1. Jacqueline R Helpern
Writing Sample
Word Count: 1,386
Burkina Faso and Bangladesh:
Three Possible Explanations for Differences in Infant and Under-Five Mortality Rates
Introduction
Burkina Faso and Bangladesh are both considered low-income countries by the World Bank (GNI
$570 and $780 USD per capita, respectively) (1-3). These two countries also have a similar population
distribution between rural and urban areas, and similar primary school enrollment as a percentage of the
total population of primary school age children in each country (see Table 1) (4,5).
According to multiple measures, Burkina Faso spends more money on health than Bangladesh.
Burkina Faso spends 6.7% of its GDP on health, while Bangladesh spends 3.5% of its GDP on health
(6,7). The government of Burkina Faso spends nearly twice as much of its total expenditures on health
compared to Bangladesh (13.5% vs. 7.4%), and has nearly three times the external resources for health
(22.9% vs. 8.0% of total expenditures on health) (8,9).
Despite spending more money and resources on health, Burkina Faso has poorer health outcomes
than Bangladesh. The infant mortality rate in Burkina Faso is 93/1000 while in Bangladesh it is 38/1000
(8,9). The under-five morality rate in Burkina Faso is more than three times that of Bangladesh (176/1000
vs. 46/1000) (8,9). Divergence in the following areas possibly explains these differences in health
outcomes: addressing the rural population, financing healthcare, and health system structure.
Table 1: Comparison Figures for Burkina Faso and Bangladesh (1-5,8,9)
Burkina Faso Bangladesh
Population 16,469,000 148,692,000
Percent Rural Population 74 72
Percent Primary School Enrollment 79 81
GDP (USD) $10.19 billion $110.61 billion
GNI per capita (USD) $570 $780
Percent GDP Spent on Health 6.7 3.5
Government Expenditure on Health
as Percent of Total Government Expenditure
13.5 7.4
External Resources for Health
as Percent of Total Expenditures on Health
22.9 8.0
Infant Mortality Rate (per 1000 live births) 93 38
Under 5 Mortality Rate (per 1000 live births) 176 46
Addressing the Rural Population
In 1992, Burkina Faso began working with international development agencies to reform its
healthcare system, with the aim of decentralizing, implementing cost-recovery programs, ensuring the
supply of essential generic drugs, and liberalizing health services and the hospital sector (10). The result
was a large increase in health facilities and pharmacies, yet urban centers almost exclusively benefitted
from this growth. “By 1996, nine of 10 private health facilities and one of four pharmacies were located
in one or the other of [Burkina Faso’s] two largest cities,” (10, p1890).

2. Resources were unevenly distributed between rural and urban areas. A study published in 2001
reported that 84% of the population living in rural areas only benefitted from 30% of public spending on
health, while the remaining 16% urban population benefitted from 70% of public spending on health (11).
Between 1990 and 1999, the number of doctors per 100,000 inhabitants increased from 3.5 to 5.0, while
the proportion of doctors assigned to rural areas decreased by 13% (10). Health programs were also more
likely to be located in urban verses rural areas of the country (12). Through reform, Burkina Faso grew its
healthcare system overall but did not specifically address the needs of children or the majority rural
population.
Bangladesh approached healthcare reform differently. Instead of aiming to simply build more
clinics and train more health professionals regardless of location, Bangladesh directly addressed the
health care needs of its rural population (13-15). In 1988, the government of Bangladesh began working
with the British Overseas Development Administration, forming the Bangladesh Population and Health
Consortium (BPHC). The BPHC funded local non-governmental organizations (NGOs) to serve the
maternal and child health needs of the rural population (13).
Since 1970, nearly 400 ‘family welfare centers’ have been constructed in rural areas (15, p6).
Specific programs such as household visits by healthcare workers and uniform diagnostic procedures
contributed to improved preventative and curative child health services (13,14). Better access to care for
mothers may also have contributed to better health outcomes for children. By focusing specifically on its
rural population, Bangladesh was able to improve infant and under-five child mortality more effectively
than Burkina Faso.
Financing Health Care
Burkina Faso adopted the Bamako Initiative in 1987, making patients responsible to pay for
medications. In one study, “Medication represented 80% of the cost of an illness episode for those who
visited a professional,” (10, p1892). Patients are also required to pay a fee for services at health centers.
This represents a demand-side financing system, where users are responsible to finance their care.
Through healthcare reforms, generic drugs were made geographically available to most of the
population, but remain inaccessible due to cost (10,17). Financial barriers continue to be identified as a
top deterrent to seeking care (10,11,16-19). As a result, “Utilization of health services has decreased
during the last 15 years,” (16, p393). Ultimately families are waiting to seek care, not seeking care at all,
or becoming impoverished as a result of seeking care.
Bangladesh has historically employed supply-side financing, whereby the government and
international aid organizations work with healthcare providers to finance care (20). Although informal
user fees are reported, government health facilities provide most services free of cost (15). The BPHC’s
management information system reports: “Women and children from the poorest households now have
service coverage almost as high as [other socioeconomic groups],” (13, p194).
The Ministry of Health and Welfare in Bangladesh allocates nearly half of its budget to primary
level care. Increased access to primary care leads to better overall health, which may contribute to
Bangladesh having lower rates of and infant and under-five mortality (15). These differences in financing
health care possibly explain why Bangladesh has better health outcomes than Burkina Faso.
Health System Structure
Burkina Faso is a highly centralized country, where information and resources flow from top
officials and agencies down to smaller local officials and agencies. Since the 1980’s, Burkina Faso has

3. attempted to decentralize by granting more autonomy to local and regional leaders, yet these attempts
have been largely ineffective (10,11,18). For example, when the state introduced a program to subsidize
deliveries and emergency obstetric care in 2006, the program was not uniformly implemented, and
resources and information were not evenly distributed among health workers (18).
By 2003, even with attempts to decentralize, “Districts and regional boards of health still only
managed about half of their material expenses,” with the rest managed by the Ministry of Health (10,
p1895). In this system, local authorities are relatively impotent as district officers are only accountable to
higher officials. Health personnel have little autonomy or opportunities for advancement, so they lack
motivation and seek employment in the private sector (10,11,21). This top-down structure has ultimately
diminished the healthcare system’s ability to meet the needs of the population.
Bangladesh adopted a more bottom-up approach to healthcare, and worked more cooperatively
with local and international NGOs to improve health services. Instead of attempting to follow a national
plan on all levels, the BPHC encourages the development of healthcare plans tailored to local context and
needs. “Since 1988, BPHC has supported over 100 NGOs to provide doorstep and clinic services,” (13,
p188). Successful programs were often started on a smaller scale at the local level, then scaled up by the
government to reach a larger population (14). Though this cooperative approach, health care has
effectively reached more of the population; health personnel are more autonomous and motivated, which
contributes to improved quality of care (22).
Conclusion
Burkina Faso and Bangladesh have similar populations in certain respects and face similar
challenges in improving their respective healthcare systems. Despite spending more money and resources
on health, Burkina Faso has worse infant and under-five mortality rates than Bangladesh (see Table 1).
These differences in health outcomes can possibly be explained by differences in addressing rural
populations, financing health care, and health system structure.
Burkina Faso focused on increasing overall numbers of clinics and doctors, uses demand-side
financing and requires patients to pay for medications and services, and has a very centralized top-down
structure to its health system. Bangladesh directly addressed the healthcare needs of the rural population,
uses supply-side financing and works with providers to help finance care, and has a more cooperative,
bottom-up structure to its health system. While there is still room for improvement in healthcare in
Bangladesh, Burkina Faso could learn from Bangladesh to more effectively address their population’s
healthcare needs and reduce infant and under-five mortality.

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