
laudable success has been the avoidance of the twin dangers of inertia and
smugness. The future will demand more from these virtues.
I declare that I have no conflicts of interest.
First published in The Lancet journal, 21 November 2013
Prof Amartya Sen, a Nobel laureate and professor of economics, Harvard University, Littauer Center, Cambridge, MA 02138, USA