93554 Knowledge Brief Health, Nutrition and Population Global Practice HARNESSING THE DEMOGRAPHIC DIVIDEND IN BANGLADESH Sameh El-Saharty, Karar Zunaid Ahsan, and John F. May November 2014 KEY MESSAGES: • Bangladesh has achieved significant economic and human development progress. Never- theless, its future socioeconomic prospects may be hampered by its population growth rate. • In 2051, the population of Bangladesh will be an estimated 218.1 million under a laissez faire (LF) projection scenario and 201.3 million under an accelerated fertility transition (AFT) scenario. • An AFT scenario would enable the country to improve the dependency ratios—possibly resulting in economic benefits from harnessing the demographic dividend for several decades. • To accelerate the demographic transition, the government will need to revitalize high-level coordination to ensure multisectoral engagement in population policies, including increasing the age at marriage, and improving education, skills development, job creation, and safety nets. • In addition, a sustained decline in fertility through increased access and coverage of family planning (FP) services is crucial, mainly by focusing on lagging regions and hard-to-reach areas, and by expanding the supply and provision of FP long acting and permanent methods (LAPMs). • The Ministry of Health and Family Welfare (MOHFW) will need to improve the synergy and coordination of service delivery between the Health and FP directorates by promoting cross- referral between programs and the efficient provisioning of FP and reproductive health (RH) services through community clinics. economies. Despite its economic growth, 32 percent of Introduction Bangladesh has made significant economic progress and remarkable strides in many areas of human the population still lives below the poverty line and about development. The last three-year trend in gross domestic 40 percent are underemployed. On the other hand, life product was an upturn of more than 6 percent a year, expectancy and literacy levels have increased, child which is equal to some of the best performing Asian immunization rates are sustained above 90 percent, and Page 1 HNPGP Knowledge Brief  maternal mortality ratio declined sharply. 15 and 64 years will stabilize. A Window of Opportunity for the Bangladesh’s 2011 Population, estimated at 149.8 Demographic Dividend million, is expected to increase by about 50 million by 2050. The country’s annual growth rate is 1.37 percent An accelerated fertility reduction will substantially but the population momentum due to the youthfulness of increase Bangladesh’s window of opportunit y to the age structure is expected to be partially offset by the capture the demographic dividend for several continued pace of declining fertility—especially if fertility decades. The demographic dividend occurs when the declines for a period of time below the replacement level value of the total dependency ratio reaches less than 0.5, of about 2.1 children per woman. for example, two workers for one dependent (Cheung et al. 2004). This presents itself when lower fertility levels Accelerating the decline in fertility could reduce increase the share of working age people along with population growth in absolute numbers by one- declining dependency ratios, resulting in a steady rise in st twelfth by the mid-21 century. Declining fertility will output per capita and potentially marked economic hinge on the successful implementation of different health growth. The AFT scenario provides a lower dependency policy measures, which include increasing the supply and ratio (Figure 2) and a more favorable demographic access to FP methods. The stabilization of the population window of opportunity until 2051. will depend ultimately on the population momentum and the continued decline in the fertility rate. Two Scenarios of Population Projections 1) Laissez faire (LF) scenario – the total fertility rate (TFR) reaches 2 by 2016 and stays. 2) Accelerated fertility transition (AFT) scenario – TFR reaches 2 by 2016 and declines to 1.7, which is below replacement level (Figure 1). Poverty reduction is closely linked to demographic factors. According to a poverty assessment study (World Bank 2013), changes in the demographic composition between 2000 and 2010 have been an important driver of poverty reduction. For example, reduction in fertility resulted in lower youth-dependency ratio thus allowing for the household income to be distributed on less number of dependents. The study estimated that the demographic factors contributed to at least 25 percent of the observed decline of poverty during the decade (World Bank 2013). The population projections also point to the challenge of population aging and its implications. As fertility decreases and life expectancy increases due to modern medical innovations and/or socioeconomic improvements, the elderly (aged 65+ years) will constitute about 14-15 Due to the ongoing demographic transition, percent of the population by 2051. Also, continuing Bangladesh’s population age structure will also socioeconomic development will further accelerate the change significantly. The proportion of youth will shift from infectious to non-communicable diseases as the decrease gradually, once fertility declines to replacement major cause of morbidity and mortality, which, together level. Over the next 35 years, both projection scenarios with population growth, may cause health expenditures to indicate that the proportion of the population under 15 will increase by 48 percent in 2020 (El-Saharty et al. 2013). decline sharply and the population over 65 will rise steadily, while the proportion of the population between Page 2 HNPGP Knowledge Brief  Bangladesh needs to capture the demographic dividend by implementing effective economic and social policies and to recognize the linkages between demographic factors and poverty reduction. The government has to put in place policies in areas such as health, education, labor market, and job creation, to harness the economic power of the youth bulge. Capturing the demographic dividend will not only contribute to economic growth but will also facilitate poverty reduction. On the other hand, the economic burden of an aging population and elderly care will require the government’s special attention to avoid cost escalation in public spending. Fertility and Family Planning Fertility decline is strongly linked to effective FP services. Between 1975 and 2011, the TFR declined from 6.3 children per woman to 2.3, while the contraceptive prevalence rate (CPR) increased from 7.7 percent to 61.2 percent (see Figure 3). However, the CPR and TFR passed through different phases (see Box 1). The FP method mix has evolved over the past decade and a half. Use of modern FP methods increased by almost 20 percentage points from 1993 to 2010, when the use of the pill almost doubled and the use of injectable contraceptives almost tripled. The use of other modern FP methods, such as condoms and NORPLANT® rose more slowly or even fell, for example, intrauterine devices, and female and male sterilization. The use of traditional methods also declined. The public sector remains the main provider of FP services, although the private sector provision has increased over the years. Despite its successes, Bangladesh’s FP program faces several challenges. The current program’s contraceptive method mix is dominated by short-term methods, whereas long-term/clinical methods are needed to accelerate and complete the fertility transition. Moreover, the age at first birth has not changed much: half of all teenage girls have at least one child. The usual pattern for couples is early marriage, rapid childbearing, and then reliance on short-term (less effective) contraceptive methods to avoid subsequent pregnancies. The TFRs and the CPRs show wide regional variations. The Western part of the country has already attained replacement-level fertility, as illustrated by the Rajshahi and Khulna divisions. In these divisions, five districts already experience below-replacement levels: 1.8 to 2.0 children per woman. However, the Eastern part of the country’s fertility level is still one child on average above replacement-level (see Figure 4). Page 3 HNPGP Knowledge Brief  coupled with expanding the safety nets for vulnerable populations. The HPNSDP should improve access to and coverage of FP services through the following actions: • Expand the supply of LAPMs, particularly injectables, to all providers beyond the social marketing companies and the government supply chain. • Increase the FP program’s focus on the hard-to-reach areas and lagging regions, whether in low CPR or high unmet needs. • Address the acute shortage of health workers by increasing the use of trained community health workers, particularly in high fertility regions. • Conduct ongoing stakeholder consultations to ensure contraceptive security and program sustainability. Unmet FP need remains high at 11.7 percent of • Strengthen the institutional and technical capacity of the Bangladeshi women. Low-performing FP coverage in Directorate General of Family Planning (DGFP) to regions like Sylhet and Chittagong in the East have the manage the procurement of FP commodities more highest unmet needs, while the high-performing regions effectively. like Rajshahi and Khulna in the West have unmet need of less than 10 percent. The MOHFW will need to improve the synergy and coordination of service delivery between the Policy and Program Harmonization Directorate General of Health Services (DGHS) and the DGFP through the following actions: The Government of Bangladesh’s Health, Population, and Nutrition Sector Development Program (2011-2016) was • Link RH services, such as antenatal and postnatal care prepared along with its five-year Program Implementation and institutional deliveries to FP services, for example, Plan and 32 Operations Plans (OPs). Among the 32 OPs, cross-referral between programs. seven are specifically designed to strengthen the delivery of family planning and reproductive health services. The • Use efficient provisioning of FP and RH services FP program operates within a complex architecture of the through community clinics and at the community level. health sector, which requires improved synergy in the service delivery system and harmonization of the • Strengthen the MOHFW’s capacity to triangulate data population policies. collected from various household surveys and use the data in decision making. The following policy interventions should be considered: The HPNSDP should help to revitalize high-level government coordination to ensure multisectoral This HNP Knowledge Brief highlights the key findings engagement on population policies. To accelerate the from the HNP Discussion Paper “Population, Family demographic transition and harness the economic Planning, and Reproductive Health Policy benefits of the youth bulge, the government must pursue Harmonization in Bangladesh” written by Sameh policies to expand education, particularly for women, El-Saharty, Karar Zunaid Ahsan, and John F. May (2014). increase the age at marriage and first birth, and invest in job creation and skills development for the unemployed, The Health, Nutrition and Population Knowledge Briefs of the World Bank are quick reference on the essentials of specific HNP-related topics, summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4