January 11, 2012, 4:37 pm by THE EDITORS
The global health community has gotten quite good at figuring out ways to ensure that dollars are going toward intended purposes. Organizations like the Global Alliance for Vaccines and Immunizations (GAVI Alliance), which is the world’s largest funder of vaccines in poor countries, regularly assesses recipient countries’ finances and conducts independent audits. our foundation also insists upon tight financial controls in our own grantmaking. Donors do more than just provide funding. by exacting high standards and requiring audits and transparency, we can also help to change the norms about what is acceptable.
BRACA BRAC health worker and community health volunteer provide prenatal care in the home of a Bangladeshi woman near Dhaka.
It’s also important to recognize that Bangladesh, a democratic country that has held a number of free and fair elections, is uniquely fueled by a powerful civil society. Bangladeshi NGOs have massive reach: the largest one, BRAC, reaches 110 million people! Many of the foundation’s projects are carried out in partnership with these NGOs. And the NGO’s emphasis on community-led development—BRAC pioneered the community health worker model, for example—means that more people are empowered and don’t wait around for the powers that be to solve their problems.
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NICK: Bangladesh has a problem with corruption, and its prime minister, Sheikh Hasina, has also gone on a vengeful warpath against Grameen Bank and its founder, Muhammad Yunus. It’s really sad to see a woman become a prime minister and then use her power to attack a man like Yunus who won the Nobel Peace Prize for his wonderful work on behalf of the world’s women.
But corruption and abuse of power are a part of life in much of the world. Business executives learn to navigate around it, and so do aid workers. Sure, some gets siphoned off, but there are ways to ensure that the great majority is properly used. There are also some innovations that increase transparency and reduce corruption, such as publishing accounts so that everybody knows how much money is going to a particular rural school. And if that school never actually was built, because the money was stolen, then local people will know enough to protest. likewise, national ID cards (as are being introduced in India) reduce corruption. So does direct deposit of sums into recipient savings accounts rather than allowing money to be funneled through middlemen. Corruption is still a problem, but we’re getting better at dealing with it, I think.
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SARAH KACEVICH: What is access to birth control like in Bangladesh? in that country’s context, how do you feel about the idea that improved access to birth control can reduce poverty via smaller family sizes & “older” mothers?
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MELINDA: Bangladesh has made huge improvements in getting women access to contraceptives since its independence 40 years ago. The program has consistently maintained strong support from the highest levels of government and society, and has had great success tapping into the tremendous amount of latent demand for contraceptives. Nearly half of Bangladeshi women use modern contraceptives today, up from just five percent in 1975. The average number of births per woman has dropped correspondingly, from 6.3 to 2.3 over the same period.
We often talk about all the benefits that stem from getting women access to family planning tools, but Bangladesh went to great lengths to prove this hypothesis. in 1977, they set up a study in a religiously conservative area called Matlab, where they selected villages as similar as possible and then introduced modern family planning services in some but not in others. they tracked these 149 villages and 180,000 people for about 20 years. The results were astounding : women in the villages with access to modern contraceptives had, on average, 1.5 fewer children. they had lower risk of pregnancy-related death and disability. they weighed more, were better educated, earned significantly more money, and lived in nicer houses. Not to mention their children, who also weighed more and went to school longer.
The next challenge for Bangladesh will be better meeting the needs of those families who indicate they do not want to have any more children. currently, their options are mostly limited to short-acting contraceptives, like pills and condoms, which require more effort and persistence to use than longer-acting methods like implants and injectables.
At several points this week, I asked women how many children they had at home. I didn’t hear many say that they had large families. in fact, the most I heard any woman say was that she had three children. Perhaps even more surprising, nearly all the women had waited three years in between children before having another. Bangladesh is unique when it comes to birth spacing—80 percent of non-first births happen at least twenty-four months after the preceding child is born. Bangladeshi women don’t just have access to family planning, they have consistent access. All of this is opening up real opportunities for these women and their families. every single woman I talked to mentioned that her husband had a job and a good percentage of those women had jobs too, mostly embroidering or tailoring. It reinforced to me that access to family planning can have a revolutionary impact not only on a woman’s potential but also on that of her family. This kind of access could pull entire societies out of poverty.
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NICK: Contraception has been neglected for a generation. Partly that’s because the population control effort was tarnished by overzealous and coercive campaigns in China and India, and partly because the whole field of reproductive health was made radioactive by the abortion debates. But access to family planning for women who want it is critical to moving forward in development. And it mystifies me that conservatives are often wary of it, because the best way to reduce abortions in the developing world is to promote family planning.
That said, I think Americans sometimes have a naïve view about how easy it is. Family planning, like everything in development, is harder than it looks. I once interviewed a 30 year-old woman in Haiti who was intelligent, lived around the corner from a clinic that provided family planning, only wanted two children – and yet was pregnant with her 10th child. Family planning requires health care providers and counseling, it requires steady supplies (no point in having the Pill in stock only every other month), and it requires consensus in the community. from Mauritania to Congo Republic, I’ve visited clinics that would only give a woman contraceptives if her husband accompanied her to signify his agreement.
There’s also some evidence that the most effective form of family planning isn’t IUD’s or the Pill, but girls’ education: when girls are educated, they end up having significantly fewer children. So we need an approach that includes educating girls, teaching communities (men included) about contraception, providing steady supplies in a comprehensive program that includes counseling, and research on new methods that don’t require health workers. The Population Council, for example, is developing a vaginal ring that does not require a doctor and that seems highly reliable and cheap. Bangladesh is a good example of the progress that is possible when a family planning policy is done right.