Community-based approaches and partnerships: innovations in health-service delivery in Bangladesh.

In Bangladesh, rapid advancements in coverage of many health interventions have coincided with impressive reductions in fertility and rates of maternal, infant, and childhood mortality. These advances, which have taken place despite such challenges as widespread poverty, political instability, and frequent natural disasters, warrant careful analysis of Bangladesh's approach to health-service delivery in the past four decades. With reference to success stories, we explore strategies in health-service delivery that have maximised reach and improved health outcomes. We identify three distinctive features that have enabled Bangladesh to improve health-service coverage and health outcomes: (1) experimentation with, and widespread application of, large-scale community-based approaches, especially investment in community health workers using a doorstep delivery approach; (2) experimentation with informal and contractual partnership arrangements that capitalise on the ability of non-governmental organisations to generate community trust, reach the most deprived populations, and address service gaps; and (3) rapid adoption of context-specific innovative technologies and policies that identify country-specific systems and mechanisms. Continued development of innovative, community-based strategies of health-service delivery, and adaptation of new technologies, are needed to address neglected and emerging health challenges, such as increasing access to skilled birth attendance, improvement of coverage of antenatal care and of nutritional status, the effects of climate change, and chronic disease. Past experience should guide future efforts to address rising public health concerns for Bangladesh and other underdeveloped countries.

Food provisioning experiences of ultra poor female heads of household living in Bangladesh.

Ultra poor women in Bangladesh are especially vulnerable to poverty and food insecurity, and they have generally been excluded from recent improvements in hunger and poverty rates in the country. An examination of the food provisioning narratives of 43 ultra poor female heads of household in Bangladesh was conducted in order to deepen understanding of this obstacle to the country's achievement of the First Millennium Development Goal. All participants were the household's sole income provider, had dependent children, and earned less than $1 USD per day. Women were purposively selected based on occupational group, context, and personal characteristics. Ethnographic interviews were conducted in January and February, 2008. Analysis of women's accounts of their daily food routine revealed chronic and pervasive food insecurity punctuated by acute episodes of absolute food deprivation that resulted from seasonal fluctuations in earnings, rising food prices, illness disrupting work, and healthcare costs. Women's accounts of their daily food provisioning experiences suggested compromises in, and trade-offs between, multiple basic needs as a result of inadequate income. Women were further constrained by social norms and gender roles that influenced their ability to work outside the home. Our method of inquiry led us to construct an organizing framework that extends knowledge of ultra poor women in Bangladesh's complex and multi-sphered experience of poverty and food insecurity. Based on these findings, we propose a strategy called whole person development (WPD), which seeks small adjustments to services, programs, and policies based on leverage points identified through in-depth narratives.