Document 6423328

 Final Report On End-­‐Line Evaluation of Health, Nutrition and Population Sector Programme (HNPSP) Implementation Monitoring and Evaluation Division (IMED) Ministry of Planning September 2011 FOREWORD The Evaluation Sector of Implementation Monitoring and Evaluation Division (IMED), Ministry of Planning was assigned to conduct the End line Evaluation of Health, Nutrition and Population Sector Programme (HNPSP) (2003-­‐2011) under the Ministry of Health and Family Welfare (MOHFW). The broad objective of this end line evaluation was to identify the successes and failures of HNPSP operation and suggest recommendations for more pragmatic and effective implementation of the programme. Findings from the study have shown that some positive impacts in health indicators-­‐ maternal and child mortality, nutrition status and poor man's access to health care services. The findings also show that the programme is still infested with procedural problems of fund release, lack of harmonized efforts amongst concerned ministries, non functional integration, chronic shortage of manpower/medical personnel, drugs and equipments at different health facilities from district level to the rural levels, lack of proper monitoring and supervisory supports towards field personnel. A team of Consultants hired by IMED, have meticulously investigated into the major issues of this gigantic programme and suggested a lot of pragmatic policy recommendations. We are very fortunate to have MM Reza, the former health Secretary as the Team Leader for the end-­‐line evaluation of HNPSP programme. He with all his expertise and proven professionalism-­‐ has persistently led other members of his team to complete the study despite stringency of time and resource. I also highly congratulate Syed Md. Haider Ali, DG, and Evaluation Sector along with his colleagues for their whole-­‐hearted efforts to provide logistics support and other technical assistance to the Team of Consultants and help the finalization of the Report on time. I hope that all the concerned Ministries and agencies of the Government and other concerned organizations will find the recommendations of this end-­‐line evaluation report useful and pragmatic for improving the performance of the next health sector programme (Md. Habib Ullah Majumder ) Secretary IMED, Ministry of Planning ii PREFACE Health, Nutrition and Population Sector Programme (HNPSP-­‐2003-­‐2011)-­‐ a second sector programme was adopted by the Government in the Ministry of Health and Family Welfare (MOHFW) which comprised of 38 Operational Plans (OP)-­‐ each being implemented by One Line Director. This programme was a follow-­‐up of the first sector programme introduced in 1998-­‐ called the Health and Population Sector Programme (HPSP). The HNPSP programme has been implemented with an investment cost of Taka 16 thousand crores. The Evaluation Sector of Implementation Monitoring and Evaluation Division (IMED), Ministry of Planning has been requested by MOHFW to carry out the end-­‐line evaluation of HNPSP at a cost of taka 25 lakhs only within four months from June to September 2011. The major assignments for this evaluation study was to look into the implementation status of some of OPs, fiduciary arrangements, improvement in health indicators, poor man's access to health services, clients and service providers notions about HNPSP, strengths and weaknesses of HNPSP and recommendations related to HNPSP issues etc. Both qualitative and quantitative approaches were adopted to collect information through review of huge numbers of documents and policy papers, consultative meetings with stakeholders at national and field level MOHFW officials and other concerned, FGD with 7 homogeneous groups, Observation of 56 health facilities from district hospitals to union level health facilities and interviewing of 490 patients who sought health services. Findings from the study have indicated that HNPSP as programme approach proved more cost-­‐effective than the earlier projectised approach of health and family planning services. Major health indicators like maternal mortality, child and infant mortality, population growth rate, CPR, immunization rate, TB case detection and cure rate or even the sero-­‐surveillance rate for HIV-­‐AIDS etc. showed remarkable performance during the programme period and gained international recognition. During the long HNPSP period, the performance of service delivery-­‐ both MCH and public health-­‐ improved, after initial slow take-­‐off. Utilization of facilities at District and levels below increased without increase in financial investment. However, the findings also show that the programme is engulfed with fund release problem, lack of coordinated efforts to work together by all the concerned sectors/directorates and agencies of the Government, more centralized and disintegrated functionaries with acute of shortage of manpower, lack of monitoring and supervisory supports from higher authority to lower level field personnel. The team of Consultants have meticulously investigated into the major issues of this vast programme and suggested a lot of pragmatic policy recommendations. We are very grateful to Mr. MM Reza, the former health Secretary for being the Team Leader for conducting the end-­‐line evaluation of HNPSP programme. He as a veteran programme expertise -­‐ invested much of his time and energy and got all of his team members effectively involved to get this report completed despite tight time-­‐
schedule and limited budget. I would also like to congratulate concerned officers of Evaluation Sector, consultants of the evaluation team and also the field interviewers for their painstaking efforts to conduct interview with the beneficiaries, observe the health facilities, FGD meetings and in-­‐depth discussion with medical professionals at field levels. Thanks are also due to all Technical and Steering Committee and Working Committee members especially to the Secretary, IMED for providing us constant guidance and taking persuasive efforts to help us to get information feedback and responses from concerned ministerial officials and stakeholders. I hope that the lesson learnt and recommendations that are made would be useful to further improve the overall HNPSP performance if duly incorporated in the different OPs and implemented by the concerned programme officials and managers with committed efforts. (Syed Md. Haider Ali) Director General Evaluation Sector, IMED Ministry of Planning iii ABCN ADB ADP AIDS AMC ANC APR APIR ARI BBS BBC BDHS BMDC BMMS BNC BNNC BRAC BSMMU BRAC BUET CBO CBR CCC CPU CCMG CDC CDR CGA CHCPs CHT CME CNO CNP COPD CPR CPTU CS CSBA CWM DDA DFID DG DGFP DGHS DMIS ABBREVIATIONS Area Based Community Nutrition Asian Development Bank Annual Development Programme Acquired Immune Deficiency Syndrome Alternate Medical care Antenatal Care Annual Program Review Annual Programme Implementation Report Acute Respiratory Infection Bangladesh Bureau of Statistics Behavioral Change Communication Bangladesh Demography and Health Survey Bangladesh Medical and Dental Council Bangladesh Maternal Mortality Survey Bangladesh Nursing Council Bangladesh National Nutrition Council Bangladesh Rural Advancement Committee Bangabandhu Sheikh Mujib Medical University Bangladesh Rural Advancement Committee Bangladesh University of Engineering and Technology Community Based Organization Crude Birth Rate Community Clinic Climate Change and Promotion Unit Community Clinic Management Group Communicable Diseases Control Crude Death rate Comptroller General of Accounts Community Health Care Providers Chittagong Hill Tracts Centre for Medical Education Community Nutrition Organizer Community Nutrition Promoter Chronic Obstructive Pulmonary Diseases Contraceptive Prevalence Rate Central Procurement Technical Unit Civil Surgeon Community Skilled Birth Attendant Clinical Waste Management Directorate of Drug Administration Department for International Development (UK) Director General Director General of Family Planning Director General of Health Services Data Management Information System DNS DOTS DPs Directorate of Nursing Directly Observed Treatment-­‐Short Course Development Partners iv DPA DSF ECNEC EGV EDPT EmOC/EOC EMP EPI EP&R ESD ESP FMAU FMR FP FWA FWV FWVTI FY GFATM GMP GOB HA HDS HED HEU HFS HFWC HIV HNP HNPSP HPSP HPN HR HRD IDA IEC IEDCR IEM IHSM IMCI IMR IPHN IPH ICT IDH IT ITMN IUD/ICD IYCF JCS JC JS LD LLP MA Direct Project Aid Demand Side Financing Executive Committee of National Economic Council Equity Gender and Voice Early Diagnosis and Prompt Treatment Emergency Obstetric Care Environmental Management Plan Expanded Programme on immunization Emergency Preparedness and Response Essential Service Delivery Essential Service Package Financial Management and Audit Unit Financial Management Report Family Planning Family Welfare Assistant Family Welfare Visitor Family Welfare Visitor Training Institute Financial Year Global Fund for AIDS Tuberculosis and Malaria Good Monitoring and Promotion Government of Bangladesh Health Assistant Health and Demographic Survey Health Engineering Department Health Economics Unit Health Facility Survey Health and Family Welfare Centre Human Immunodeficiency Virus Health Nutrition Population Health Nutrition And Population Sector Programme Health and Population Sector Programme Health Population Nutrition Human Resource Human Resource Development International Development Agency Information Education and Communication Institute of Epidemiology, Disease Control and Research Information Education Motivation Improved Hospital Service Management Integrated Management of Childhood Illness Infant Mortality Rate Institute of Public Health Nutrition Institute of Public Health Information Communication Technology Infectious Diseases Hospital Information Technology Insecticide Treated Mosquito Net Intra Uterine Contraceptive/ Device Infant and young Child Feeding Joint Cooperation Strategy Joint Chief Joint Secretary Line Director Local Level Planning Medical Assistant v MATS M&E MEU MCH MCRH MCWC MDGs MDR MICS MIS MNCH MOWCA MOE MOF MOHFW MOLGRDC MSA MTEF/MTBF MTR MWM NASP NCD NEMEW NGO NIO NIDCH NIPORT NIPSOM NMR NNP NRR NSP NTC NWT OP OPD PA RPIP SWAp USAID VAW WATSAN WB WHO WID Medical Assistant Training School Monitoring and Evaluation Monitoring and Evaluation Unit Maternal and Child Health Maternal Child and Reproductive Health Maternal and Child Welfare Center Millennium Development Goals Multidrug Resistance Multi Indicators Cluster Survey Management Information System Maternal Neonatal & Child health Ministry of Women and Children Affairs Ministry of Environment Ministry of Finance Ministry of Health and Family Welfare Ministry of Local Government Rural Development and Cooperatives Management Support Agency Medium term Expenditure/ Budget framework Mid Term Review Medical Waste management National AIDS STD Programme Non Communicable Diseases National Electro Medical Equipment Workshop Non Government Organization National Institute of Ophthalmology National Institute of Diseases of Chest and Hospital National Institute of Population Research and Training National Institute of Preventive and Social Medicine Neonatal Mortality Rate National Nutrition Programme Net Reproduction Rate Nutritional Services Programme National TB control Programme National Working Team Operational Plan Out Patient Department Project Aid Revised Programme Implementation Plan Sector wide approach United States Agency for International Development Violence Against Women Water and Sanitation World Bank World Health Organization Women in Development . vi CONTENTS Foreword Preface Abbreviations Executive Summary Pages ii iii iv-­‐vi xi-­‐xii 1.4 1.5 Part -­‐I Introduction Background : Sector-­‐Wide Approach SWAP In The Context Of Political Changes Socio-­‐Economic Context : Changes During The HNPSP Implementation Period Terms Of Reference For The End-­‐Line Evaluation Of HNPSP Methodology And Limitation 2.1 2.2 2.3 2.4 Main Features Of HNPSP Goal, Purpose And Aim Of HNPSP Components Of The Programme Reform Agenda Boundary of HNPSP as a Sector-­‐wide programme 6 Management Of Programme Implementation Structure Of Implementation And Co-­‐Ordination Monitoring And Review Of HNPSP Assessing Achievement of Priority Objectives -­‐ How Pro-­‐poor was the Impact Strengths And Weaknesses Of HNPSP Recommendations 11 20 Chapter1: 1.1 1.2 1.3 1 Chapter 2: Chapter 3: 3.1 3.2 Chapter 4 : Chapter 5 : Chapter 6: 31 37 Part II Chapter 7 : 7.1. Reports On Selected Operational Plans I ) Operational Plans On Service Delivery: Service Delivery OPs-­‐ DGFP A) Clinical Contraception Service Delivery Programme B) Family Planning Field Services Delivery Programme. C) Maternal, Child And Reproductive Health Services Delivery Progrmmme 39 41 46 48 7.2 Operational Plan On Service Delivery -­‐ MOHFW: A) Nutrition : NNP And Micronutrient Supplementation Operational Plans On Service Delivery-­‐ DGHS B) Essential Services Delivery C) Improved Hospital Services Management 67 79 92 vii II ) Operational Plans On Support System-­‐ 7.3 Human Resource Management And Capacity Development. 7.4 Operational Plans On : A) Improved Financial Management B) Procurement. Logistics & Supply Management 104 111 123 Chapter 8: 8.1 8.2 8.3 8.4 Part III Findings Of Field Surveys And Investigation Findings From Observation And Record of Health Facility. Findings From Face To Face Interview With The Service Recipients Findings From FGD Meetings With 7 Homogeneous Groups Findings From Consultative Meetings With The Service Providers and Key Stakeholders 130 135 138 140 145 viii List Of Tables Table 4.1 Table 7.1.2 Table 7.1.3 Table 7.1. 4 Table 7.1.5 Table 7.1.6 Table 7.1.6 Table 7.1.7 Table 7.1.8 Fertility, Family Planning, Reproductive Health and Nutrition By Wealth Quintile :Bangladesh 2004-­‐2010 Planned Target :Projection for MC& RH Services Proposed Actions for inclusion in the area of MNCH in OP July 2008-­‐June 2010 Recommendation for MNCH and FP Physical Performance of Long Acting /Permanent Methods of Family Planning: 2005-­‐
2011 Physical Performance of Operational Plan CCSDP : 2003-­‐2011(8 Years): Financial Performance of Operational Plans Under DGFP: 2003-­‐2011(8 Years) Fertility, Family Planning and Reproductive Health Services: 1993 -­‐2010 23 48 51 54 58 59 60 60 62 Progress in Maternal, Neonatal and Child Health, Family Planning, and MDG4 and MDG5 During HNPSP. Table 7.2.1: Table 7.2. 2 Table 7.2. 3 Table 7.2.4 Table 7.2.5 Table 7.2.6 Table 7.2.7 Table 7.2.8 Table 7.2.9 Table 7.2.10 Table 7.2.11 Table 7.2.12 Table 7.2.13 Table 7.2.14 Year wise Progress Report in some core service indicators based on MPR (APIR -­‐ 2010) Facility Health Information System Mother and Children indicators of NNP. (APIR 2010) Prevalence of malnutrition among the under <5 children (Year 2000 to Year 2008) Coverage of pregnancy care MIS-­‐DGHS Coverage of Newborn and young children services from (Years 2004 to 2009) Prevalence of anemia in Bangladesh MIS-­‐DGHS 2009 Utilization of Essential Service Delivery (UESD) Survey 2010 Emergency obstetric care facilities in 2009, DGHS-­‐MIS Types of birth-­‐MIS DGHS 2010 Economic Evaluation of some ESD indicators (APIR 2010) Status of DSF used by permanents Progress in Implementation by training of staff and by service delivery: Priority activities and overall progress of IMCI (MIS-­‐DGHS 2010) 70 71 72 73 73 74 79 82 84 85 85 86 86 87 Table 7.2.15 The achievements in reproductive and limited curative care (MDG targets and indicators, MIS-­‐DGHS 2010) Improvement in Reproductive health: BMMS – survey 2010 Disease pattern in children aged 0 to 59 months as a part of IMCI, (MIS-­‐DGHS-­‐2010). HNPSP priority objectives achievements (APIR 2009). Upozila Health Complexes by Bed occupancy rates from 2005 to 2009 (MIS-­‐DGHS 2010) Average daily attendance and bed occupancy Secondary and Tertiary Level Hospitals Number of admissions, deaths and out-­‐patient visit in different types of health facilities (Health Bulletin 2010, MIS-­‐DGHS) Progress in manpower indicators APIR 2010 Progress in Training and research (IHM) APIR 2010 Progress in capacity building indicators Distribution of OPD patients in different health care facilities. DGHS-­‐MIS, Health Bulletin 2010 Number of Sanctioned, filled up and vacant posts ( MIS-­‐DGHS 2010) 89 Budget allocation for HRM OPs Estimated Expenditure by 3 HRM OPs Summary of Approved budget for HNPSP (2003-­‐2011) by sources of financing Summary of Approved budget and Expenditure Statement of HNPSP (2003-­‐ 2011) Observation Regarding Financial Matters at Health Centers ( Zila Hospital / MCWC / UHC and UHFWC) : Average Number of Patients Served the day before the survey by Health Facility Average Numbers of Patients Served From 7 MCWCs by years -­‐Wise (2003-­‐2011) Average Numbers of Patients Served From 7 MCWCs by years -­‐Wise (2003-­‐2011): 106 107 115 118 136 Table 7.2.16 Table 7.2.17 Table 7.2.18 Table 7.2.19 Table 7.2.20 Table 7.2.21 Table 7.2.22 Table 7.2.23 Table 7.2.24 Table 7.2.25 Table 7.2.26 Table 7.3.1 Table 7.3.2 Table 7.4.1 Table 7.4. 2 Table: 8.1.1. Table: 8.1.2. Table: 8.1.3 Table: 8.1.3 89 90 91 97 97 99 100 100 100 101 101 137 139 139 ix Table: 8.1.5 Table: 8.1.6 Table: 8.1.7 Table: 8.1.8 Table: 8.3.1 Table: 8.3.2 Table: 8.3.3 Table 8.3.4 Table 8.3.5 Table 8.3.6 Table 8.3.7 Fig 1 : Fig 2 : Fig 3 : Fig 4 Fig 5 : Fig 6 : Fig 7 : Fig :8 Fig : 9 Fig :10 Annex-­‐ A Annex-­‐ B Annex-­‐ C Annex-­‐ D Annex-­‐ E_1 Annex-­‐ E_2 Annex-­‐ F Annex-­‐G Annex-­‐ H Status of Sanctioned/ Filled in Post and Presence of Health/FP Service Providers on the 139 Day of Survey at the Zilla hospital. Status of Sanctioned/ Filled in Post and Presence of Health/FP Service Providers on the 140 Day of Survey at the MCWC. Status of Sanctioned/ Filled in Post and Presence of Health/FP Service Providers on the 140 Day of Survey at the UHC. Status of Sanctioned/ Filled in Post and Presence of Health/FP Service Providers on the 140 Day of Survey at the UHFWC (n=28) Responses of 14 number of Teachers at Gurudaspur Union from FGD Meetings 141 Responses of 12 number of Youth Leaders at Kulaura from FGD Meetings 142 Responses of 14 number of Male Patients at Tongi UHC from FGD Meetings 143 Responses of 12 Female Patients at Dagonbhuyian from FGD Meetings 143 Responses of 12 chairman/members at Lalmohon UHC from FGD Meetings 144 Responses of 12 Private medical practitioners at Monirumpur UHC from FGD Meetings 144 Responses of 12 number of farmers at Mithapukur from FGD meetings 145 75 76 76 List of Figures Status of malnutrition among <2 yrs. children Pregnant Women under SF <2 yrs. children SF Low Birth Weight ( LBW) Pregnancy Weight Monitoring % of Pregnant Women referred for ANC EBF, CF & Colostrums feeding rate in NNP Areas Present Planning Procedures Forex Accounts -­‐-­‐ Fund Flow Fund Flow Arrangement List of Annexes A Note on Sample Size and Spots. Evaluation Team, Steering Committee, Technical Committee and Working Committee Distribution of Tasks Assigned to Consultants Indicators with Benchmark, Targets and Achievements of HNPSP Priority Objectives as in Table-­‐ I RPIP, 2008 List of Key Stakeholders Consulted List of Service Providers consulted at the field levels. Comparative statement of budget of original approved PIP of HNPSP (2003-­‐
2006), approved first revised PIP of 2003-­‐2010 and the proposed 2nd revised PIP of 2003-­‐2011 Approved Costs and Estimated Expenditures of HNPSP by 38 OPs Data Collection Instruments References: x 76 77 77 78 114 115 116 164 167 170 171 172 174 176 177 189 Executive Summary 1. The Report presents the End-­‐line Evaluation of HNPSP as per TOR prepared by the Evaluation Sector of IMED. HNPSP is the second sector-­‐wide programme of the Ministry of Health and Family Welfare and continued from 2003 to 2011. The implementation of the Programme involved three separate governments: (1) from 2003 to end-­‐2006, (2) from 2007 to end-­‐2008, and (3) from 2009 to June 2011. Implementation picked up from 2007 after the Annual Programme Review diagnosed HNPSP as a patient needing intensive care under the threat of becoming terminally sick. This prompted even the-­‐
then Chief Adviser's Office (of the care-­‐taker government) to establish monthly monitoring of the Programme. A mid-­‐term review of HNPSP was done in 2008 followed by revision of the Programme Implementation Plan (PIP) and that of all the 38 OPs for the remaining period. In view of the expenditure patterns, it was decided to extend the HNPSP for an additional year i.e. upto June 2011, (sec. 1.1). 2. In line with its TOR, the End-­‐line Evaluation attempts to assess how far HNPSP has been able to achieve its declared goals and targets, to identify its strength and weaknesses and to offer recommendations for 'more pragmatic and effective implementation of the Programme' (sec 1.4). 3. Both quantitative and qualitative data have been used in preparing the Report. Annual Performance Review (APR) reports and a considerable number of periodic national surveys and occasional reports provided the secondary material which has been supplemented by the findings of a quantitative survey, FGDs and intensive qualitative interviews with the stakeholders. The findings of the field survey and interviews are placed at Part III of the Report (sec. 1.5). These are in broad agreement with, and supportive of, the findings of the national level surveys and affirm quite high level of user's satisfaction with HNPSP services. 4. Part II of the Report contains studies on a number of Operational Plans prepared by 4 Consultants covering some of the major OPs dealing with (a) services delivery and with (b) the services delivery support systems. The service delivery OPs include 3 from DGFP: Clinical Contraception Service Delivery Programme, Family Planning Field Services Delivery Programme and the OP on Maternal, Child and Reporductive Health Services Delivery Programme. 2 OPs from DGHS have been covered: OPs on Essential Services Delivery and Improved Hospital Services Management. In addition 1 OP on Nutrition has been included, so that 6 OPs related to service delivery have been covered. The following OPs on Service Delivery Support System have been covered by the Consultants: 3 OPs on human resource management along with the investments on xi capacity development, spread over a large number of OPs and 3 OPs on Public Financial management and 2 on Procurement (Chapter 9). These Reports are also accompanied by an Executive Summary. 5. The Report presents an assessment of the major impact indicators (Ch.4 and Annex-­‐ D) which shows considerable improvements in health outcomes both for the achievement of MDG and PRS goals: reduction of maternal and child mortality, reduction of malnutrition and TFR, improvements in: CPR, Vit-­‐A supplementation, women receiving ANC & PNC, delivery at health facility, assistance by medically trained provider during delivery and the nutritional status of women and children etc. TB case detection and cure rate was higher than targeted, while HIV-­‐AIDS had remained low in coverage. The poor performed better thereby reducing the gap with those in the highest quintile, though the remaining gap is still very substantial. 6. It is however not possible to apportion these improvements to health sector interventions or specifically to HNPSP alone. A number of socio-­‐economic factors seem to have influenced the outcome (sec 1.3). Moreover, the HNPSP represented only a part of the resources being invested in the health sector: it did not include the non-­‐public sector; neither did it include all the resources of the MOHFW. Infact, it did not even include all the development budget interventions of the Ministry: e.g. 11 development projects in ADP (2010-­‐2011) including the project on Revitalization of the Community Clinics were outside its purview. In view of its limited boundary, it will be unrealistic to assign the national health outcomes to effects of HNPSP. However there is an international recognition that Bangladesh must have been doing something right to achieve the improvements in health status. 7. The Report has specifically focused on the structure of implementation and co-­‐ordination in HNPSP (sec. 3.1), with coverage of its monitoring mechanism (sec. 3.2). The planning, processing and approval of OP, the role of the Line Director and the various monitoring mechanisms like APR, APIR, Stakeholders Consultation, the monthly co-­‐ordination meetings etc. have been highlighted with notes on lessons learnt and suggestions (section 3.2.4). 8. Strength and weaknesses of HNPSP-­‐both structural and operational-­‐have been identified (Ch. 5) with recommendations linked to the weaknesses (Chapter 6). The four Reports on the OPs at Part II also include analysis of weakness and strength with recommendations for those OPs. xii Director General Evaluation Sector IMED. Subject: Submission of Final Report on End-­‐line Evaluation of HNPSP Kindly find attached herewith the Final Report on End-­‐line Evaluation of HNPSP. The draft final report submitted earlier has been revised in the light of decisions taken in the Steering Committee meeting held on 22.09.11. The Evaluation Team acknowledges with thanks and gratitude the support provided to it during the assignment and the courtesies extended to it personally by Syed Haider Ali, D.G. Evaluation Sector, IMED. ( M.M. REZA) Team Leader xiii xiv Part I Chapter-­‐ 1 Introduction 1.1 Background: Sector Wide approach Health, Nutrition and Population Sector Programme (HNPSP) (2003-­‐2011) is the second sector programme adopted by the government in the Ministry of Health and Family Welfare (MOHFW). It followed the first sector programme introduced in 1998-­‐ called the Health and Population Sector Programme (HPSP). The Sector-­‐wide approach (SWAp) saw the end of the projects-­‐based development interventions in the health sector and signaled the transition from more than 120 projects in the earlier 5-­‐ year programme to a single consolidated sector programme. In the SWAp MOHFW proposed to be in the driving seat identifying the goals and objectives of the Government in the health sector and devising strategies and programme of actions to meet the goals /objectives so identified. This was in contrast to the donor-­‐driven projects-­‐approach where each donor developed projects in the areas of their interest, leading to segmentation in the sector and to overlap and thereby misallocation and wastage of scarce resources. The Sector Programme attempted to combine the Government‘s own resources with those provided by the Development Partners (DPs) in the form of financial inputs and technical assistance. The draft 6th 5-­‐Year Plan has also proposed to continue with the Sector-­‐wide approach, which underlines continuity and consistency in methodology of planning and management in the health sector while allowing for adjustment and changes to reflect changing socio-­‐economic, epidemiological and demographic challenges. 1.2
SWAp in the context of Political Changes: The first SWAp-­‐ i.e. HPSP-­‐ was launched for implementation from July 1998 while a new Government led by the other major political party came to power in 2001, allowing less than 3 years for HPSP to roll out major reforms contained in HPSP e.g. the unification of health and family planning services, the introduction of a new tier of service-­‐provision at the ward-­‐level called the Community Clinic, the reorientation of resources to provide an Essential Services Package (ESP) directed towards the poor, women and children etc. The new Government however declared HPSP to have 'structural fault-­‐lines' and but for ESP, reversed all innovations introduced in HPSP by the earlier Government e.g. it cancelled the service unification, abandoned the community clinic programme and discontinued the hospital autonomy pilot etc. Those actions led to serious misunderstanding with the DPs to a point where the World Bank as the funds manager suspended all fund flows to MOHFW. It was in that environment that a 3-­‐
year HNPSP was adopted by MOHFW (1993-­‐96). However the Government developed a longer-­‐
term vision reflected in the Sector Investment Plan (SIP) which projected a ten-­‐year trajectory of the health sector’s priorities and strategies (2004-­‐2014). On the basis of SIP, MOHFW fleshed out HNPSP to continue till 2010. A Development Credit Agreement (DCA) was accordingly signed between GoB and the World Bank in 2005 to support HNPSP upto 2010. A no-­‐cost extension of the credit for one year (i.e. upto 2011) was agreed in 2010 extending the life of HNPSP to end-­‐ June 2011. It is worth noticing that here again the Government changed-­‐ in end-­‐
2006 -­‐-­‐allowing it very little time to implement HNPSP which had taken nearly two years to formulate, as was the case with the formulation of HPSP. Two years of non-­‐representative Government followed during which time the mid-­‐term review of HNPSP was done in 2008 and then a new Government was elected in Jan. 2009. The current Government has guided the Programme to its end on 30th June 2011 without reversing the main orientation of HNPSP. These political changes however resulted-­‐ for each political transition-­‐in change of personnel from those involved in policy guidance and monitoring at the centre to field-­‐level implementation, thereby affecting overall programme implementation. HNPSP started as a 3-­‐
year sector programme (2003-­‐2006), was revised after signing credit agreement with the World Bank in 2005 as HNPSP (2003-­‐2010) and then it underwent a second revision in 2008 which also extended HNPSP upto 30 June 2011. Thus one Government developed the Programme while three Governments had been involved in its implementation, with varying priorities, as captured in the Annual Programme Reviews (APR) conducted by Independent Review Team (IRT) in 2006, 2007, the Mid Term Review( MTR) in 2008 and the APR in 2009. The last Review conducted in 2010 was described as ‘light-­‐touch APR’ allowing MOHFW to concentrate on the development of a new sector programme scheduled to be implemented from July 2011 for the next five years (called HPNSDP 2011-­‐2016). 1.3.
Socio-­‐economic Context: Changes during HNPSP implementation period. The programmes of health interventions in HNPSP were undertaken for implementation in the context of socio-­‐economic changes taking place in Bangladesh. It is relevant to recognise that the health outcomes are being affected by these contextual changes while also contributing to these changes. We will point out some of the key socio-­‐economic changes which had taken place nationally during the HNPSP period and seem to have influenced its outcomes. 1.3.1 Economic growth and reduction of poverty: Bangladesh economy has consistently registered growth of around 6 per cent during the last decade. This growth is shared by the rural population also and has led to substantial reduction of poverty in the country. The recently published (preliminary) findings of the Household Income and Expenditure Survey ( HIES) 2010 conducted by the Bangladesh Bureau of Statistics found that the average monthly household income has increased by more than 59 per cent ( to Tk. 11,480 in 2010 from Tk. 7,203 in 2005) between 2005 and 2010. Remarkably the household income at the rural level also increased by 58 per cent during that period-­‐ almost at par with the national average. It is significant that this growth in average household income has been accompanied by impressive reduction in poverty-­‐ from 40 per cent in 2005 to 31.5 per cent in 2010. Moreover, the regions which contain poverty pockets in Bangladesh registered higher rates in reduction of poverty than the national average e.g. while the average rate of reduction of poverty per annum during 2005 to 2010 was 1.7 per cent, it was 3.1 per cent in Rajshai Division (which includes the Rangpur figures), 2.72 per cent in Khulna Division and 2.52 per cent in Barisal Division! The above findings have obvious implication for health and nutrition outcomes achieved during the period covered by HIES Survey 2010. 1.3.2 Reduction of illiteracy and spread of female education: Impressive gains have been achieved in the reduction of illiteracy, coverage of primary education and especially in the spread of female education throughout Bangladesh, thanks to the consistent and innovative interventions by the Government as well as the NGOs. Coupled with higher income and better connectivity, this is contributing to increase in health-­‐seeking behaviour in the public and in the expanding private sector health-­‐services. 1.3.3. Increased connectivity: Physical infrastructural growth is making it easier to move from one place to another, making it possible to seek services e.g. health, education, banking etc, much more easily compared to past. Mobile telephony is facilitating access to information and intercommunication thereby enabling final_report_hnpsp 2 decision-­‐ makers in the family to access needed/ better health services. A virtual revolution is taking place in communication, breaking down access barriers except in a few hard-­‐to-­‐reach areas. 1.3.4 Empowerment of Women. Social barriers are also eroding in the face of increasing empowerment of women due to the socio-­‐economic factors mentioned earlier as well as due to social pressure created by economic and political decisions of the Government as well as due to NGO and civil society activism. A resurgent mass media-­‐ Press, TV etc. with awareness of trends in the world outside is also contributing to defence of human rights and to social empowerment of the citizens, including empowerment of women. Empowerment of women appears to be playing a critical role in awareness-­‐raising about health issues and health-­‐seeking behaviour, among other behavioural changes. Terms of Reference for the end-­‐line evaluation of HNPSP. The objective of this evaluation is to identify the successes and failures of HNPSP operation and suggest recommendations for more pragmatic and effective implemenation of the programme. Within that broad objective, the following have been included as part of the Terms of Reference (ToR): I. review of financial management, disbursement, procurement and contract management arrangements under HNPSP; II. review of the management and implementation of major components (operational plans) of the HNPSP; III. assess the functional status of capacity development; IV. assess the satisfaction and notions of the field level personnel and beneficiaries towards the HNP services; and V. assess the impact of HNPSP programme/services so far achieved on reduction of maternal and child mortality, reduction in malnutrition, TFR and population growth rate and improvement in access of the poor to health care services. The Evaluation Team would also like to assess how far HNPSP was pro-­‐poor which was one of its major stated goals. We would also throw light on the management aspects of programme implementation, especially its policy co-­‐ordination, monitoring and supervision aspects. Methodology and limitations: 1.5.1
Methodology A detailed guideline as to methodology to be used was issued along with the ToR by the Evaluation Sector, IMED including both Qualitative and Quantitative methods. The Evaluation Team has also kept in view the Results Framework (RFW) containing indicators and their Means of Verification (MOV) which was built into HNPSP for monitoring progress of its implementation and for evaluation. The MOV of the impact indicators were identified in the RFW as the major national surveys like Bangladesh Demographic and Health Surveys (usually conducted every three years), Maternal Mortality Survey and Census data etc. The MOV for the process/output/ outcome indicators required conducting specific surveys for generating relevant data e.g. Utilisation of Essential Services Delivery (UESD) conducted usually every two years, the final_report_hnpsp 3 Facilities Utilisation Survey etc and other surveys determined by MOHFW and the DPs. In addition, different Annual Program Reviews (APR) succeeded in introducing other data sources for monitoring and evaluation e.g. stakeholder opinion surveys conducted by independent organisation ( like BIDS) or the Annual Programme Implementation Report( APIR) prepared by the Monitoring and Evaluation Unit of MOHFW-­‐ both the sets of information were to be available preceding the APR. The Mid-­‐term Review (MTR) of HNPSP conducted in 2008 led to revision of the performance indicators in the Results Framework in favour of more realistic and fewer indicators. The Team of Consultants has taken cognisance of the indicators in the Results Framework as well as the means of verification of the indicators identified therein. We have supplemented data generated so far through various Surveys by collecting primary data particularly for assessing both provider and recipient's satisfaction and for assessing health facilities. However, it needs to be emphasized that, unlike HPSP, no baseline survey was conducted for HNPSP with which the outcome of the currently conducted field survey could be compared to assess progress since the implementation of HNPSP. Keeping in view the objectives of the Evaluation ( Sub-­‐section 1.4) and the limitation pointed out, both qualitative and quantitative methods have been followed as detailed by IMED in the ToR and Evaluation Methodology. Qualitative Assessment: For Qualitative assessment of programme management and efficiencies, the following data collection methods were utilize: • Document search through HNPSP RPIP,Mid-­‐term Review Report 2008, Annual Programme Review (APR) 2009 , Annual Programme Implementation Report (APIR) 2010, Light Touch APR 2010, BDHS Reports, BMMS Reports, UESD Survey Reports, Health Bulletins, MIS Reports and other relevant documents. • Consultative meetings with Stakeholders: Secretary, MOHFW, DGHS, DGFP, Member, SEI Division, Division Chief, IMED, Joint Chief/Deputy Chief, Planning Wing, MOHFW, Line Directors/ PMS/DPMs, Consultant PPC, and the health team of the World Bank, Dhaka Office etc. At the Regional and local levels DDs, Civil Surgeons, MOs of MCWC, UHCs and UF&FWCs were consulted. • Observation Checklist and Document Review to assess facilities at service delivery points(District Hospitals, MCWCs, UHCs and UH&FWCc) • Focus Group Discussions (FGD) moderated by UNOs with seven homogenous group of stakeholders at the Upazila level. Each of the following formed a FGD group: (i) Male patients (ii) Female patients (iii) Private medical Practitioners (iv) Teachers (v) Community Youth Leaders (vi) Cairman/Members of Union Council and (vii) Farmers. Quantitative assessment: For Quantitative assessments of the programme effectiveness the data collection instrument used was semi-­‐structured Questionnaire for conducting • Client Exit Interviews at District Hospitals, MCWCs, UHCs and UH&FWCs and Beneficiaries Survey in the programme catchment areas of UHCs and UH&FWCs Service statistics as available and relevant have also been used. A separate note on sample size and the questionnaires used are placed at the Annex-­‐
-­‐A, along with information relating to the recruitment of field staff and their training. Details of the Evaluation Team, the Steering Committee, the Technical Committee and the 4 Working Committees by the Evaluation Sector, IMED are given at Annex -­‐-­‐ B. final_report_hnpsp 4 1.5.2.
1.6
Limitations of Methodology: i.
A detailed methodoligical guideline for the evaluation was provided to the evaluation team by the Evaluation Sector, IMED. ii.
Selection of the analysis of operational plans (OPs) was guided by the objectives of the ToR iii.
While comparing the aggreagate level indicators, some values were not available upto the terminal year of the programme iv.
In the field survey information on health facilites and service providers were based on small size. The evaluation team was constrained by time and budget to make such choice. This factor has to be kept in mind while interpreting the results. Composition of the team of consultants and distribution of tasks: A team of five consultants conducted the evaluation study. Their details and the distribution of tasks among them are placed at Annex-­‐-­‐C final_report_hnpsp 5 Chapter-­‐ 2 Main Features of HNPSP 2.1
Goal, Purpose and Aim of HNPSP The Health, Nutrition and Population Sector Programme (HNPSP) defined its main purpose as the following: “to increase availability and utilisation of user-­‐centered, effective, efficient, equitable, affordable and accessible quality of services for a defined Essential Service Package along with other related services. The goal was to -­‐-­‐ 'achieve sustainable improvement in health, nutrition and reproductive health including family planning status of the people, particularly of vulnerable groups including women, children, the elderly and the poor'. It also proposed to 'emphasise on reducing severe malnutrition, preventable mortality and fertility, promoting healthy life styles, and reducing environmental, economic social, behavioural and other leading risk factors and causes to human health with a sharp focus on improving the health of the poor and other vulnerable.' [Quoted from Sec. 5 'Goal, Purpose and Aim of HNPSP' , p1: RPIP, 2005] 2.1.1 Priority Objectives: RPIP 2008 mentioned the following as Priority Objectives, by which the success of HNPSP was to be measured : (i) reducding MMR (ii) reducing TFR, (iii) reducing malnutrition (iv) reducing infant and under-­‐five mortality, (v) redcing the burden of TB and other diseases and (vi) prevention & control of non-­‐communicable diseases inclulding injuries. 2.2
Components of the Programme HNPSP is arranged under 4 components as described in Schedule 2 of the Development Credit Agreement (DCA). 2.2.1 Component A : Accelerating achievement of Health, Nutrition and Population-­‐related MDGs and PRS goals; under which there were three sub-­‐components : 1. Reducing maternal, neo-­‐natal and childhood mortality and improving maternal and childhood nutrition. Following activities were specified: a) raising awareness of problems related to pregnancy and delivery, including the need for better maternal and early childhood nutrition; b) expand Skilled Birth Attendant pilot and scale up a national-­‐level SBA training and service program; c) strengthen Comprehensive Emergency Obstetric Care at UHC and MCWC and to increase the numbers of basic and comprehensive centers; d) provide health voucher programmes to increase demand for maternal and neonatal health services and insure against the costs of normal delivery by skilled providers and EOC. 2. Reducing total fertility to replacement level, with the following activities: a) carrying out public information campaigns to shift family planning use from short-­‐term to longer-­‐term and permanent methods, b) deliver selective outreach services to urban slums, hard-­‐to-­‐reach and low-­‐performing areas. final_report_hnpsp 6 3. Lowering the burden of Tuberculosis and Malaria and preventing and controlling HIV/AIDS, under which the following interventions were proposed: a) strengthen the National Tuberculosis Programme at all levels and including the activities in the non-­‐governmental organisations; b) carry out the Revised Malaria Control Strategy, along with community involvement and partnerships with NGOs and private sector; c) carry out services of HIV-­‐AIDS prevention programmes. 2.2.2 Component-­‐B : Meeting Emergency HNP Sector Challenges, under which there were 4 sub-­‐components. 1. Reducing injuries and improving emergency services, involving the following interventions: a) raise community awareness to improve road, water and industrial and awareness of domestic injuries, including burns and injuries due to violence; b) provide medical counselling and legal advisory services to women victims of violence; c) develop emergency care facilities, including those existing at upazila and districts; d) develop a policy for public financing of insurance against catastrophic treatment costs. 2. Prevention and control of major non-­‐communicable diseases (NCD) involving the following activities: a) assess NCD disease burden and estimate cost implications for supporting the poor; b) carry out public information campaigns to increase awareness of the risks of smoking, unhealthy diet and physical inactivity; c) establish a system for improved screening for the early detection of obesity, hypertension and diabetes; d) promote improved diagnosis and management for major NCDs; e) assess a system to public financing of Insurance against emergency treatment costs of NCD. 3. Urban Health Services Development, with the following activities: a) strengthen co-­‐ordination between DGHS, DGFP and municipal authorities; b) provide clinical staff to M/O Home Affairs for prison services; c) carrying out consultation with the stakeholders for developing an integrated urban health development plan; d) carrying out feasibility study for establishing a Centre of Excellence at the National Medical University. 4.
Improving HNP response to Disasters including the following : a) strengthen inter-­‐sectoral and intra-­‐sectoral co-­‐ordination; b) provide technical services and equipment for strengthening stock management; c) participate in the development of co-­‐ordinated risk managment plan. 2.2.3 Component C : Advancing HNP Sector modernizations under which there were three sub-­‐components : final_report_hnpsp 7 1. Public health sector managment and stewardship capacity; with the following specified activities: a) strengthen management skills within MOHFW including planning and monitoring, procurement, financial managment and audit, and training on information managment, reform management, aid managment and the managment of contracts with private and non-­‐governmental providers; b) establish an enhanced and co-­‐ordinated HNP managment information system; c) improve budget management through formal resource planning; d) provide technical advisory services; training and equipment to strengthen decentralisation and local-­‐level planning; e) strengthen capacity building at all levels on policy formulation, regulation, resource allocation, monitoring and performance managment. 2. Health Sector Diversification, which involved capacity building to make MOHFW and municipalities more active service purchases in partnership with NGOs and private providers. 3. Stimulating Demand for HNP Services, with the following activities: a) Carrying out programmers on communication, education and information strategies involving prevention, early detection and management of key health problems; and on the promotion of healthy life-­‐styles and behaviour; b) Supporting demand-­‐side financing for the essential services through piloting and scaling up successful pilots. 2.2.4 Component-­‐ D: Enhancing performance, through the establishment of annual performance-­‐based financing indicators agreed upon during the Annual Programmed Reviews (APR). To sum up, the components are inter-­‐linked. The first component focuses on service delivery in the domain of PHC and for achieving MDGs, the second component relates to developing policies and strategies to respond to changing disease burden due to ubanisation and aging of population, and the third component aims to address reforms and strategies to achieve better equity and efficiency in the HNP sector. The fourth ties up performance with financial rewards as a tool to introduce changes and reforms. 2.3 Reform agenda: HNPSP contained a large number of reform commitments for modernising the health sector and for improved service delivery. These included: (a) introducing outsourced new agencies from the private sector to support MOHFW in management ( like PSO and MSA etc) ; (b) decentralisation and local level planning; (c) service diversification for underserved population through outsourcing community clinics and union level facilities to NGOs/ private providers ; and (d) stimulating demand through piloting voucher programme or other demand-­‐side financing (DSF) initiatives to encourage institutional delivery. Many of these reforms needed agreement, support and participation of other Ministries of the Government for initiation and implementation e.g. the Ministry of Finance for all the above mentioned reform areas, the Ministry of Planning, as well as the Ministry of Establishment etc. It needed creation of new processes and exceptions to existing procedures of Government and a clear understanding that final_report_hnpsp 8 a SWAp demands different treatment from the project-­‐oriented processes built into the existing government system. The needed understandings were not obtained by MOHFW either before undertaking the reform commitments or during the subsequent implementation of HNPSP. As a result, the progress of implementation of HNPSP as a sector programme, in general and the reform commitments, in particular faced hindrances which were bound to affect the overall performance of the programme. Moreover, the reform commitments appear to have added to the complexity of an otherwise ambitious, widespread and complicated Programme, operating within a bureaucratic and centralised administrative structure. 2.4 Boundary of HNPSP as a sector-­‐ wide programme There is little doubt that HNPSP, despite its claim as the (health) sector programme, did not include all the programmes under implementation in the health sector. For example, it did not include the programmes implemented by the NGOs and by the private sector-­‐
both of which are considerable in size and variety and have been expanding over the years. Neither did HNPSP include all the public sector health interventions e.g., it did not include the urban heath programmes of MOLG or the considerable financial outlay of the M/O Social Welfare in health. The ADP document (for 2010-­‐2011) included a total of 38 projects under 'Health, Nutrition, Population and Family Welfare' sector under a number of Ministries. This included 21 investment projects and 13 TA projects plus 4 projects under Japanese Debt Cancellation Fund. HNPSP was shown as one of the 21 investment projects! In fact HNPSP did not even include all the financial resources of the MOHFW. Not merely did it not include all the resources under the Revenue budget of the Ministry, it did not either include all the resources of the development budget! Thus there were eleven (11) investment projects under ADP (2010-­‐2011) of MOHFW which lay outside HNPSP. So, HNPSP was neither sector-­‐wide nor MOHFW-­‐wide, a fact which was highlighted during the Mid-­‐term Review (2008) of HNPSP. In fact, it included most, but not all, the development projects, under the Ministry's 'development' budget. Thus a large project like the 'Revitalization of Community Clinics,' introduced in 2009, remained outside the HNPSP. It is therefore necessary to clearly indicate these limits of the boundary of HNPSP to be able to realistically assess its outcome. It is relevant to point out that the various Annual Program Reviews (APRs) of HNPSP did not limit themselves to the OPs of HNPSP but took a broader view in their evaluation and their assessment of achievement of targets. The targets, as set in the indicators of the Results Framework of HNPSP (2005) as well as those in the revised indicators (2008), however, reflected the heath sector as a whole, rather than the constraining boundary of HNPSP. Strictly speaking the indicators were not for HNPSP as such. The performance of the health sector, as measured by the various national surveys like BDHS, UESD or the Bangladesh Maternal Mortality Survey etc. had been assumed to be the performance of HNPSP for purposes of its evaluation. One has to be careful in attributing such outcome / impact to HNPSP, in view of its limited scope as described above. It is also relevant to recognise that a broader view of the health sector as a whole is meaningful within the wide socio-­‐economic context of the country (described in sub-­‐section 1.3) within which the health sector operates. To sum up, HNPSP is not a sector programme. It is neither a MOHFW-­‐wide programme. It included most, but not all, the interventions under the Development budget of the Ministry. On the contrary, both the size of the 'parallel' programmes outside the 'pool' final_report_hnpsp 9 funded programmes in HNPSP as well as the number of projects of the Ministry (MOHFW) outside HNPSP had increased in size compared to the earlier (first) sector programme (HPSP 1998-­‐2003). The sector porgramme in MOHFW, instead of increasing its inclusiveness, seems to be accommodating greater diversity in financing, planning and monitoring of programmes, thereby undermining the very rationale of the sector programme. It looks as if the Ministry is in two minds about following a sector-­‐wide approach-­‐with a clear drift towards increasing number of projects from the governments own development budget and accommodating larger DP investments outside the HNPSP pool fund. This appears to be guided more by expediency, rather than being a policy shift. Comments on this feature of HNPSP can also be seen at section 7.1 (6.2) final_report_hnpsp 10 Chapter 3 Management of Programme Implementation: 3.1 Structure of implementation, co-­‐ordination and monitoring. The components of HNPSP-­‐ described at Chapter 2-­‐ were translated into programme/activities through the Operational Plans (OP) -­‐ a total of 38 OPs. Each was planned and implemented separately. The quality and contents of an OP and the leadership of the concerned Line Director in charge of OP together shaped the way in which HNPSP objectives and targets were implemented in practice. 3.1.1 Operational Plan: 38 Operational Plans were adopted following approval of the Programme Implementation Plan ( PIP) by ECNEC. The list of OPs , approved cost, and estimated expenditure can be seen in Annex-­‐G. The Directorate of Health Services was the implementing authority of 19 OPs and the Directorate of Family Planning of 10 OPs while the Ministry of Health and Family Welfare (MOHFW) itself was in charge of implementation of 7 OPs. The Directorate of Nursing Services (DNS) and the Directorate of Drug Administration (DDA) implemented one OP each concerning their area of responsibility. Three of the OPs were common to DGHS, DGFP and MOHFW i.e. each of them implemented an OP on Sector-­‐wide Management, Human Resource Management and Improved Financial Management. In addition, 4 OPs were common to both DGHS and DGFP-­‐-­‐each implemented a OP on Education and Communication, Procurement and Supplies Management, Research and Development and on MIS. Like the other 31 OPs, these seven OPs were also implemented without any link to each other, even though they were implementing same/similar programme intervention across DGHS, DGFP and MOHFW (in the case of 3 out of 7 OPs mentioned earlier). These were implemented as stand-­‐alone programmes and no attempt was made to 'cluster' them even for the purpose of monitoring from the Ministry. Opportunity of getting a co-­‐ordinated picture of the seven programme areas which could have allowed MOHFW to get an overall view of the sector programme, did not therefore materialise. Even the MIS data were generated separately for the Health and the Family Planning Directorates, making it impossible for the Ministry to get a comprehensive view of total programme implementation. Key programme focus of HNPSP on areas like maternal and child health, reproductive health or nutrition got splintered over a number of OPs being implemented as separate programmes by the two Directorates and the Ministry depriving the focus areas the benefits of interaction and much-­‐needed cross-­‐ fertilisation. It also meant overlap and wastage as well as inefficiency in use of scarce human and material resources. Similarly, an area like human resource, which is vital for health services delivery, was splintered over more than half a dozen OPs: 3 OPs on Human Resource Management as mentioned earlier, 1 OP each on Pre-­‐Service education and In-­‐Service training, 1 OP on NIPORT and 1 on Quality Assurance. As a result, the Programme did not have any clear idea of the human resource issue, a matter which was highlighted in APR 2009. Multiple OPs encouraged ‘tunnel’ view, rather than a balanced comprehensive approach. 3.1.2. Effect of Stand-­‐alone OP: a case study. The structural inadequacy of HNPSP based on 'silo' like OPs (APR 2008) is exposed dramatically by the case of proposed construction related to 7 new medical colleges. The issue came up during the revision of OPs following the mid-­‐term review (MTR 2008). It was then pointed out that an Annex in the OP on Physical Facilities (under DGHS) contained, among other listed construction programmes, a reference to building new medical colleges when the PIP of HNPSP was originally approved by ECNEC in 2005! Various pressure groups lobbied for siting the construction of new medical colleges in the location of their own choice. The issue could have been discussed in and piloted by the OP on medical education (Pre service training), after a policy decision regarding human resource had final_report_hnpsp 11 been taken by the Ministry, which was not the case. A number of issues would have been relevant for such a policy decision: the need for producing more doctors in the public sector, its effect on the existing perverse ratio of doctor : nurse : technicians; how was the requirement for teachers and other supporting staff like nurses and technicians be met, considering the existing shortages; what would be the financial requirements for needed machinery and equipment for the colleges and the attached hospitals; how far the resource withdrawal needed for the new medical colleges and hospitals (for at least the next decade) going to affect the pro-­‐poor, pro-­‐
Primary Health Care orientation of HNPSP etc. None of the other related OPs reflected the needed activities or budgets e.g. the various OPs related to Human Resource, the OPs on Procurement to cover the needed equipments and machinery, the corresponding need to create new posts to run the medical colleges and hospitals attached to these (a long process involving the Ministry of Establishment and the Ministry of Finance). MOHFW has a Human Resource Development Cell, which could have dealt with the range of issues involved in the matter but was not involved. The Ministry was unfortunately forced to deal with a complicated situation, initiated by an innocuous entry in a list of constructions tucked away in the annex to the OP on Physical Facilities. The issue of construction rationally should have followed the Ministry's policy decision regarding tertiary level medical education vis-­‐a-­‐vis HNPSP. Moreover, the implications of such a decision once taken-­‐ had to be reflected in a number of related OPs e.g. procurement, pre-­‐service Education etc which was not done. On top of that it had implications for the Revenue budget which was not spelt out for the decision makers either! This case also raises an important relevant issue for the Government involving both MOHFW and the Planning Commission: the way in which OPs are approved and processed. 3.1. 3. Processing of OPs : Theoretically, OPs were finalised following approval of Programme Implementation Plan (PIP) by ECNEC. The PIP contained summary description of each OP along with their estimated budgets, which were fleshed out in greater details in the OPs after the approval of PIP. The Steering Committee in the MOHFW chaired by the Honourable Minister for MOHFW is the approving authority of the OP. Representatives from the Planning Commission, M/O Finance and other relevant Ministries are members of the steering committee. The Steering Committee approved the 38 OPs in 3/4 sittings-­‐-­‐ thus covering a large of number of OPs in each session. The same practice was followed in processing OPs during the earlier sector programme as well i.e. HPSP 1998-­‐2003. Under the circumstances, the Committee had little time to examine if the programme activities in the OP were consistent with the objectives and whether the resources budgeted for the activities were adequate to meet the targeted output. These crucial considerations were left to those who helped write the OPs at the beginning of HNPSP-­‐-­‐ a combination of programme management staff of the Line Directors in the office of the Director Generals, assisted by a handful of experts engaged in the programme preparation cell (called PPFT) and the half-­‐staffed Planning Wing of MOHFW. In view of tight time-­‐ schedule, the OPs were prepared in hurry and there was limited scope to critically examine internal consistency, logical framework and inter-­‐relations with other OPs or their implications for the Revenue budget or inter-­‐linkages with other relevant Ministries. This practice of hurriedly preparing detailed OPs created opportunities for incorporation of half-­‐baked programme/ activities like case of new medical colleges cited earlier. There are abundant examples of other such cases where buildings lie unutilised either because these have not been co-­‐ordinated with procurement of needed equipments / machinery and / or the placement of needed manpower or the provision of needed budgets. Box 1: Case of Moulvibazat District Hospital final_report_hnpsp 12 An example of mismatch resulting from planning OPs in isolation from each other is the case of Moulvibazar District Hospital undergoing upgradation from existing 100-­‐bed to 250-­‐bed. The construction of a new 3-­‐storey building to accommodate additional 150-­‐bed had been planned and completed under OP on Physical Facilities. A brand new hospital building had been lying completed from more than six months, because the requirement for equipment and machinery was not concurrently planned or implemented. Steps are now being taken to reflect the requirement for equipments and machinery needed for making the new facility operational in a separate OP (Improved Hospital Management) being drafted under the new Sector Programme, HPNSDP 2011-­‐2016. In all probability, it may take more than a year for the equipments to be supplied and installed so that the hospital building will remain unutilised for more than a year and a half after the completion of the physical structure-­‐ if everything works out well! In addition, provision will have to be made for manpower for running the newly created facility, which again will be a time-­‐consuming exercise. After a decade of Sector Wide planning (SWAp) in the manner as pointed out, it is urgently necessary to look into the existing procedure of processing of OPs so that more time and attention is paid for thorough and critical examination of the contents of OPs before these are approved by the Government.. Suggestion: The Planning Wing of MOHFW which currently is responsible for preparation of an OP could be assisted by any or all of the following: (a) by the Planning Commission, (b) by interested development partners: possibly through utilising the existing Task Groups/Working groups, or / and (c) by employing technical assistance, as was used during revision of PIP and OPs, following the Mid-­‐term Review in 2008. A concerted and intensive effort could help to make sure that the proposed detailed activities in the OP and the budget allocations reflect overall objectives of the Sector Programme are consistent with the Programme priorities and are internally consistent, so that it helps to produce feasible and efficient output. 3.1.4 Line Director: An Officer of the level of a Director was put in charge of implementation of a OP in the Directorate while a Joint Secretary including Joint Chief, Planning Wing was the LD. for the Ministry's OPs. In the case of OP on Policy Reform, the Secretary MOHFW himself was the Line Director. The LD was assisted by a Programme Manager (PM) and Deputy Programme Managers (DPMs) -­‐ their number depending on the size of a OP. The LDs and their support staff were usually drawn from the Revenue structure and were therefore carrying out additional tasks on the 'development' side. They were responsible for efficient implementation of various programme components down to the district, Upazilla, union and grassroot levels using the existing manpower and administrative structure. Their tasks involved monitoring and supervision, periodic reporting and routine MIS, maintaining accounts and preparation of reimbursement claims from the World Bank for expenditure of 'pooled funds', among other range of tasks. Theoretically the LD either helped in preparation of the OP or prepared the OP during its formulation, and also had played the same role while the OP was revised in 2008 after the Mid-­‐term Review (MTR) of HNPSP. But he was not provided with any extra human resource for any of these functions even though some of these needed special skills and training like fund management, budgeting and planning etc. Neither was he provided with formal training. Worse still, there were quick turnovers of LDs so that the new LDs did not have the benefit of accumulated experience of working as a LD. Attempt was however made, as per recommendation of an Annual Programme Review (APR 2007), to declare at least ten major OPs final_report_hnpsp 13 (the ones with big budget) as 'anchor OPs' to ensure that at least some of the major OPs could be led by LD without frequent changes. Even that attempt was only partly successful due to the peculiar administrative culture obtaining in the country regarding transfer of officers. There was no systematic arrangement for providing even a simple orientation to a new LD who had no previous exposure to the multifarious new functions he was supposed to co-­‐ordinate and lead. Not even a brochure or leaflet was prepared explaining the contents/ purpose of HNPSP during all these years of its implementation! As a result, many of those involved in implementation at the district level and below after so many years are not able to say what HNPSP stood for! The effect of multiplicity of OPs and of implementation agencies was made far worse by the ill-­‐
prepared LD leadership resulting in 'ownership crisis' for the Programme-­‐ a subject mentioned with considerable concern during APRs of 2006 and most loudly in APR 2007. The APR 2008 even suggested to take steps to publicise, HNPSP through adopting a meaningful communication programme but no concrete steps were taken by MOHFW to that end. 3.2. Monitoring and Review of HNPSP 3.2.1 APR: An Independent Review Team (IRT) conducted the Annual Programme Review (APR) of HNPSP first in 2006 and then for all subsequent years till 2009. The last APR, called ' light-­‐touch APR ' was conducted in 2010 by a group composed of representatives from local offices of the Development Partners and MOHFW officials. Reading through the reports of the APRs gives a picture of the progress of implementation of HNPSP over the years. Each APR Report, in addition to assessment of current situation, also contained identification of a Plan of Action for that year jointly developed with MOHFW officials. The next year's APR followed up on the implementation of the earlier year's suggested Plan of Action. The first two APRs-­‐ for 2006 and 2007 record dismal progress in implementation of HNPSP. Most worrying finding was the absence of ownership of HNPSP, not merely at the field level but even at the central level. While elaborate documentation was prepared as part of development of HNPSP (e.g. SIP, the HNP Programme etc.), the implementers including even some of the L.Ds and policy makers in the MOHFW were found to be not familiar with HNPSP and its main features. The APR 2007 assessment was a repetition of the finding of APR 2006 but with greater ferocity. It came to the conclusion that HNPSP as of Feburay 2007 -­‐ ''...was like a very ill patient in need of intensive care without which it is likely to become a terminally ill patient.'' The Mid-­‐term Review (MTR) of HNPSP -­‐ held mid-­‐way through the Programme in March 2008 recognised certain improvements in Programme implementation but yet came to the conclusion that HNPSP as a patient was ''.. still in critical condition but recovering. There is no life-­‐
threating situation anymore''. MTR and Follow-­‐up-­‐ It may be noted that there was change of Government in Bangladesh towards end-­‐2006, when a Care-­‐taker Government took over. The harsh and stark findings of APR 2007 jolted the then-­‐Government into action so much so that the Chief Adviser's Office started monthly monitoring of the implementation of the Action Plan recommended by the APR. This close monitoring from the Chief Adviser's Office continued through MTR 2008. MTR 2008 paid special emphasis on maternal health and nutrition and what needed to be done to address the urgent issues e.g. better co-­‐ordination between Health and Family Planning Directorates in their field activities, the need for a dedicated cadre of midwives, improved logistics and supply management etc. MTR 2008 also raised doubts about the usefulness of the approach of HNPSP with its focus on introducing a range of reforms. In fact, it suggested redesigning the Programme to emphasise on service delivery, rather than reforms in the interest of better achieving of Programme's main objectives of improving and extending access to service delivery. The MTR final_report_hnpsp 14 2008 also took steps to develop a more concise and usable set of indicators for the Results Framework and halved their numbers to 30 indicators. The MTR put fresh energy and orientation among the stakeholders-­‐ both GOB (MOHFW) and the DPs-­‐ and succeeded in infusing greater interest among the implementers and policy makers. These were reflected in the revision of PIP and the OPs in 2008 which followed the MTR. The Monitoring and Evaluation Cell under the Planning Wing of MOHFW also took steps to help LDs develop a set of indicators for the OPs in line with the change in indicators of HNPSP. This was the first time that such an exercise was done. APR 2009 followed up on the steps taken to implement the Plan of Action adopted in 2008 following MTR 2008 and also helped to develop a new Plan of Action for 2009 following a Policy Dialogue where MOHFW and DP representatives participated. Joint working groups set up around major Programme areas debated and decided upon the Priority Plan of Action during the Policy Dialogue. The Policy Dialogue following the IRT Report and the preparation of Priority Plan of Action became a regular part of the APR process and helped to concentrate the attention and effort of MOHFW and the stakeholders for taking accountable follow -­‐up action within the financial year. APR 2009-­‐ In line with the MTR's focus on a specific subject (e.g. maternal health), APR 2009 highlighted the issues regarding nutrition and recommended to abandon the National Nutrition Programme as a stand-­‐alone intervention and mainstream it within the existing structure of the two Directorates of Health and Family Planning. The recommendation was accepted by the Government and the new Sector Programme (2011-­‐2016) has reportedly taken follow-­‐up steps accordingly. APR-­‐ 2010-­‐ The Light-­‐ touch APR 2010, as its name implied, was a less ambitious activity than the APRs done earlier but took stock of the follow up on the Priority Plan of Action 2009, on the basis of which it 'identified a set of actions as the way forward.' Moreover, it specifically reviewed the performance of MOHFW in achieving six priority actions earmarked as indicators for qualifying for performance-­‐based financing for 2010 and recommended for release of funds, tied to performance-­‐based financing for that year. Effect of APRs-­‐ The provision of having annual APRs through an Independent Review Team composed of expatriate and local consultants/ specialists was designed to provide the stakeholders in the sector Programme-­‐both in the 'Pool Fund' and those outside it -­‐ a clearer appreciation and evaluation of the progress of implementation of HNPSP on an annual basis. The Policy Dialogue which followed-­‐ allowed them to participate actively in the adoption of future course of action. On the other hand, it allowed MOHFW to have a comprehensive view of the direction of the Programme as evaluated by an independent team and encouraged it to adopt a set of specific priority actions to keep it on track for the achievement of HNPSP targets. 3.2.2 : APIR: It needs to be pointed out that MOHFW had annually prepared its own assessment of the progress of implementation of various OPs prior to holding the APR to assist the Independent Review Team get their side of the story. These annual reports were called the Annual Programme Implementation Report (APIR). These were collated by the Monitoring and Evaluation Cell under the Planning Wing of MOHFW on the basis of report of progress of implementation by the Line Directors of each OP. The M&E Cell started producing APIRs since its inception in 2007 and the last APIR was produced for 2010. The APIRs provided uptodate information on the status of implementation, but did not provide analysis. Policy issues were also not discussed or raised in APIR. They had limited value in enabling the policy makers to take a coordinated view of the progress of the Programme, since it was targeted to feeding APR needs. final_report_hnpsp 15 3.2.3 Co-­‐ordination of Programme Implementation 3.2.3.1. MOHFW-­‐DP Co-­‐ordination : HNPSP provided for a number of agencies to help co-­‐
ordinate the Programme at the policy level: (a) HNP Co-­‐ordination Committee, (b) HNP Forum and (c) DP Consortium. The Co-­‐ordination Committee and the Forum were led by the MOHFW while the Consortium consisted of only the Development Partners involved in the Health Sector and was in effect the health component of the LCG-­‐ the forum of the DPs in Bangladesh. The Co-­‐
ordination Committee and the Forum dealt with the implementation issues in HNPSP and functioned as institutional mechanism for both MOHFW and the DPs to participate jointly in assessment of progress of implementation of the Programme and related management and policy issues. The DP Consortium aimed to co-­‐ordinate the position of the very large number of DPs in the health sector in order to have a common voice while interacting with MOHFW. The Consortium brought together DPs who were members of the 'Pool fund' and those who were outside the Pool i.e. providing parallel funds for programmes and activities in HNPSP. One of its main goals was to achieve harmonisation and alignment with government procedures and systems as per Paris Declarations on Aid Effectiveness. Unfortunately, the Consortium failed to live up to its promise, even though it met quite regularly. Harmonisation and alignment remained a pious wish. The Consortium even failed to arrange compliance from its members to its request for regular reporting to the Government about the activities or expenditure they were financing parallel to the 'Pool Fund'. The HNPSP Co-­‐ordination Committee and the Forum were active, more so since APR 2007. The senior officers of the MOHFW attended the Co-­‐
ordination Committee Meetings along with the selected representatives of the DPs to develop a shared perception of the implementations progress of the Programme. The Forum, originally set up to facilitate inter-­‐ministerial decision-­‐makings met without clear regularity, although it was supposed to meet quarterly. Neither of the fora however engaged in systematic policy review because there was little demand /need for policy discussions from either the Ministry or the DPs. 3.2.3.2 Development Co-­‐ordination Meetings and use of MIS : The Secretary MOHFW and the two DGs (of Heath and F.P Directorates) held monthly development Co-­‐ordination Meetings of all projects in the ADP which mainly included the OPs. The Secretary reviewed OPs above a fixed threshold (over 50 crore taka), leaving the rest of OPs to be reviewed by the Additional Secretary and the Joint Chief, Planning. The Ministry reviews were conducted on the basis of financial performance while at the Directorate level, use was made of MIS reports, supplemented by occasional field visits by the DGs. But the monitoring process was highly centralized, with the Divisional / District or Upazilla level managers having little discretion over resources (financial or human) or with no power whatsoever to bring in changes in Programme details or adjusting resources as per felt need. The MIS data were generated at the field level separately by the two Directorates and ended up for aggregation at the centre; at the field level, there was no mechanism for their analysis or use for Programme monitoring. 3.2.3.3 Task Groups: Four Task Groups were formed, as per recommendation in APR 2006 to assist the Ministry with in-­‐depth analysis in the fields of (1) Nutrition, (2) Monitoring and Evaluation (3) Financial Management and (4) Equity, Gender and Voice. A few more TGs were added in subsequent years. The TGs brought together MOHFW and DP experts and assisted in following up on the issues raised in the APRs, depending on the quality of membership. Some of the TGs were more active and productive than others. The potentiality of the TG as a forum of technical assistance to expedite the implementation of the large array of Programme activities in the Sector Programme could be better utilised in the next Programme by a more aware leadership of the TGs from MOHFW's senior management. 3.2.3.4 Programme Support Office and other innovation: PSO was a new institution created by HNPSP to assist the Secretary and the Joint Chief to establish and manage Technical final_report_hnpsp 16 Assistance needs to augment capacity in implementation of HNPSP. It was outsourced to a private company and consisted of five specialists: On Public Health, Procurement, Financial Management, Health Economics and Gender. The office of PSO started work in mid-­‐2007, even though it was planned to begin 2 years earlier. It provided significant support to decision making of the central management at MOHFW but found itself in tussle with existing institutions, once the leadership changed in the Ministry. Then afterwards, it could perform only as a lame duck. Institutional innovations are difficult to embed within a traditional administrative set-­‐up and in future, more thought could go into it before planning and investing in such initiative. Two other institutional innovations the: Management Support Agency (MSA) and the Performance Management Agency (PMA) were planned to assist in awarding contracts to NGOs and for their performance monitoring as part of the reform objective of making MOHFW a 'purchaser' rather than its traditional role as a 'provider' of health services. In spite of its contractual commitment, the MOHFW could not complete the process of appointing PMA. However the MSA could be appointed in late 2008 only and worked in a limited area relating to NGO selection for the HIV-­‐AIDS Programme and for NNP, but its key function i.e. outsourcing management of CCs and Union level facilities to non-­‐government providers, did not come into being, since the Government refused to go along that line due to changed political conditions in 2008-­‐09. These three outsourced agencies-­‐-­‐ PSO, MSA and PMA were part of the architecture of implementation mechanism as originally conceived in HNPSP (as per the DCA 2005) but played little fruitful role in implementation of the Programme. In the end, it remained an expensive experiment and left considerable ill-­‐feelings within MOHFW functionaries. 3.2.3.5 External Surveys: There was recognition among the designers of HNPSP that the existing monitoring and MIS system in use in MOHFW could not provide adequate and satisfactory input to the Managers of the Programme for its proper monitoring. It therefore provided for generating supplementary data through external surveys. Utilisation of ESD Survey was conducted every two years i.e. 2006. 2008 and 2010 with special emphasis on generating data regarding the service utilisation by the lower income quintiles. The Bangladesh Health Facility Survey was conducted in 2009 to assess health facilities at Districts and below, the condition of access and utilisation of services by different sections of the population including the poor and women as well to assess provider's satisfaction etc. It is designed to be repeated every two years. The Bangladesh Maternal Mortality Survey was conducted in 2010 and provided valuable insight into changes which had occurred since the last such survey was conducted a decade ago. These were in addition to the Bangladesh Demographic and Health Survey conducted every three years since 1993. 3.2.3.6 Stakkeholders Consultation Report-­‐ To supplement the supply-­‐side data generated by the available MIS and the above mentioned surveys, a Stakeholder's Consultation was conducted in 2007, 2008 and 2009 prior to the annual APRs to obtain the demand side picture from service recipients. It is however not very clear how the information generated by this Consultation was utilised by the Programme Managers or Planners. Nonetheless it provided the Independent Review Team conducting the APR a feel of the opinion of the service recipients-­‐
-­‐ particularly the poor and those living in hard to reach areas, even though this appeared to have little impact on the programme's content or its implementation (OP revisions which took place in 2008 and the third revisions of OPs which took place subsequently do not show any indication of taking cognisance of the Stakeholders Consultation reports). 3.2.4 Lessons learnt from monitoring implementation of HNPSP : a. What Worked: final_report_hnpsp 17 1) APR: APR conducted by Independent Review Team composed of expatriate and Bangladeshi Consultants was the key monitoring mechanism for assessing HNPSP progress annually, as discussed in details at sub-­‐section 3.2.1. This annual event energised MOHFW as well as the DPs-­‐ in preparing for the event, developing priority Plan of Action and following such plans through the various co-­‐ordinating forums mentioned at sub-­‐section 3.2.3. The APIR and the Stakeholders Consultation Reports were generated to feed into the APR. The Performance-­‐based Financing indicators would be fixed for the year following APR recommendations, which would require, MOHFW and its agencies to achieve those indicators to trigger fund release earmarked for PBF. The Task Groups were the outcome of recommendation of APR and actively participated in the APR and Post-­‐APR process. Thus the APR provided the major stimulus for the HNPSP implementation process and helped identify problems and obstacles, with suggestions for moving the process forward. Suggestion: The APRs were conducted within a short span of time very intensively. MOHFW could benefit more from it-­‐ if it, along with the LDs, prepared in advance for participation in the APR exercise in a co-­‐ordinated fashion. This would have also allowed it to have better control over establishing the priority plan of action-­‐ through the Policy Dialogue at the end of APR. 2) External Surveys: These generated very useful and topical data for the Policy Planners, Managers as well as all stakeholders in the Sector Programme. These filled in the vacuum created by absence of reliable routine MIS data for monitoring. b.
What worked but needed improvement : 1. The MOHFW-­‐ DP co-­‐ordination mechanism could fulfill their purpose better if the meetings were planned to cover policy issues also, rather than concentrating on the specifics of follow-­‐up on Priority Plan of Action generated by APRs 2. The monthly Development Co-­‐ordination meetings at the Ministry and the Directorate levels could help establish the Government's leadership in the Programme if the reviews could go beyond the financial performance and included the Programme data supported by reliable MIS reports. 3. The Task Groups could yield better results if the senior management in the MOHFW could play more active and purposive role in setting agenda and co-­‐
ordinating available technical expertise of its members. c.
What did not work 1. The institutional innovations introduced through the outsourced private agencies engaged for providing capacity support to MOHFW e.g. PSO, MSA, PMA failed to click into the Ministry's management set-­‐up or to deliver. PMA never came into being. MSA could work for a short time and that too in a limited area, because the Government had changed its mind about outsourcing CCs and Union -­‐ level service facilities. PSO lost its support as soon as the Government changed in 2009 and MOHFW did not feel the need for extending PSO's contract beyond 2010, even though HNPSP continued till 2011. The effort, time and scarce resources taken up in the process of introducing these new institutions weighed heavily on the finite managerial resource of MOHFW. It is doubtful if this attempt to introduce these innovations was worth it. 2. The Planning Wing of MOHFW had set up a Monitoring and Evaluation Unit in 2007 with the technical assistance of GTZ to help the senior management final_report_hnpsp 18 with ongoing evaluation and monitoring of implementation of HNPSP. 3 deputed officers were not replaced by the Ministry after they were transferred at different times, as a result only one deputed officer was left to serve the M & E Unit. The M&E Unit could not take initiative in providing the MOHFW management with useful monitoring data or analysis, nor did the MOHFW develop or show appetite for it. As a result, the M & E Unit failed to live up to its goal, which was unfortunate, since a vibrant M. & E Unit could have supported MOHFW management in productively monitoring and guiding implementation of HNPSP Programmes. Programme Monitoring in HNPSP remained the poorer because of this deficit. Chapter 4: Assessing the Achievement of Priority Objectives -­‐How Pro-­‐Poor was the Impact 4.1 Achieving the Priority Objectives: RPIP 2008 identified 7 priority objectives of HNPSP (see sub-­‐section 2.1.1) and 15 indicators for assessing the achievement of those objectives (with benchmark data for all but two of these indicators and projected target for mid-­‐2011), presented in Table-­‐I of RPIP, 2008. Data relating to achievement of the indicators can be seen at Annex-­‐D of the Report. Substantial improvements can be noticed from the figures quoted in Annex-­‐D, even through uptodate data has not been avaailble for most of the indicators except for maternal mortality reatio and TB, for which data for 2010 have been quoted. Bangladesh is on track for MDG-­‐4 and possibley MDG-­‐5 i.e. reducing child mortality and maternal mortality respectivelly. International award for making needed progress for the achievement of MDG-­‐4 had already been recived. The 2 indicators in tthe Priority Objective relating to child nutrition are related to MDG-­‐1-­‐ i.e. theereductionof hunger and poverty. BDHS 2007 shows improvement in reducing proportion of underweight children but figures for the severly underweight childeren were not available. However, malnutrition among children final_report_hnpsp 19 remains at an unacceptably high level and needs to be addressed through co-­‐ordinated steps and multi-­‐sectoral approach. Table 4.1 in this chapter provides further data on the nutrition status of children and women as well on micro-­‐nutrient intake among mothers and children. As for MDG-­‐6 relati8ng to combating HIV-­‐AIDS, Malaria and other diseases, impressive gains have been recorrded in both case detection and cure rate for TB, while HIV prevalence does not seem to have deteriorated except for most-­‐at-­‐risk population in central Dhaka. Inspite of the fact that reducing Non-­‐communicable Diseases (NCD) was included as one of the seven Priority Objectives of HNPSP, data are not available for assessing the achievement of any of the four indicators listed in the Table. Even Benchmark data was not available for 2 of these indicators to start with. A NCD Strategy was developed and approved during HNPSP period. However the OP on NCD had little to show for activities and did not reflect the priority attached to NCDs in RPIP 2008, thereby indicating the disconnect between HNPSP objectives and the concerned OP. Steps need to be taken to avoid the situation in the next Sector Programme, with NCDs going to assume greater importance in the coming years. It is also noteworthy that Diabetes was not included among the indicarots for NCD in the Priority Objectives of HNPSP. This ommission would also need to be addressed in the next Sector Programme. The indicators relating to TFR, Population Growth Rate and related issues of Family Planning and reproductive health have been intensively discussed and assessed in Part II, in the Report on OPs relating to Service Delivery DGFP at Chapter-­‐7.1 It is relevant to reiterate that impressive gains had been achieved in health status during HNPSP period and interest has been expressed by international academic circles in trying to analyse and understand what right steps had Bangladesh taken to achieve-­‐ what has been described as 'good health at low cost' (see London School of Hygiene and Tropical Medicine’s study of 5 countries including Bangladesh, supported by the Rockfeller Foundation and published in October, 2011. The Report on Bangladesh is titled ' Health Transcends Poverty-­‐ the Bangladesh Experience ') 4.2 How Pro-­‐poor was the Impact: For assessing the impact of health sector programme inputs on Pro-­‐poor especially poor women and children we have analyzed the output variables according to the wealth quintile of the Women. Such information is available in BDHS, UESD Survey and BMMS. The definition of the variables adopted in the surveys is quite comparable. The findings on fertility, family planning, Reproductive and Child Health and Nutrition of Mother and Child are presented below. The findings are presented in Tabular form (Table 4.1 at the end of this Chapter) for all the five quintiles along with data for the overall picture of each of the variables mentioned above. Detailed comments explaining the data are presented below. To sum up, considerable improvements in health outcomes appear to have been achieved between BDHS 2004 and BDHS 2007. The UESD survey 2010 and the Bangladesh Maternal Mortality Survey 2010 confirm the trend. The data also show that the very poor, represented by Quintile1 (Q-­‐1) have achieved improvments for all the variables presented in the Table and have been able to narrow the gap with the richest i.e. those in Q5. However, it is also important to note that the absolute gap between the two in health status is still very large for most of the variables. This calls for attention of the policy planners. Fertility. Several measures of behavioural and normative measures of fertility are available by Wealth Quintile of the Women. For the BDHS2004, the highest value of TFR of 4.1 is found for the women in the poorest quintile (1st) quintile) which gradually increases to 2.2 for women in the final_report_hnpsp 20 richest(5th) quintile. The TFR for women in all the quintile is 3.0. During the period 2004-­‐07 the TFR in the 1st, 2nd and 3rd quintile has decreased from the corresponding values. In the BDHS2007, declining values of TFR with the rise in wealth quintile has also been observed. However in the 1st, 2nd and 3rd quintile there has been decline in fertility in BDH2007 while compared to the corresponding values of 2004. The fertility of the 4th and 5th (richest) quintile has remained same in the two survey periods. The over all TFR for BDHS2007 is 2.7 while compared to a value of 3.0 in 2004. The TFR in BMMS2010 further declined to 2.5. Similar variations have also been observed for Wanted TFR, Unwanted TFR and Ideal number of children given in the table. The percentage of women who want no more children is higher, 61.2% in the Poorest (1st quintile) and 61.3% in the 2nd quintile, while compared to the higher quintiles in BDHS2004. The over all percentage of women who want no more children is 59.3 per cent in BDHS2004 which increased to 62.5 per cent in BDHS2007. The findings suggest that for further reductions in fertility more and more ELCOs from the 3 lower quintiles have to be brought under the family planning programme. Table -­‐-­‐ Age at First Marriage: The median age at first marriage of the woman is somewhat similar in both BDHS2004 and 2007 surveys in the poorest quintile. It is only in the richest wealth quintile where we find about 2 years rise in the median age at marriage while compared to the poorest (1st) quintile. The median age at first marriage of the women has increased by 0.5 years during the period 2004-­‐07. Contraceptive Prevalence Rate (CPR) for Any Method: In the BDHS CPR for any method was 58.1 per cent which declined to 55.8 per cent in 2007. The CPR increased to 61.7 per cent in UESD2010. In both 2004 and 2007 the CPR increased along with the increase in quintile groups of the women. In the UESD2010, the CPR in the lower four quintiles increased considerably while the value of the CPR in the richest (5th quintile) decreased slightly. The ratio of the CPR of richest/poorest quintile was 1.2 in 2004, 1.1 in 2007 and 0.9 in 2010. Contraceptive Prevalence Rate (CPR): Any Modern Method: The value of CPR for any modern method was 47.3 per cent in 2004, 47.5 per cent in 2007, but in UESD2010 it increased to 54.1 per cent. There was increase in the CPR of modern methods in the first four quintiles, while in the richest (5th) quintile it decreased slightly. The ratio of CPR for any modern of richest/poorest quintile was 1.1 in 2004, 1.0 in 2007 and 0.8 in 2010. CPR for Long Acting and Permanent Method (LAPM). The CPR for long acting and permanent method (LAPM) is more or less stagnant 7.2-­‐7.4 per cent during the period 2004-­‐10. In the 1st and 2nd quintiles there has been slight increase in the CPR of LAPM while there has been decline in the richest quintile keeping the over all CPR of LAPM at about the same level. The ratio of CPR of LAPM of poorest/richest quintile was 1.4 in 2004, 1.9 in 2007 and 2.1 in 2010. Unmet Need for Family Planning. The unmet need for family planning increased from 11.3 per cent in 2004 to 17.1 per cent in 2007. The unmet need for family planning showed a decreasing trend along with the rise in wealth quintile. The ratio of unmet need for poorest/richest quintile was 1.5 in 2004 and 1.1 in 2007. Reproductive Health Care. Antenatal Care (ANC): The over all ANC from any source has increased from 55.9 per cent in 2004 to 71.2 per cent in 2010. Similar increase in the ANC has been found for women in all the quintile groups. The ratio of ANC of women in richest/poorest quintiles was 2.5 in 2004, 2.1 in 2007 and 2.0 in 2010(UESD) and 1.7(BMMS). Similar variation was found for ANC from any Medically Trained provider. Place of Delivery at Any Health Facility: The per cent of live birth having any health facility (Public, private or NGO) increased from 9.3 per cent in 2004 to 23.7 per cent in 2010. The per cent of birth having any health facility as the place of delivery increased with the increase in wealth quintile of women. The ratio of the per cent of delivery of richest/poorest quintile is 15.1 in 2004 9.9 in 2007, 7.4 in 2010(UESD) and 7.0(BMMS). Government Health Facility. Similar variations was observed having government health facilities as place of delivery. The per cent of live births having government health facilities as place of delivery increased from 6.1 per cent in 2004 to 10.8 per cent in 2010. The ratio of the final_report_hnpsp 21 per cent of births delivered by richest/poorest quintile was 9.3 in 2004, 6.8 in 2007 4.2 in 2010(UESD) and 3.8(BMMS2010). Assistance during Delivery: The per cent of live births having assistance at the time of delivery by medically trained provider increased from 13.4 per cent in 2004 to 26.5 per cent in 2010. Such percentage also increased with the increase in the quintile group of women. The ratio of parentages of deliveries having assistance of richest/poorest quintile was 11.6 in 2004, 10.8 in 2007 and 6.9 (UESD), 6.2(BMMS) in 2010. Delivery by C-­‐Section. The per cent of birth delivered by C-­‐section has increased from 3.5 per cent in 2004 to 13.0 per cent in 2010. Such increase has been observed in all quintile groups. The proportion of birth delivered by C-­‐Section is very low in the poorest quintile and gradually reaches the richest quintile. The ratio proportion of births by C-­‐Section of Richest to poorest (Richest/Poorest) quintile is 144 in 2004, 14.3 in 2007 and 11.4 in UESD2010 and 12.4 in BMMS2010. Post natal Care (PNC) for Mothers: the per cent of mothers receiving postnatal care (PNC) from a trained provider slightly improved from 17.8 per cent in 2004 to 22.7 per cent in 2010. The Per cent of mothers receiving post natal care was lowest in the poorest quintile which gradually reached the highest level in the richest quintile. The ratio of per cent of mothers receiving PNC of richest poorest (richest/poorest) quintile Post natal care for New Born: the level and trend of new born receiving PNC from medically trained provider was similar to that of the mothers. Vaccination of Children: The percentage of children of age 12-­‐23 months who received all vaccinations increased from 73.1 per cent in 2004 to 82.0 per cent in 2010. The percentage of children vaccinated increased in all the wealth quintiles between the two surveys. The ratio of percentage of children vaccinated of richest to poorest (richest/poorest) quintile was hound to be 1.5 in 2004, 1.1 for 2007. Tetanus Toxoid Vaccination of Pregnant Women. (TT Injections): Pregnant Women Receiving 1 TT Injection: In BDHS2004, the percentage of pregnant women who received 1 TT Injection during pregnancy varied between 19.1 to 23.3 in different quintiles. The over all percentage being 21.2 per cent. In the UESD2010 survey the over all percentage of pregnant women who received 1 TT Injections slightly increased to 21.6 per cent. Tetanus Toxoid Vaccination of Pregnant Women. (2 or more TT Injections): The percentage of women who have received 2 or more TT Injections increased from 56.0 per cent in the poorest quintile to 70.7 per cent in the richest quintile in BDHS 2004. The over all mean percentage was 63.6 per cent. In the UESD2010 there appears to be some decline in the percentage of women having 2 or more TT injections. The over all percentage declined from 63.6 per cent in 2004 to 51.2 per cent in 2010. Higher declines occurred in the upper quintiles. It is worth elaborating here that II injections are given during pregnancy for the prevention of neonatal tetanus. To achieve protection for herself and her new born baby, typically pregnant woman should receive at least two doses of TT. On the other hand, if a woman was fully vaccinated during a previous pregnancy, she may require one dose during her current pregnancy to achieve such protection. Five doses are considered adequate. Another point is that in the BDHS2004, the reference period of birth was 5 years and in the UESD2010, the reference period of birth was3 years. Nutrition: Vitamin A Supplement: The percentage of children of age 9-­‐59 months who received Vitamin A supplements was found to be 81.8 per cent in 2004, 88.3 per cent in 2007 and 82.6 per cent in 2010. There was not much variation in Vitamin A supplement intake according to wealth quintile in recent years. Higher percentage of intake was found for the year 2007. Micronutrient among Mothers: The percentage of women with birth in five years preceding the survey who received a Vitamin A dose in the 1st two months after delivery increased from 14.5 per cent in 2004 to 19.5 per cent in 2010. The Vitamin A intake among mothers was found final_report_hnpsp 22 to be lowest in the poorest quintile and gradually increased to highest level in the richest quintile. The ratio of the percentage of mothers receiving Vitamin A supplements of richest to poorest (richest/poorest) quintile was 3.0 in 2004 and 2.2 in 2007. Nutritional Status of Children. Hieight for Age (Stunting): Percentage below -­‐2SD. The over all percentage of stunting remains about 43.0 per cent in both 2004 and 2007. The percentage of stunting is highest (about 84%) in the poorest quintile in both the surveys which gradually decreased to 25 per cent in 2004 and 26.3 per cent in 2007. The ratio of percentage of stunting of richest to poorest (richest/poorest) quintile is 2.2 for 2004 and 2.0 for 2007. Weight for Height (Wasting): Percentage below -­‐2SD. The over all percentage of wasting increased from 12.8 per cent in 2004 to 17.4 per cent in 2007. Similar increase in the percentage of wasting has also been found in the respective quintiles between the two surveys. The ratio of percentage of wasting of poorest to richest quintiles (poorest/richest) quintile is 1.6 in both the years. In the year 2007 the prevalence of stunting was 20.8 per cent in the poorest quintile which decreased to 13.2 per cent for children in the richest quintile. Weight for Age (Underweight): Percentage below -­‐2SD. The over all percentage of underweight children has decreased from 47.5 per cent in 2004 to 41.0 per cent in 2007. The proportion of underweight children is highest in the poorest quintile and lowest in the richest quintile in both the surveys. The ratio of percentage of underweight children of poorest to richest quintile (Poorest/richest) is 1.9 in both the periods. Nutritional Status of Women: Percentage of Women with BMI < 18.5(Thin): The percentage of thin (BMI< 18.5) women has decreased from 34.3 per cent in 2004 to 29.7 per cent in 2007. The highest proportion of thin women was found to be 43.4 per cent in the poorest quintile in 2004 which decreased to 13.4 per cent in the richest quintile. The ratio of the percentage of thin women of poorest to richest quintile (poorest/richest) was 2.7 in 2004 and 3.2 in 2007. Percentage of Women with BMI (18.5 – 24.9):Normal: the percentage of women with BMI 18.5-­‐24.9 (Normal weight) was found to be 56.8 per cent in 2004 which increased by 2 percentage point to 58.5 per cent in 2007. The ratio of the percentage of women having normal weight of richest to poorest(richest/poorest) quintile was 1.1 in 2004 and 1.0 in 2007 indicating that the composition of women of normal weight has remain same according to wealth quintile in recent years. Percentage of Women with BMI ≥ 25.0 (Overweight): The percentage of overweight women is very low (2-­‐3%) in the poorest quintile which increased to 9.5-­‐11.7% in the 4th quintile. The percentage of overweight women was enormously high in the richest quintile. It was 24.8 per cent in 2004 increasing further to 31.4 per cent in 2007. The over all percentage of overweight women increased from 8.9 per cent in 2004 to 11.8 per cent in 2007. The ratio of percentage of overweight women in the richest to poorest (richest/poorest) quintile was 11.8 in 2004 and 9.8 in 2007. From the above analysis of the level and trend of indicators, it appears that the HNPSP has been quite successful in providing services in the field of reproductive health and nutrition of the women from the lower wealth quintiles and their children. Table 4.1 : Fertility, Family Planning, Reproductive Health and Nutrition By Wealth Quintile:Bangladesh 2004-­‐2010 Fertility Wealth BDHS BDHS UESD BMMS Quintile 2004 2007 2010 2010 Total Fertility Rate(TFR) Q1 4.1 3.2 Q2 3.2 3.1 final_report_hnpsp 23 Q3 3.0 2.7 Q4 2.5 2.5 Q5 2.2 2.2 All 3.0 2.7 2.5 Wanted TFR Q1 2.6 2.1 Q2 1.9 2.0 Q3 2.1 1.9 Q4 1.7 1.8 Q5 1.6 1.6 All 2.0 1.9 Unwanted TFR Q1 1.5 1.1 Q2 1.3 1.1 Q3 0.9 0.8 Q4 0.8 0.7 Q5 0.6 0.6 All 1.0 0.8 Ideal Number of Children Q1 2.6 2.1 Q2 2.5 2.2 Q3 2.4 2.1 Q4 2.4 2.0 Q5 2.3 2.1 All 2.4 2.1 Women who Want no more children (%) Q1 61.2 68.9 Q2 61.3 64.0 Q3 58.4 61.5 Q4 59.5 59.3 Q5 56.3 59.4 All 59.3 62.5 Contraceptive Prevalence Rate(CPR)% : Any Method Q1 53.6 54.8 62.8 Q2 57.6 54.7 64.4 final_report_hnpsp 24 Q3 57.8 54.1 61.4 Q4 58.5 55.2 61.5 Q5 62.5 59.9 57.5 All 58.1 55.8 61.7 Any Modern Method Q1 44.7 46.9 56.5 Q2 47.7 47.2 57.3 Q3 46.6 46.1 53.2 Q4 47.6 47.6 54.6 Q5 50.0 49.6 47.7 All 47.3 47.5 54.1 Any Long Acting/Permanent Method (IUD,Implants, Male Sterilization, Female Sterilization) Unmet Need for Family Planning Child Mortality Infant Mortality/1000 Live births Under 5 Mortality/1000 Live births Median Age at First Marriage of Women(20-­‐49) Antenatal Care(ANC): Per cent of Women who had a live birth in the five years preceding the survey who had any antenatal care(ANC) during pregnancy of the most recent birth Q1 8.5 10.0 11.0 Q2 Q3 Q4 Q5 All Q1 Q2 Q3 Q4 Q5 All Q1 Q2 Q3 Q4 Q5 All Q1 Q2 Q3 Q4 Q5 All Q1 Q2 Q3 Q4 Q5 All 7.6 7.6 6.3 5.9 7.2 13.0 11.7 11.7 11.3 8.6 11.3 90 66 75 59 65 65 121 98 97 81 72 88 14.3 14.3 14.6 15.1 16.5 14.8 7.5 7.5 7.3 5.1 7.3 17.4 18.6 17.1 17.0 15.6 17.1 66 67 63 46 36 52 86 85 83 62 43 65 14.4 14.9 15.2 15.6 16.9 15.3 8.1 7.0 5.7 5.2 7.4 Q1 33.7 41.6 45.9 54.6 final_report_hnpsp 25 Per cent of Women who had a live birth in the five years preceding the survey who had any antennal care(ANC) during pregnancy of the most recent birth by medically trained provider Place of Delivery: Per cent of live birth in the five years preceding the survey having any health facility (Public, Private & NGO)as the place of delivery Per cent of live birth in the five years preceding the survey having public health facility as the place of delivery Assistance During Delivery. Per cent of live birth in the five years preceding the survey having assistance at the time of delivery by Medically trained provider/a Caesarean Section(C-­‐Section) Per cent of live birth in the five years preceding the survey delivered by Caesarean Section(C-­‐Section) Post natal Care(PNC) final_report_hnpsp Q2 Q3 Q4 Q5 All 46.0 58.3 66.5 84.1 55.9 47.4 58.9 71.9 86.4 60.3 53.5 62.0 69.8 92.6 62.4 62.9 69.5 80.9 90.9 71.2 Q1 Q2 Q3 Q4 Q5 All 24.9 38.6 48.8 60.6 81.1 31.3 30.8 36.3 47.9 65.6 83.5 51.7 35.4 45.6 56.0 65.2 91.2 56.0 31.2 41.2 51.5 66.9 81.9 53.7 Q1 Q2 Q3 Q4 Q5 All 2.0 3.2 5.5 11.9 30.3 9.3 4.4 5.2 8.9 17.0 43.4 14.6 8.0 12.8 21.3 29.7 59.3 23.7 7.5 12.1 19.0 29.4 52.8 23.4 Q1 Q2 Q3 Q4 Q5 All 1.8 2.5 4.6 8.4 16.7 6.1 2.5 3.7 5.5 8.9 17.1 7.1 4.5 7.7 12.7 13.6 18.8 10.8 4.4 7.6 9.2 13.3 16.7 10.0 Q1 Q2 Q3 Q4 Q5 All 3.4 4.5 10.5 17.4 39.6 13.4 4.8 6.7 12.1 22.5 51.9 18.0 9.2 14.5 23.5 33.3 63.4 26.0 9.2 14.2 22.4 33.7 57.0 26.5 Q1 Q2 Q3 Q4 Q5 All 0.1 0.9 1.7 3.1 14.4 3.5 1.8 1.9 3.3 8.5 25.7 7.5 3.2 6.2 11.6 16.3 36.6 13.0 2.6 4.4 9.3 14.8 32.2 12.2 26 Percentage of last live births for which the mother received PNC from a trained provider within 42 days of delivery Percentage of last live births for which the children received PNC from a trained provider within 42 days of delivery Treatment Seeking Behaviour Percentage of births in the five years preceding the survey who had at least one complication around delivery by assistance sought from medically trained providers. Treatment of ARI Among Children under 5 with ARI during the two weeks preceding the Survey, Percentage Taken to Health Facility or medically trained Providera Treatment Seeking for Children With Fever Percentage of Children under 5 years with fever In the two weeks preceding the Survey who were Taken for treatment at Health Facility/Medically trained Provider Vaccinations of Children Percentage of children aged 12-­‐23 months who received all vaccinations final_report_hnpsp Q1 Q2 Q3 Q4 Q5 All 5.1 8.6 12.7 22.3 46.9 17.8 7.6 10.0 13.6 27.6 52.0 21.3 8.2 11.6 19.4 29.0 57.6 22.7 Q1 Q2 Q3 Q4 Q5 All 5.6 7.9 13.2 20.3 47.1 17.5 8.0 10.0 14.1 29.4 52.3 21.9 7.9 12.5 19.2 29.6 58.3 23.0 Q1 Q2 Q3 Q4 Q5 All 14.0 17.6 25.8 42.8 55.8 28.7 22.5 29.3 39.9 49.8 74.4 42.0 Q1 Q2 Q3 Q4 Q5 All 10.8 15.5 18.7 27.4 45.3 20.3 17.0 23.8 29.0 44.2 59.9 30.2 24.4 41.1 29.9 41.6 72.5 38.0 Q1 Q2 Q3 Q4 Q5 All 9.2 12.7 17.6 21.6 40.7 18.5 13.3 18.9 22.7 31.1 38.7 23.9 Q1 57.4e 79.9e 80.1 27 Tetanus Toxoid Vaccination of Pregnant Women. Per cent of women who had a live birth in the five years preceding the survey who had one TT Injection during pregnancy of the most recent births.) Q2 Q3 Q4 Q5 All 76.0 74.1 78.7 86.7 73.1 75.4 79.0 87.1 88.4 81.9 79.9 76.2 86.3 89.5 82.0 Q1 Q2 Q3 Q4 Q5 21.4 20.8 23.3 19.1 21.4 18.1 20.9 21.2 22.7 27.6 Per cent of women who had a live birth in the five years preceding the survey who had 2 or more TT Injection during pregnancy of the most recent births.) Micronutrient Intake Among Children Percentage of children age 9-­‐59 months who received Vitamin A Supplements in the six months preceding the Survey Micronutrient Intake Among Mothers: Percentage of Women with a birth in the five years preceding the survey who received a Vitamin A dose in the first two months after delivery Nutritional Status of Children Height for Age(Stunting):Percentage below -­‐2SD All 21.2 21.6 Q1 Q2 Q3 Q4 Q5 All 56.0 61.2 63.5 69.6 70.7 63.6 51.7 53.9 50.8 52.0 45.9 51.2 Q1 Q2 Q3 Q4 Q5 All 77.2 82.1 81.2 83.3 87.6 81.8 88.8 84.9 88.8 89.5 90.0 88.3 82.6 83.0 81.4 82.4 83.8 82.6 Q1 Q2 Q3 Q4 Q5 All Q1 Q2 Q3 Q4 8.5 8.9 14.7 17.9 25.9 14.5 54.4 46.7 42.4 39.9 12.5 15.7 18.8 24.9 27.0 19.5 54.0 50.7 42.0 38.7 final_report_hnpsp 28 Weight for Height(Wasting):Percentage below -­‐2SD Weight for Age(Underweight):Percentage below -­‐
2SD Nutritional Status of Women Body Mass Index(BMI ) < 18.5 (Thin)/b BMI 18.5-­‐24.9 (Normal) BMI ≥ 25.0 ( Over-­‐weight) Q5 All Q1 25.0 43.0 15.5 26.3 43.2 20.8 Q2 Q3 Q4 Q5 All Q1 13.5 13.5 10.8 9.4 12.8 59.3 17.8 16.9 17.6 13.2 17.4 50.5 Q2 Q3 Q4 Q5 All Q1 Q2 Q3 Q4 Q5 All Q1 Q2 Q3 Q4 Q5 All Q1 Q2 Q3 Q4 Q5 All 52.9 45.1 43.4 30.2 47.5 47.1 40.5 35.6 31.3 17.2 34.3 50.8 56.6 59.4 59.2 58.0 56.8 2.1 2.9 5.0 9.5 24.8 8.9 45.9 41.0 38.1 26.0 41.0 43.4 35.4 32.7 25.2 13.4 29.7 53.4 60.6 60.0 63.1 55.3 58.5 3.2 4.0 7.3 11.7 31.4 11.8 final_report_hnpsp 29 Chapter 5 Strengths and Weaknesses of HNPSP 5. HNPSP is the second programme of MOHFW using a sector-­‐wide approach, as mentioned in section 1.1 of the introductory chapter of this Report. Some of its strengths and weaknesses can be traced to its inheritance. These appear to fall into 2 broad categories: structural and operational. Below are some of them, which are not exhaustive but may be representative. 5.1 Strength of HNPSP : a) Structural-­‐ In spite of reservations about certain operational aspects of the Programme, the planners and policy formulators of MOHFW recognise the usefulness of the sector-­‐
wide approach (SWAp), however limited and constrained it is in coverage of health services delivery in the sector. They emphasise on the fact that the SWAp allowed them to concentrate on specified objectives, develop programmes to match those objectives, fix targets for achieving improvements and marshal needed financial resources to support the various activities for achieving the targets. Moreover, this helped MOHFW to be in the driving seat while allowing the development partners a broader role in the total process of planning and implementation of the Programme. The sector-­‐wide approach had bestowed upon MOHFW the responsibility of taking a holistic view of the health sector and had raised expectations about the Ministry's stewardship role for both the public and non-­‐
public sectors through setting service standards, accreditation and quality control etc. This had led to increased awareness and ownership of the Programme by MOHFW. b) Operational-­‐ 1. At the operational level, HNPSP provided flexibility to adjust to new challenges, e.g. the Avian flu or the health risks posed by cyclone Aila etc. and to develop fully funded programme activities to meet those emergencies. Moreover, Inter-­‐OP fund adjustments could be made based on annual review / assessments to improve utilisation, even through it was felt that there was scope for improving upon the flexibility in HNPSP operation. 2. HNPSP practised a 'soft' sector-­‐wide approach which allowed it to mix sector and project resources to overcome or side-­‐step constraints of accessing 'pool' funds as needed. This was used as an option by MOHFW to avoid or to reduce shortfall in procurement planning, or to address needs which the established processes were failing to respond to, or to pilot new interventions / approaches. 3. Major health indicators like maternal mortality, child and infant mortality, population growth rate, CPR (Table 4.1), immunization rate, TB case detection and cure rate or even the sero-­‐surveillance rate for HIV-­‐AIDS etc. showed remarkable performance during the programme period. See Annex-­‐ D for the achievement of benchmark indicators. Impressive improvements in health outcomes have been consistently reported by variety of surveys, reports and studies. It is however common knowledge that a host of conducive socio-­‐economic factors influenced the positive health outcomes (see section 1.3) and it would be difficult to apportion the responsibility to only the health interventions. Yet there is an increasing awareness in international circles that Bangladesh and MOHFW must have been doing something right to take forward and sustain the positive trends. There is no better evidence than these to affirm the success of the policy and programmes being followed by MOHFW. 4. During the long HNPSP period, the performance of service delivery-­‐ both MNCH and public health-­‐ improved, after initial slow take-­‐off. Utilisation of facilities at District and final_report_hnpsp 30 levels below increased without increase in financial investment, indicating achievement of efficiency gains. Access of the poor to utilisation of public services also improved steadily, even though it remained considerably lower than that of the highest quintile. 5. Fiduciary risk management consistently improved over time within the constraints of MOHFW's financial management structure. 5.2 Weakness and Constraints of HNPSP Some of the constraints and weaknesses of HNPSP followed from its structure-­‐the way in which the Programme was designed or its activities were structured, while quite a substantial number of the weaknesses appear to be of operational nature-­‐ the way in which the programme and the activities were implemented. 5.2.1 Structural weakness and constraints 1. The Programme design of HNPSP was both complex and rigid. The 4 major components described at section 2.2 indicate the vastness of its scope and ambition. The beginning of a policy shift from MOHFW being a 'provider' of health services to a 'purchaser' was skillfully built into the Programme, with provision of institutional support in the form of 3 private sector agencies assisting MOHFW to take the necessary steps. The burden of these 'reforms' weighed heavily on the scarce managerial resources of MOHFW, made more challenging by the political transitions which took place in end-­‐2006 and again in early 2009. The Mid-­‐term Review in 2008 recognised this design-­‐aspect as a major draw-­‐back of HNPSP and suggested re-­‐designing the Programme with emphasis on the service delivery system and a strengthened support system (to include human resource, procurement, M. & E. and financial management etc.) The suggestion was not acted upon and the constraints posed by the mentioned aspects of the Programme's design remained to the end. 2. Procurement and funds release posed serious points of contention and misunderstanding between MOHFW implementers and the fund manager, the World Bank, throughout the HNPSP period. The dissatisfaction often reached the planners and policy formulators in MOHFW and this became quite voluble when the new government took charge in 2009. Delays in procurement processing and in logistic supply as well as the fund's release conditionalities (involving 3 categories of payments, the annual conditionalities around release of performance based financing and the quarterly fund release system through reconciled FMRs etc.) adversely affected the progress of implementation of the Programme. Limited steps could be taken by MOHFW and the World Bank to reduce the difficulties but both were hobbled by their built-­‐in institutional inadequacies. The procedural rigidities connected with delays in procurement and funds release could be traced mainly to the type of loan which Bangladesh (ERD) negotiated with the World Bank-­‐ an investment loan which reflected perception of higher level of fiduciary risk, as opposed to say, policy lending. Public financial management system of Bangladesh is the responsibility of the Ministry of Finance and the issues connected with perception of fiduciary risks are beyond the scope of MOHFW. The fact, however, remains that HNPSP was implemented within the rigidities imposed by the investment loan and suffered procedural delays and considerable management challenges in smooth implementation of the Programme. 3. The structural divide between the Revenue and Development aspects of budget in the governmental financial system had serious implications for planning and implementation final_report_hnpsp 31 of HNPSP. For example, shortage of needed (health) human resource due to difficulties in creation of posts or in filling up vacancies-­‐ both of which are functions of Revenue budget created shortfall in service delivery as a constant feature of HNPSP. Systems were not set up to trigger the creation of posts or the filling of vacancies in the revenue set-­‐up of the Ministry to tie-­‐up with the creation or upgradation of additional physical facilities (for hospital or medical training etc.) through HNPSP OPs. This explains existence of newly built physical facilities failing to provide the planned services due to acute shortage of needed manpower e.g. doctors, nurses or technicians with specific skills. Development expenditure through OPs was thus robbed of creating improved service impact due to absence of synchronisation between the Revenue and Development budgets of MOHFW. 4. 5. Additional structural rigidity was introduced by the way in which each of the 38 OP were designed as separate units independent of each other. This led to misuse and misallocation of resources as has been pointed out in sub-­‐sections 3.1.1 and 3.1.2. Thus, for example, investments through OP on physical facilities were made without providing those with supply of equipments through OP on Improved Hospital Management Services. This was made worse by the absence of co-­‐ordinated steps for supply of needed human resource on the Revenue side. MTR 2008 and APR 2009 drew attention to the constraints created by the structure of stand-­‐alone OPs and their 'tunnel' visions. The uncompromising bi-­‐furcation of services between the two Directorates-­‐of Health and Family Planning-­‐from the centre to the lowest service delivery points at the field level -­‐ led to duplication and avoidable wastage of financial and human resources. Both the MTR 2008 and APR 2009 commented on the negative effects of the bifurcated services and urged upon improved co-­‐ordination in the absence of any realistic possibility of providing integrated services. Unfortunately, those who were MOHFW policy formulators during the planning of HNPSP supported and contributed to the bi-­‐furcation of the services. It is a negative legacy with which subsequent health programmes will also have to grapple with. 5.2.2 Operational Weakness and Constraints The operational weakness and constraints could be traced mainly to the ways in which OPs were planned, processed and implemented, the management’s performance: in procurement, placement and retention of HR, supervision and monitoring of implementation, MOHFW's stewardship role, quality of service, and governance etc. 1) OPs -­‐ planning, processing and implementation: a. OP Planning: OPs were the main instruments for the content and implementation of HNPSP. Unfortunately, these were centrally planned, without any input from or interaction with the field-­‐level implementers. The top-­‐down planning was accompanied by top-­‐down implementation, without being responsive to the needs or suggestions originating from the actual implementers of the programme-­‐
activities. There was no scope for learning from experience. This approach, for example, used a traditional facility-­‐based resource allocation formula which failed to take into account the specific area-­‐based needs or the needs of poverty stricken areas. Studies were made with suggestion to develop more rational resource allocation formula, e.g. based on population and poverty, but these remained as academic exercise only. Similar was the fate of studies undertaken with HNPSP funds for the operationalisation of district plans or local level planning, which failed even to generate a small-­‐scale pilot. b. OP Processing: The OPs were hastily prepared, processed and approved (Sections 3.1.1-­‐3.1.3), each OP as self-­‐sufficient stand-­‐alone unit unconnected with each other. final_report_hnpsp 32 The ill-­‐effects of such an approach have been pointed out in Section 3.1 and commented upon especially in MTR 2008 and APR 2009. 2) LD -­‐ most important manager: The line director was a key manager of HNPSP. He also provided the basic input for planning and revising the OP. However, he had neither the training, exposure or institutional support needed to effectively play his role as planner or manager of implementation. Not even the dozen LDs, each of whom handled over 50 crore taka worth of programmes under their OPs, had any specialised support for fund management, disbursement, accounting or reporting. They were not given even a preliminary orientation to the scope or contents of HNPSP or what constituted a sector-­‐
wide approach. To complicate matters, there were quick turn-­‐over of LDs often: there were stark examples of 5 LDs within a year for an OP! The choice of a LD was not based on merit but on seniority, where only an officer of the level of a Director in the Directorates was given the responsibility. As a result, quite often, officers became LDs at the fag end of their career when learning new things or being enterprising or imaginative would be very exceptional. The quality of leadership from the most important manager of implementation of HNPSP, i.e. Line Director, suffered due to deficiency in management support system as well as due to poorly prepared individual leadership. The same holds true of the LDs in the Ministry as well. 3) Management Performance: The management's performance in procurement, placement and retention of HR, monitoring and supervision of implementation in the field, ensuring quality of service and good governance etc. left scope for considerable improvement. a. Procurement: Deficiency in procurement planning, processing and tracking were reasons for complaints and frustrations of most LDs and implementers, especially against centralised procurement. More unfortunate and counter-­‐productive was the fact that there were many instances where procured equipments or drugs were allocated to places or institutions which had no use for them either because they did not need those or because the required technical staff/resources for their operation were not made available. A survey of procured equipments by the World Bank found considerable wastage of HNPSP resources due to uncoordinated central procurement. (Bangladesh Equipment Survey, 2008, WB) b. Placement and Retention of HR: Given the fact that there is overall shortage of health service providers in the public sector-­‐ doctors, nurses and technicians, there is a pressing need to make judicious and equitable use of this critical input for ensuring promised service delivery. In spite of the widespread recognition of this need, the MOHFW management failed to evolve a system for national placement and retention of service providers. The rural and hard-­‐to-­‐reach areas continued to remain at the receiving end, while the absence of appropriate skill-­‐mix deprived the people of services for which investments had been made e.g. EmOC services. MOHFW made attempts from time to time to address the problem, but these were neither consistent nor driven by legal or ideological compulsion. c. Monitoring and Supervision of Implementation: Like planning, monitoring of implementation in HNPSP was concentrated at the Centre, with little opportunity or responsibility to the other tiers of MOHFW structure like the Division, District or Upazilla managers. MIS data originating from the ward level (by the Health Assistant/ Family Welfare Assistant) travelled upward all the way to the Directorate HQ (of DGHS and DGFP) where these got aggregated, but the field implementers had little scope to utilise them in programme monitoring. Neither were these used at the monthly co-­‐ordination and review meetings held at the level of Secretary MOHFW or final_report_hnpsp 33 of the DGs at the 2 Directorates. At the field level, there were no systemic requirements for regular and periodic supervision. As a result, no Supervision Manual or guideline was developed. Monitoring was restricted to one-­‐way reporting from the field to higher levels, with little systematic feedback from those levels or from the LD or the DGs. The Ministry's Monitoring and Evaluation Cell had little role to play in analysing the MIS data , the field reports or the monthly IMED reports sent by the Planning Wing of MOHFW. Neither did IMED prepare or discuss Monitoring Report on HNPSP with MOHFW. Monitoring and Supervision remained a neglected activity in HNPSP. d. Quality of Service and Good Governance: Quality of service and good governance suffered partly due to absence of an established regime of field-­‐level monitoring and supervision. It was also partly a result of absence of quality-­‐culture. The OP on Quality Assurance did develop Quality Manuals in the form of Standard Operating Procedures for different health facilities and conducted training workshops to orient and train the service providers at some districts and upazillas. However, these were not implemented and put into practice. While the top managers did not possibly feel it important and urgent enough for introduction, there was no community pressure or demand from the public representatives associated with the Management Committees of those facilities. The community's voice had little institutional role in HNPSP for improving service quality or poor governance e.g. absenteeism, informed payments, non-­‐receipt of available service or mistreatment, etc. 4) MOHFW's stewardship role: MOHFW is not merely the public service provider but also the regulator for all service providers: public, private, NGOs etc. The private sector's role has been gradually expanding in providing medical education (for doctors, nurses, technicians, etc.), hospital and clinical services and in drug production etc. So has been the NGO's role in piloting new technology, new medicine, new service delivery methods and targeting the disadvantaged people or hard-­‐to-­‐reach areas etc. The quick expansion of the non-­‐public sector has raised issues about standards and quality and the need for the Government to ensure that the public receives an assured and dependable service. MOHFW exercises its role as regulator through enactment of laws and through institutions specifically created to administer those laws e.g. BMDC, BNC and SMF for registration of doctors, nurses and technicians respectively. The expanding non-­‐public sector is making demands on the capacity and resources of the regulators, for which they are not adequately equipped and resourced. Accreditation and standard-­‐setting are crucial for ensuring quality for the private and the public sector as well. MOHFW had failed to take major steps during HNPSP period to convince that it took its stewardship role of the health sector as seriously as needed. 5) Response to New Challenges: Increasing and rapid urbanisation together with improving income are posing serious health challenges in the form of the non-­‐communicable diseases like hypertension, diabetes, etc. while drawing attention to inadequate public service provisions for the expanding number of urban dwellers. HNPSP identified both as important areas of concern but failed to take adequate steps to address these. The OP on NCD was inadequate in leadership, programmes and implementation while MOHFW failed to take meaningful steps to establish an urban health strategy or engage the Ministry of Local Government for joint initiatives in addressing the challenges of urban health. 6) Absence of Strong Leadership of HNPSP: The sector-­‐wide approach expects strong leadership from the Government while the development partners provide support-­‐ both financial and technical for the successful final_report_hnpsp 34 implementation of the sector programme. The Annual Programme Reviews lamented the absence of ownership of HNPSP by the senior leaders of MOHFW particularly during the APRs of 2006 and 2007. Things improved since then but no follow-­‐up action was taken by MOHFW on recommendations by the APRs for branding HNPSP or developing a communication strategy for its recognition by the service providers and recipients. Instead of the MOHFW leadership, the APRs became the main source of dynamism in performance evaluation and establishing the future course of action for the year. Similarly, the Task Groups for different functions (see sub-­‐section 3.2.3.3) failed to yield optimum service in the absence of adequately prepared government leadership. MOHFW felt diffident in taking up and resolving problems HNPSP was facing regarding release of funds, procurement processing, sudden personnel changes, uncertain reporting by parallel funders and similar other issues involving other Ministries of the Government (like M/O Finance, M/O Establishment, etc.) and those involving the World Bank or the DPs. The need of SWAP for different dispensations separate from a project was not systematically made at inter-­‐ministerial levels by MOHFW appeared to be a reluctant leader during most of the HNPSP period. final_report_hnpsp 35 Chapter 6: Recommendations The TOR wanted the Evaluation team to suggest recommendations for more pragmatic and effective implementation of the Programme. The 4 Reports on selected Operational Plans placed at Part-­‐II of this Report contain specific operational recommendations for those OPs. The Recommendations in this Chapter relate to the strength and weakness of HNPSP identified in the earlier chapter (i.e. Chapt. 5). It will be sensible to recommend that MOHFW consolidates and strengthens what it considers to be the strengths and successes of the sector programme based on its experience of implementing such programmes for over a decade (i.e. since 1998), and at the same time takes steps to address the identified weaknesses as far as practicable. The following suggestions are made in that light. 1) MOHFW may like to continue with the sector-­‐wide approach and utilise its advantages while trying to reduce its pains, with the co-­‐operation and assistance of different stakeholders e.g. different Ministries of the Government like Finance, Planning, Establishment, Local Government, etc. as well as the DPs including the World Bank. 2) An essential pre-­‐requisite to achieve the above-­‐mentioned goals is for MOHFW and its lead agencies and managers to fully own the next Programme and play its leadership role in setting annual work plan and identifying bottlenecks etc. In short, it needs to play a pro-­‐active role, rather than being goaded into action as happened during HNPSP (During 2007-­‐2008, the Chief Advisers Office was regularly monitoring its implementation!). 3) Given the timing of the launching of a sector programme which invariably involved at least 2 governments for its implementation (in fact, HNPSP involved 3 governments) and the culture of personnel changes for each political transition, MOHFW should keep orientation materials ready so that the new implementers and managers do not have to start from scratch to know about what needs to be done to carry forward the Programme under implementation. BCC campaigns should ensure brand recognition of the new programme by all stakeholders, especially the service recipients and the community leaders throughout the Programme period. 4) Clear focus should be on improving service delivery, with the OPs synchronised to get value for money. These co-­‐ordinations should be pursued across the Revenue-­‐
Development divide and across the bi-­‐furcation between Health and Family Planning.While planning OPs and revising them, the inter-­‐relation between OPs and the implications of investment in one OP on another must be seriously looked into. Moreover, the steps which are needed to be taken from Revenue budget have to be be identified, planned and coordindated with investments made from OP. These will help reduce the current mismatch, for example, between completed physical facilites and availability of services. In other cases, these will help in maximising service benefits out of investments made from Programme budget. Space could also be created to achieve reconciliations with the large number of non-­‐public actors in the health sector to cover unmet need and needs of the unserved or less-­‐served groups. 5) Procurement hassle and delay had been the achilles heel in the sector programmes. The problems are known, so are the solutions (as reiterated in MTR 2008 and APR 2009). The constraints imposed by the Government and the World Bank procurement rules can be moderated with flexibility and foresight shown by MOHFW as well as the World Bank. It is a must for improving service delivery and programme implementation and final_report_hnpsp 36 for improving the bond of partnership which is the vital plank of the sector-­‐wide approach. 6) Along with procurement, the human resource inadequacies identified in the earlier chapter (Chapt. 5) have to be seriously addressed with keen focus throughout the period of the next programme. These two (i.e. procurement and HR) together hold the key to strengthening the service delivery function of the next Programme. It is worth repeating that MTR 2008 held that MOHFW would need to strengthen the existing service delivery system to achieve further improvements in health outcomes, since the benefits from the vertical programmes appear to have been nearly exhausted. 7) The management structure centred around the Line Director need immediate support through personnel with specialised management, planning and accounting skills. Management training piloted during the later years of HNPSP needs to be made more widely available for the field-­‐level managers. Renewed attempts should also be made to ensure continuity of LDs for a minimum number of years, at least for the big OPs. 8) Programme monitoring must be improved with greater stress on programme data, rather than the existing focus only on financial performance. No temporary measure would be enough to substitute the need for generating reliable data through routine MIS. Detailed recommendations as to what needs to be done were made in both MTR 2008 and APR 2009. Relevant programme data would be generated only when needed and demanded by supervisory managers and the Ministry-­‐level policy makers. MOHFW and the DGs can strengthen their leadership role with informed monitoring of the state of implementation of the Programme. 9) Field level supervision has to be upgraded into a periodic and regular inspection system with supportive inspection guidelines. Common complaints of patients and service seekers should be addressed and resolved to ensure better quality of service and to remove opportunities for misgovernanace. Lessons learnt from associating the community with running the Community clinics can be utilised in the next programme to improve service delivery through public participation and support. 10) The new sector programme may keep provision for periodic revision of OPs, as and when deemed necessary, to accommodate the relevant aspects of the rrecommendations made in this Report. 11) Separate guidelines for processing the sector-­‐wide programme and its components (OPs) may be developed through inter-­‐ministerial consultations in the interest of improved planning and implementation of SWAp in the MOHFW. 12) Counterpart Plan of Action only Revenue side to support /complement annual work plan in OPs may be developed e.g. for filling up vacancies and deployment, recruitment and promotion as needed, creation of posts, supplemented by training and capacity development for newly created/upgraded facilities. A Monitoring body within MOHFW could be set up to coordinate the needed steps. final_report_hnpsp 37 Part II Chapter 7 Reports on Selected Operational Plans. The Reports on the OPs cover some of the major OPs. The focus is on a) OPs on Service Delovery and b) those on Support System. Following OPs on Service Delivery have been reported on : 1. DGFP : A) Clinical Constraception Service Delivery Programme B) Family Planning Field Services Delivery Programme C) Matenal, Child and Reproductive Health Services Delivery Programme 2. MOHFW: OP on NNP DGHS : A) Essential Services Delivery B) Improved Hospital Services Managment The following OPs on Support System have been covered: A) Human Resource Managment ( DGHS, DGFP, and MOHFW) B) Capacity Development C) Improved Financial Management ( DGHS, DGFP, and MOHFW) D) Procurement Logistics and Supply Managment (DGHS and DGFP) OPs ON SERVICE DELIVERY-­‐ DGFP Summary findings 7.1. Operational Plans on (a)Clinical Contraceptive Service Delivery Programme (CCSDP), (b)Family Planning Field Service Delivery Programme ( FPSDP) and (c)Maternal, Child and Reproductive Health Service Service Delivery Progemme (MC & RH). The objectives and targets of the OP on CCSDP • Promoting a more effective method-­‐mix of Contraceptive Prevalence Rate (CPR) with increased share/proportion of permanent and long acting family planning methods. Attaining replacement level fertility by 2010 at the earliest, and its continuation and Performing VSC-­‐17,50,000; IUD -­‐23,00,000 and Implant -­‐10,50,000 and also multisectoral collaboration during the period of HNPSP(2003-­‐2011). The Objectives and Targets of the FPSDP were i)
To reduce Total Fertility Rate(TFR) from 3.3 to 2.2 per woman by 2011 ii)
To increase CPR from 54% to 72% by 2011 iii)
To reduce discontinuation rate of contraceptive uses from 44.5%(BDHS2007) to 20% by 2011 iv)
To continue the NRR at replacement level after 2011. The Objectives and Targets: of the OP on MC & RH •
•
final_report_hnpsp 38 To increase coverage of care during pregnancy, child birth and post partum by skilled personnel. • To promote identification of at risk pregnancy and complication of Antenatal and post partum period and their management or referral to appropriate Institutions. • To increase availability of and access to effective and timely interventions dealt with Obstetrical Emergengies at MCWCs, MCHTI, MFSTC and selected UH&FWCs • To reduce unsafe abortion and practices and provide post-­‐abortion care. • To establish MCH-­‐HP facilities as women, baby and adolescent friendly • To make better use of existing facilities • To strengthen the provision of MC&RH care services pro-­‐poor by increased deployment of programme personnel and resources in disadvantaged geopgraphic areas including urban slums and by reducing recognized access barriers for poor and vulnerable groups. • To support EPI programmme of Health Directorate for ensuring Universal Immunization Coverage of children towards the reduction of infant and child mortality, morbidity and disability. • Achievement of those specific objectives was addressed jointly with Family Planning Field Services Delivery Programme, NGOs efforts and intensified IEC campaigns and also multisectoral collaboration. Physical Performance of the OP on CCSDP: The physical performance of the OP on CCSDP. The target of performance of permanent method (Tubectomy and Vasectomy) has been achieved (99.74%). The performance of IUD insertions has been achieved by 87.25 per cent. The target of performing sub-­‐dermal Implants has been achieved by 89.27 per cent. The target of making 1500 UH&FWC as User’s friendly for VSC and Implant Services has been achieved. About financial performance, it was found that The OP on FPFSD could utilize 87.68 per cent of the allocation. The CCSDP could utilize 82.66 per cent of the allocation. The financial performance of the OP on MC & RH is found to be 85.36 per cent of the allocation. The over all performance of this three OPs was 85.36 per cent. The financial performance of the other OPs of DGFP was 66.03 per cent. Out of a total allocation of Tk 351231 lakh, the DGFP could utililize Tk 294366 or 83.81 per cent. There is thus not only problem of availability of fund but efficient utilization of the available fund as well. The Total fertility rate (TFR) after remaining stalled at about 3.3 in the 1990s has declined to 2.7 in BDHS2007 and a further decline to 2.5 has been observed in the BMMS2010. Over the period CPR for any method showed an increasing trend up to UESD 2006 but in BDHS 2007 slightly lower value of 55.8 per cent was found. But in the USED2010 increased CPR of 61.7 per cent has been observed. The CPR for any modern method has also shown an increasing trend. But CPR for long lasting and permanent method (LAPM) in the last decade has been low and stagnant. In the BDHS2004 the CPR for any LAPM was 7.2 per cent and in UESD 2010 it slightly increased to 7.4 per cent. The field workers home visit has increased from 18.2 per cent in BDHS2004 to 21.0 per cent in BDHS2007. Reproductive Health Services: Compared to the decade of 1990s, antenatal care (ANC) has improved in the last decade. In the BDHS 2004 50.5 per cent of women received ANC from medically trained provider. Since then it has been hovering about 54 per cent in recent years. For women in the lowest two wealth quintile, the use of ANC has increased from32.5 per cent in UESD2006 to 40.3 Per cent in UESD2010. This is an indication that more and more women from poor families are getting access to ANC. There has been lot of improvement in the percentages of deliveries attended by skilled personnel. It increased from 15.7 per cent in BDHS2004 to 26.5 per cent in BMMS2010. The deliveries attended by skilled personnel also increased for women in the lowest two •
final_report_hnpsp 39 quintile groups. It increased from 4.1 per cent in BDHS2004 to 11.8 per cent in UESD2010. The percentage of mothers who have been receiving postnatal care (PNC) increased form 19.3 per cent BDHS2004 to 22.4 per cent in UESD2010. The proportion of new born who received post natal care was similar to that of their mothers. It increased from 19.0 per cent in BDHS 2004 to 22.7 per cent in UESD2010. It appears that Bangladesh is well on track to achieve the MDG4: Achieving IMR 33/1000 and U5 mortality rate 48/1000 live birth by the year 2015. Regarding MDG5 of attaining maternal mortality rate of 144/100,000 live births in 2015 there appears to be some uncertainty. Given the maternal mortality rate of 194/100,000 live births in BMMS 2010 Bangladeshi Policy makers have to express far more commitment and the implementors of the programme have to make vigorous effort to make the reproductive health programme far more efficient. Commitment and Leadership of Policy makers. Bangladesh has along history of Government supported Population control programme starting as early as 1960. After the creation of Bangladesh, Population control programme was attached priority in the first five year plan (1973-­‐78). Since then it has remain a priority topic in all the development plans. But there has been variation in commitment and leadership of policy makers over the last 4 decades or so. This has been depicted in the family Planning Programme Effort Studies conducted in 1999, 2004 and 2009. On the policy component the effort score of Bangladesh has decreased considerably over the period 1999-­‐2009. The annual rate of increase of contraceptive use in recent years has been low or negligible. Major reasons for this are organizational weakness of the programme, low field workers home visits, no increase in the share of LAPM, high and increasing discontinuation rate and increasing unmet need for family planning. Funding and Its Utilization. There has been inadequate funding in the FP, Maternal and Child health and RH programme. However due to programme inefficiency, they have been unable to spend the fund allocated. Contraceptive Supply and Stock outs. Under the HNPSP, the procurement of goods and services were to be carried out in line with IDA and World Bank Guidelines. However, due to lack of experience on the part of DGHS and DGFP regarding IDA an World Bank procurement guideline, the procurement process caused a lot of delay. To address this problem USAID's DELIVER (2007) projectprovided technical assistance to train the procurement staff of DGHS and DGFP. Some of the Observations of the DELIVER are given below DELIVERs technical assistance support over the last few years has contributed toward a significant strengthening of the Bangladesh FP-­‐MCH supply chain. Notable improvements have been achieved in contraceptive procurement as well as in improved supply chain performance. 7.1. A. Clinical Contraception Service Delivery Programme (CCSDP) Objectives: Main objective of the programme was to promoting a more effective method-­‐mix of Contraceptive Prevalence Rate (CPR) with increased share/proportion of permanent and long acting family planning methods. The specific objectives were • Attaining replacement level fertility by 2010 at the earliest, and its continuation and final_report_hnpsp 40 •
Performing VSC-­‐17,50,000; IUD -­‐23,00,000 and Implant -­‐10,50,000 and also multisectoral collaboration during the period of HNPSP(2003-­‐2011). Achievement of those specific objectives was addressed jointly with Family Planning Field Services Delivery Programme, NGOs efforts and intensified IEC campaigns and also multisectoral collaboration. Programme Contents: Key Strategies adapted to Achieve Replacement Level Fertility by 2010. 1. Shifting contraceptive use patterns towards more effective longer-­‐acting and permanent methods from short-­‐term hormonal and traditional methods; and promoting increased male participation specially No-­‐scalpel Vasectomy(NSV): 2. Multi-­‐sectoral efforts for raising female age at marriage and first birth through promoting female education(including female school/college stipend programme) and employment, and more effective enforcement of the legal age of marriage: 3. Intensifying Public information and motivation campaigns to bring about over all changes in attitudes and awareness creation among all stake-­‐holders(beneficiaries, service providers, community people etc.) on enhancing longer acting and permanent methods , delayed marriage, poularizing maximum two –child family size norm, minimizing dropout & unwanted fertility, male involvement in NSV, availability of FP services, female education etc. 4. Reinvigorating domiciliary visit especially in hard to reach, far-­‐flung, low-­‐
performing areas by well infirmed field staff I.E. FWAs, NGO field workers/depot holders. LIP’s female volunteers who can effectively counsel couples to maximize continuation of FP methods, minimize unnecessary methods switchings; motivating, selecting and bringing clients to nearby service centers for adopting permanent and longer-­‐acting methods 5. Establishing strong coordination with MoLG&RDC especially with city corporations for starting domiciliary services and registration of eligible couples especially in urban slums, thickly populated peri-­‐urban & industrial areas through existing contracted NGOs of UPHCP and keeping provision in UPHCP phase-­‐II 6. Introducing new variety of medically safe & easily applicable hormonal and non-­‐
hormonal longer-­‐acting contraceptives methods in national FP programme for meeting wide range of choices and minimizing methods switching side-­‐
effects/complications and drop-­‐outs. 7. Bringing couples having unmet need for FP (11.3% of the whole(?) eligible couples into FP methods use particularly for long-­‐acting and permanent methods. 8. Expanding new service delivery facilities close to door steps of the users and organizing special programmes on clinical contraception, and converting all facilities more attractive and user’s friendly by improving management of services and by improving provider’s attitude. 9. Improving access to family planning services through offering high quality services through introducing ‘Medical Eligibility Criteria’ as developed by WHO and implementation of standard operational procedures for improving the appropriate and adequate counseling, screening, follow-­‐up, side-­‐effects management and treatment of complications. 10. To promote the Long term & permanent Family Planning methods in all over the country there is the shortage of service providers. To solve the shortage of service providers coordination between GO & NGO has been taken in the program. NGOs like EngenderHealth, Marry Stopes Clinics Society, Life Buoy friendship Hospital services are working in different areas. final_report_hnpsp 41 11. Recently the National Population Council directed to work as multi-­‐sectoral approach for the population program. A policy will be formulated to provide support and incentives in the areas of health, education and employment to the parents of one child. Priority Issues of the Programme: The priority activities undertaken through this OP were 1. Promoting increase coverage of permanent and longer-­‐acting methods. To increase more share/proportion of modern FP methods in CPR by performing following projected clinical FP services during the period of 2003-­‐2011. Services to be Achievement and Projection for Permanent and longer-­‐acting FP Services provided 2003-­‐04 2004-­‐05 2005-­‐06 2006-­‐07 2003-­‐07 Total Total 2007-­‐11 2003-­‐11 VSC(Tubectomy 93971 143744 124960 191700 554375 1000000 1554375 & NSV) IUD 195018 256170 266499 221694 939381 1400000 2339381 Implant 68315 117914 75879 13804 275912 680000 955912 Source : RPIP 2. Up grading of UH&FWCs as User’s Friendly: To make 1500 UH&FWCs as User's friendly close to-­‐clients for providing VSC and Implant services along with other safe motherhood services through equipping, finishing and renovating in phases. 3. Introducing new variety of longer-­‐acting FP methods in national FP programme: Efforts will be undertaken to replace the existing Norplant and Copper-­‐IUDs Tcu-­‐380A with superior varieties in terms of Implantation/insertion & removal procedures, effectiveness, costs and user safety. Table 7.1.1 Annual achievement and projection for permanent & longer acting FP methods and other activities. Indicators Units of Benchmark Year-­‐wise Achievement and Projection measurement (Mid 2003) 2003-­‐07 2007-­‐
2008-­‐
2009-­‐
08 09 10 VSC Number of 73325 554375 199125 250000 250000 (Tubectomy & VSC (FPCSTS/QATS, Vasectomy) performed in 2002-­‐2003 a Financial Year IUD Number of 171980 939381 231514 350000 350000 IUD inserted (FPCSTS/QATS, to users in a 2002-­‐2003 Financial Year Sub-­‐dermal Number of 61008 275912 171942 170000 170000 Implant Sub-­‐dermal (FPCSTS/QATS, Implant 2002-­‐2003 provided in a Financial Year Discontinuation % of eligible 48.6% 44.5% 44% 36% 30% Rate of couples aged (BDHS/1999-­‐
(BDHS2007) final_report_hnpsp 42 2010-­‐
To
11 200
250000 155
350000 233
170000 955
20% 20%
Contraception 15-­‐49 years 00 who discontinued use of (modern contraceptives methods) Making Number of No 1500 UH&FWC as UH&FWC User’s friendly equipped & for VSC and furnished as Implant User’s friendly Services in ayear Source: RPIP Implementation Modalities: Implementation responsibilities of these strategies are not only mandate of DGFP or MOHFW, but also require multi-­‐sectoral efforts and involvement (like female education & employment, urban FP-­‐MCH services. Under population sub-­‐sector of HNPSP these strategies were addressed and materialized through three direct FP-­‐MCH services delivery related Operational Plans of DGFP i.e. • OP of Clinical Contraception • OP of Field Services and • Op of MC&RH Services Delivery Programmes The other implementation modalities and issues were i)
Providing Financial Support for Permanent and Longer-­‐acting Contraceptive Servicers: Since inception of permanent and longer-­‐acting contraceptive services i.e VSC(Tubectomy & NSV) , IUD, Implant and Recanalization services in national FP programme of Bangladesh, some financial support through ‘Impress Fund” system are being arranged and paid instantly on the spot and will be continued during the HNPSP period. ii)
Strengthening Service Delivery Provision in Existing Static Centers: iii)
Promoting Intra and Post-­‐partum contraception iv)
Organization of special VSC Programme v)
Provision of Recanalization Services vi)
Introducing New Variety of Longer-­‐acting Contraceptives in National FP programme GO-­‐NGO Collaboration: Collaborative support continued with NGOS like BAVS, Engender Health, FPAB, MSCS, BRAC, NSDP funded NGOs, UPHCP’s NGO Clinics and other private sector clinics/hospitals for enhancing performances of permanent and longer-­‐acting FP methods. Quality of Care and Infection Prevention: Contraceptive Manual, MCWC Opertion Manual, UH & FWC Operation Management Manual has been prepared and updated. Medical eligibility criteria developed by WHO have been adopted in national FP programme for selecting appropriate FP methods for users by ensuring adequate information and effective counseling. Institutional Strengthening: Existing 8 Regional FPCSTs/QATs are being and will be continued in HNPSP (2003-­‐11). The overall goal of these FPCSTs/QATs is to monitor the outlets of clinical FP services along with EOC-­‐RH services of MCWCs and final_report_hnpsp 43 150
to identify measures for improving the quality of clinical contraceptive and EOC services of MCWCs. Estimated Cost (Taka in Lakh) Original Approved Cost for 1st Revised Approved Cost 2nd Revised Proposed Cost 2003-­‐2006 for 2003-­‐2010 for 2003-­‐2011 GOB PA Total GOB PA Total GOB PA Total 9620 5690 15310 22580 26330 48910 32860 27855 60715 Source : RPIP final_report_hnpsp 44 7.1.B. Family Planning Field Service Delivery Programme (FPFSD). Objectives and Targets: The objectives and targets of this OP were i)
To reduce Total Fertility Rate(TFR) from 3.3 to 2.2 per woman by 2011 ii)
To increase CPR from 54% to 72% by 2011 iii)
To reduce discontinuation rate of contraceptive uses from 44.5%(BDHS2007) to 20% by 2011 iv)
To continue the NRR at replacement level after 2011. Key Strategies adopted to Achieve Replacement Level Fertility by 2011. 1. Reinvigorating domiciliary visit specially hard to reach, far flung , low performing areas by well skilled field staff i.e. FWAs, NGO field workers/depo holders/Volunteers who can effectively counsel couples to maximize continuation of temporary FP methods, minimize unnecessary methods switching; motivating, selecting and bringing clients to nearby service centers for adopting permanent & longer acting FP methods. 2. Bringing couples having unmet need for FP(11.3% of the whole eligible couples into FP methods use particularly for long-­‐acting and permanent methods 3. Multi-­‐sectoral efforts for rising female age at marriage and first birth through promoting female education(including female school/college stipend programme) and employment, and more effective enforcement of the legal age of marriage: 4. Establishing strong coordination with MoLG&RDC especially with city Corporations for starting domiciliary services and registration of eligible couples Especially in urban slums, thickly populated peri-­‐urban & industrial areas through existing contracted NGOs of UPHCP and keeping provision in UPHCP phase-­‐II 5. Intensifying Public information and motivation campaigns to bring about over all changes in attitudes and awareness creation among all stake-­‐olders(beneficiaries, service providers, community people etc.) on enhancing longer acting and permanent methods , delayed marriage, poularizing maximum two –child family size norm, minimizing dropout & unwanted fertility, male involvement in NSV, availability of FP services, female education etc. 6 Shifting contraceptive use patterns towards more effective longer-­‐acting and permanent methods from short-­‐term hormonal and traditional methods; and promoting increased male participation specially No-­‐scalpel Vasectomy(NSV): 7. By intensifying Conduction of Satellite Clinics and upgrading periodically all the UH&FWC, quality service will be ensured to the clients and all UH&FWC will be made user friendly. Priority Issues of the Programme: To ensure achievement of the specific objectives, priority issues considered were follows a) Reviving domiciliary FP-­‐MCH services with appropriate record keeping using Unit wise FWA registers b) Expanding program coverage to under served areas including low-­‐performing areas, groups and urban slums final_report_hnpsp 45 c) Reducing discontinuation rate of different contraceptives and encouraging gradual transition of family planning acceptors to long acting and permanent methods by frequent visit and follow up and ensuring switch over from one method to another. d) Promoting a more effective method mix of CPR with increased share/proportion of permanent and longer acting FP methods. e) Improving the appropriate and adequate counseling , Screening, follow up and side effects management and treatment of complications for reduction of discontinuation rate of temporary contraceptive methods i.e decreasing drop out f) Intensify the Organization of satellite clinics g) Improving management skills, supportive supervision and performance monitoring h) Promoting the factors for increasing the average age of child bearing through delaying marriage, first birth and then increasing the space between births to counteract population momentum effects. i) Promoting Social Marketing of condom, oral pill, injectables, implant and other methods of contraceptives after due trial and test. Other Issues To be Addressed. i)Urban FP-­‐MCH Services Delivery ii) Assuring Availability of Contraceptives iii) Reviving and ensuring domiciliary visits of FWAs iv)Reintroduction of Unit-­‐wise FWA Registers v)Intensifying conduction of Satellite Clinics vi) Management and maintenance for 3991 UH&FWCs vii)Maintenance of Security and Cleanliness of UH&FWCs viii) Procurement of Bicycle, Motor Cycles and Jeeps ix) Providing Special Uniform x) Strengthening services of UH&FWCs xi) Displaying of lists of available Services at 3991 UH&FWCs wall by Painting and Gardening xii) Program Management in Riverine Areas xiii) IEC & Information Cmpaigns xiv) MIS GO-­‐NGO Collaboration. There are, throughout Bangladesh, abpout 400 national and local-­‐level NGOs working in the field of family planning services delivery. NGOs are thus playing an increasing important role in the promotion and service delivery for RH:FP-­‐MCH . Implementation Modalities: Implementation responsibilities of these strategies are not only mandate of DGFP or MOHFW, but also require multi-­‐sectoral efforts and involvement (like female education & employment, urban FP-­‐MCH services. Under population sub-­‐sector of HNPSP these strategies will be addressed and materialized through three direct FP-­‐MCH services delivery related Operational Plans of DGFP i.e. • OP of Clinical Contraception • OP of Field Services and • Op of MC&RH Services Delivery Programmes final_report_hnpsp 46 Estimated Cost : (Taka in Lakh) Original Approved Cost for 1st Revised Approved Cost 2003-­‐2006 for 2003-­‐2010 GOB PA Total GOB PA Total 13500 98050 111550 21850 165950 187800 Source: RPIP 2nd Revised Proposed Cost for 2003-­‐2011 GOB 34198 PA Total 165002 199201 7.1. C. Maternal , Child and Reproductive Health Services Delivery Programme (MCRH). This programme was intended to deliver quality safe motherhood, child and other reproductive health services along with FP services as a package organizational structure of DGFP for improvement of health and family welfare status of the mothers, children and adolescents, and to facilitate decline in maternal, infant and child mortality and morbidity within the broad perspective of reproductive health Components: There are four components under this OP. • Safe Motherhood Services • Child Health Care Services • New born Care • Adolescent Health Care for girls and boys Objectives and Targets: • To increase coverage of care during pregnancy, child birth and post partum by skilled personnel. • To promote identification of at risk pregnancy and complication of Antenatal and post –
partum period and their management or referral to appropriate Institutions. • To increase availability of and access to effective and timely interventions dealt with Obstetrical Emergengies at MCWCs, MCHTI, MFSTC and selected UH&FWCs • To reduce unsafe abortion and practices and provide post-­‐abortion care. • To establish MCH-­‐HP facilities as women, baby and adolescent friendly • To make better use of existing facilities • To strengthen the provision of MC&RH care services pro-­‐poor by increased deployment of programme personnel and resources in disadvantaged geopgraphic areas including urban slums and by reducing recognized access barriers for poor and vulnerable groups. • To support EPI programmme of Health Directorate for ensuring Universal Immunization Coverage of children towards the reduction of infant and child mortality, morbidity and disability. Table 7.1.2 Planned Target:Projection for MC& RH Services Indicators Unit of Benchmark Achieved Projected Target Measurement With year and data source(Mid 2003) 2007-­‐08 2008-­‐09 2009-­‐10 2010-­‐11 ANC Number of 1500000 4008339 4150000 4300000 4450000 final_report_hnpsp 47 mothers received ANC in a year PNC Number of 570000 12000000 1300000 1400000 1500000 mothers received PNC in a year Safe MR Number of 250000 191138 250000 3000000 350000 women received MR services in a year Safe Number of 465000 1293015 1350000 1425000 1500000 Delivery Pregnant obtained safe child birth care oth at home and facilities provided in a year Availability Number of 1500 2000 2500 3300 Of safe UH&FWCs staffed delivery at and equipped for UH&FWC safe delivery and Obstetric First Aid. Source: RPIP Programme Strategies for Implementing MC & RH Services Delivery: • Expansion of Maternal, Child and Adolescent Health Coverage through reactivating and strengthening of Satellite Clinics (8 per month per union which can be relaxed in special situations) covering all hard-­‐to-­‐reach areas and urban slums. • Reviving and strengthening of domiciliary MC& RH-­‐FP services by FWAs with appropriate record keeping and reporting by using FWA registers. • Upgrading, equipping and furnishing selected UH&FWCs(3300 out of total 3622) as women-­‐children-­‐adolescent friendly’ for safe delivery, obstetric first aid, Basic EOC(where trained MOs and Midwifery trained FWVs are available), essential new born care and adolescent health care services. • MOH&FW already developed Bangladesh National Strategy for Maternal Health.Under the HNPSP this National Strategy for Maternal Health will be fully operationalized with emphasis on ANC, Skilled Birth Attendants and the phase-­‐wise expansion of obstetric first aid and EOC. • Upgradation of 30 existing MCWCs for providing comprehensive RH-­‐FP and EOC services by expansion of bed capacity from 10 to 20 beds based on the performance and needs during HNPSP. Other MCWCs would be expanded by phases during the plan period. • Expanding coverage of Comprehensive Emergency Obstetric Care(EOC) through operationalization of additional 5 MCWCs now already constructed and 2 new MCWCs to be constructed during HNPSP. • Further strengthening of on-­‐going RH-­‐EOC/FP services at MCWCs, MCHTI and MFSTC. • Expanding the on-­‐going training on Midwifery Practices for existing FWVs and CSBAs for FWAs for developing skilled manpower to provide safe delivery, Obstetric first aid, basic EOC(in case trained MO is posted) at UH&FWCs and safe delivery and obstetric first aid. final_report_hnpsp 48 •
•
•
•
•
•
•
•
Strengthening the referral system for proper management of ‘at risk’ pregnancies, complicated pregnancies and labour at different level of Family Planning and health facilities. Making all MCWCs women, baby and adolescent friendly Strengthening of Clinical Management, Supportive Supervision and Performance Monitoring. Scaling up essential new born care in service centres and also in domiciliary services. Providing greater importance to Quality of Care specially at EOC facilities and upgraded UH&FWCs. Initiating audit of all maternal and perinatal deaths in MCWCs for ensuring quality of care and developing accountability of service providers. Logistic support to all MCWCs, MCH units of UHCs, UF&FWCs, MCHTI, MFSTC, Satellite clinics and other facilities under DGFP. Utilization of NGOs for MCH activities Establishing an effective functional coordination with DGHS for providing EmOC, MVH-­‐
HP, EPI, adolesecent health services, newborn care specially at UHCs, District Hospitals, Model FP Clinics of Medical College Hospital and RDs. Priority Issues of the Programme: 1. Promoting coverage of ANC, PNC, Safe delivery at home and facilities by skilled personnel and MR services. 2. Making upgraded 3300 UH&FWCs as ‘User friendly’ for providing safe motherhood (safe delivery, obstetric first aid and bsic EOC), newborn care and adolescent health care services along with VSC and implant services through upgrading, equipping, furnishing and renovating in phases. 3. Increasing coverage of safe delivery care by skilled personnel through development and deployment of CSBAs. The qualified CSBAs are certified and registered under the Bangladesh Nursing Council 1983 Ordinance No. LXI, Section 14. 4. Developing Adolescent Health Strategy in collaboration with all stakeholders. 5. For ensuring quality of Service, different forms and Registers would be used at service centers. 6. Introduction of Health Voucher Scheme to increase demand for maternal and neonatal health services. Pregnant women would be given vouchers to purchase antenatal, normal delivery and postnatal services from a designated provider of their choices for the first and second pregnancy. Estimated Cost : (Taka in Lakh) Original Approved Cost for 1st Revised Approved Cost 2nd Revised Proposed Cost 2003-­‐2006 for 2003-­‐2010 for 2003-­‐2011 GOB PA Total GOB PA Total GOB PA Total 4200 12150 16350 9250 44590 53850 15323 53771 69094 Source: RPIP final_report_hnpsp 49 Implementation Modalities: 1. Upgradation of UH& FWCs as User Friendly 2. Assuring availability of essential commodities 3. Increasing Coverage of Conducting Safe Deliveries, Close-­‐to-­‐Users, by providing training and deployment of skilled personnel. 4. Develeopment of Adolescent Health Strategy 5. Introducing Emergency Contraceptive Pill(ECP) 6. GO-­‐NGO collaboration 7. Activities undertaken by the Development Agencies (a) Reproductive Health Interventions through DGFP supportedby UNFPA through 7th Country Cycle progamme(2006-­‐2010) (b) Accelerating Progress Towrads Maternal and Neonatal Mortality and Morbidity Reduction Project(MNH Project) (c) Ensuring equitable access to good quality Sexual and Reproductive Health Services-­‐WHO BIENNIUM 08-­‐09 (d) Safe Motherhood Promotion Project, Japan Interntional Cooperation Agency(JICA) 8. Strengthening Service Delivery of MCHTI, Azimpur, Dhaka 9. Establishment of Maternal and Child Health Training and Research Institute(MCHTI), Lalkuthi, Mirpur, Dhaka 10. Upgradtion of Mohammadpur Fertility Services and Training Centre(MFSTC), Dhaka Document Review: MTR and APR, APIR Mid_Term Review(MTR) 2008 : Priority Action Plan Table 7.1.3 Proposed Actions for inclusion in in the area of MNCH in OP July 2008-­‐June 2010 Actions to be taken Immediate Short term Medium term Before June 2008 In next OP 2008/09 Before end HNPSP 1.Family Initiate a study on Implement remedial Review and refine Planning:Improve barriers to use measures home visit use of long lasting strategy for and greater impact permanent contraception 2. Expand IMCI Set targets with dates Integrate IMCI and Integrate IMCI for ANCB(NNP) in defined into TOR of all Expansion of Upazilas target of Upazilas future NNP having IMCI for contracts for unqualified providers NGOs 3. Improve maternal 1. Revise targets for 1. In MH Voucher health during HNPSP HNPSP Upazilas: periods Increase services for normal childbirth in public and private facilities 2. Based on a study, propose measures to increase maternal health services for final_report_hnpsp 50 4. Prepare for broader approach to meeting maternal health needs 5. Joint planning and monitoring urban poor 1. Establish Task Adopt revised Maternal Adopt midwifery Group to review Health Strategy work force Maternal Health strategy and begin Strategy implementation of 2. Establish workforce some preparatory subgroup on mid-­‐
Measures wifery 2. Provide results of MMR study Prepare, implement and report progress on consolidated annual district plans for maternal and child health, family planning and nutrition. Main Report MTR 2008, p14 Key Recommendations: Family Planning: The decline of TFR is on target but CPR remained stagnant • HNPSP has sustained gains but did not achieve its objectives of accelerating long lasting methods. • Unmet needs, particularly for clinical methods is increasing , yet use has not increased. Recommendation: Implement a study on problems in using long term and permanent methods and design appropriate measures. This should include a review of the technical (clinical) quality of care and access to services for complications for complications of long lasting methods. Maternal Health: Progress is slower than desired and is predicted to achieve only about 70% MDG target • Skilled attendance during child birth has increased (13% to 18%) but the gain is mostly from use of private sector and probably not among the poor • Home deliveries by untrained persons remains extremely high(about 80%) • Shortage of mid-­‐wifery skills in the country is the most critical bottleneck which retards the increase in skilled attendance • EmOC has been established at all district level facilities and some at Upazila level. The ‘met need for management of complications of pregnancy at Upazila level increased from about 13% to 15% but is far below target, while caesarian rates in these facilities indicate a large unmet need remains in those districts or Upazilas Recommendations. 1. Revise targets to realistic levels for the remaining period of HNPSP, and initiate measures to achieve those targets 2. Accelerate actions to improve maternal and new born health. 3. Carefully monitor implementation of the maternal health voucher scheme 4. Urban Poor:Initiate a study to assess the feasibility of mobilizing NGOs to provide MNCH/FP packages (including bEOC and referral to cEOC) for urban poor within the HNPSP period. final_report_hnpsp 51 5. Review specific sections of the Maternal Health Strategy, 2001 particularly to clarify and strengthen measures to (i) improve referral systems including referral transport (ii) build positive linkages with TBAs to promote referrals and (iii) strengthen the focus on promoting normal childbirth in health facilities, including counseling by field workers on birth planning. 6. Prepare fast-­‐tracked human resource development plan for mid-­‐wifery services for the country through a mid-­‐wifery workforce planning sub-­‐group 7. Implement a maternal mortality survey that will provide MMR information to feed into the final evaluation of HNPSP. Integrated Planning and Monitoring of MNCH Prepare, implement and report progress on consolidated annual district plans for maternal and child health, family planning and nutrition, including specific measures to improve •
•
•
•
Clinical supervision of each lower level facility Referral and follow up e.g. for clinical contraception, maternal health Birth planning for mothers to encourage institutional delivery in identified facilities that have available bEOC and cEOC services but lower utilization than expected Monitoring of achievements in similar activities that are implemented under different operational plans(e.g. EmOC, bEOC, ANC, PNC) Annual Programme Review (APR): 2009: Since the MTR 2008 , significant steps have been taken to implement the agreed recommendations.They include (a) expression of commitment to improving nursing(and midwifery) at the highest political level (b) a massive recruitment exercise including filling vacancies for doctors and FWAs (c) adoption of a National Strategy (d) acceptance of proposed Midwifery strategy to increase midwifery skills in the country (e) steps to train pairs of doctors(obstetric and anaesthesia) to provide EmOC and incentives to place them in upgraded upazila level facilities (g) steps to expand IMCI through NGOs working at the community level under NNP. Child Health. Expansion of the facility based IMCI is progressing well, but expanding the implementation of IMCI at community level and including pharmacies and ‘village doctors’ is relatively slow. Collaboration with sussessful social marketing approach used by the family planning programme that trains private sector pharmacists and traditional and informal providers could be a way forward. Another critical challenge is neonatal mortality which remains high-­‐it was 42 in 1999-­‐2000, 41 in 2004 and 37 in 2007. Only 22% of children receive appropriate care within 24 hours of birth. The challenge is that 82% of births occur in home. It is necessary to educate communities and care givers who attend new born children at home on simple life-­‐saving measures for the new born. Maternal Health. ANC coverage is 51% (target 55%) but wealth disparity is marked (31% in LQ1 compared to 83% in LQ5. final_report_hnpsp 52 Skilled attendance at birth has increased slightly since 2004, largely due to increased use of private sector by the wealthier quintiles. The recently completed massive receuitment of staff including doctors and FWAs did not include nurses and FWVs. The nurse recruitment was stalled, and efforts underway to revive the process require urgent attention. Severe inadequacy of midwifery trained persons is a major constraint to increasing skilled attendance for births both at home and in facilities. A strategy for increasing midwifery skills in the country has been outlined and accepted. Several issues need attention. These include (a) administrative, legal and fianancial measures to enable the creation of the proposed new cadre of Junior Nurse-­‐Midwives (b) coordination of the Junior Nurse-­‐Midwife proposal with other parallel proposals such as training of Community Paramedics (c) empowering the private sector to provide skilled attendance for childbirth by enabling the proposed new category(ies) as well as CSBAs to work as employees or self-­‐employed. The upward trend in use of emergency obstetric care is encouraging, but the gap between between poor and rich is very great (Caesarean rate is LQ1 is 1.8% compared to 25% in LQ5). Maternal Voucher Scheme has been implemented in 33 Upazilas of which 9 Upazilas have universal eligibility, while the others use defined poverty criteria. Initial reports indicate improved utilization of services. Family Planning: There has been little progress in increasing contraceptive prevalence which is stagnant at 47.5 for modern methods. Threre is 17% unmet need for contraception. Use of oral contraception has probably reached a saturation levels. Only 13% use permanent and long term methods (PLTM); this has declined from the 1993-­‐94 level of 26%. The focus on increasing the use of PLTM implies the need for a higher skilled workforce. The key messages for population and Family Planning are • Energise the entire nation toward rapid population stabilization • Make family planning the concern of all arms of MOHFW-­‐not confined to DGFP • Adapt implementation strategies to the needs of different regions • Increase innovative approaches to address hard to serve communitiesl Table 7.1. 4 . Recommendation for MNCH and FP Actions to be Next Year Last Year undertaken July 2009-­‐June 2010 July 2010-­‐June 2011 1. Expand use of CEmOC 1. Improve coverage and use of Expand quality ANC, EmOC and PNC standards and 2.Establish, implement and monitor monitoring quality standards Decide on future of 3.Evaluate the Voucher scheme and voucher scheme revise 2. Increase 1. Mainstream, and expand CSBA 1.EstablishCSBA CSBA/midwifery for training, restart FWV training, and practice in public & improving skilled implement recruitment of nurses private sectors attendance 2. Establish time targets for making 2.Implement new the midwifery strategy operational midwifery strategy 3. Complete the review of MH strategy including acceptable roles of TBAs, CSBA and junior nurse-­‐
midwives 3.Expand IMCI and 1.Set time targets to expand each Further expansion of improve postnatal and aspect of community IMCI and extend IMCI . Implement action final_report_hnpsp 53 neonatal care 4.Promote inter-­‐sectoral measures to support population stabilization 5. Increase permanent and long term contraceptive use and reduce drop out rates F-­‐IMCI to District Hospitals 2. Draft and implement action plan with time targets for the Neonatal Strategy 1.Promote awareness of population issues among policy makers 2 Participate in inter-­‐sectoral mechanisms to support measures to support fertility reduction 1. Prepare district/upazila specific strategies and begin implementation 2. Develop a time bound plan to integrate family planning into all services offered by MOHFW Develop and implement BCC suited to each district. plan with time targets for the Neonatal Strategy Evaluate impact of district strategies and refine accordingly 6. Reduce unmet need Assess impact of BCC and increase CPR and develop strategies. Source and Note: APR 2009, Vol 1, p 62 APIR 2010: Problems identified , Action Taken and Lessons Learned. Problems • Lngthy and complicated procedure for procurement uner IDA Guideline, some essential commodities like Implant, IUD and MSR(Sharee and Lungi) could not be procured within the stipulated time. Consequently there wer 2 years stock-­‐out of Implant and IUD, Sharee and Lungi for one year. • Shortage of Skilled Manpower in service center and grass root level. • Timeliness is not maintained for distributing required fund in ADP allocation Actions Undertaken/Yet to Take: • Logistics coordination forum is formed. Procurement plan and procurement processing schedule is prepared on need assessment • Contraceptive Security system is maintained • Simplification of IDA procurement procedure and deployment of expert personnel in logistics and Supply Unit of DGFP. • Fund should be available in proper time • Manpower need to be recruited urgently Lessons learned. • Male participation in accepting NSV has insignificantly increased. This is because of strong campaign and easy surgical procedure NSV acceptors ramin highly satisfied. • Due to shortage of Implant and IUD, coverage of those services have declined • Wage loss, dietary charge and transport cost of LAPM service recipient and incentive/fee of service providers in hard to reach area have been increased. APR 2010. Progress on the Prioritized Action Plan and Way Forward. Since the last APR(APR 2009), initiatives have been taken to foster implementation of agreed recommendations, which are crucial for achieving Maternal, Neonatal and Child Health(MNCH) final_report_hnpsp 54 outcomes in HNPSP. Major achievements and the way forward observed during the period are given below. Maternal Health: The major achievement during the period • Expansion of emergency obstetric care(EmOC) services with increased utilization during the review period. A total of 257 GOB facilities including district hospitals, UHCs and MCWCs are providing EmOC services. • Focus on increasing the number of CSBA as well as initiation of midwifery training to increase coverage of skilled attendance during delivery. A total of 1137 C-­‐SBAs were trained during the period covered by the review • Development by the Bangladesh Nursing Council(BNC) of a strategic direction paper on mid-­‐wifery, which was approved by MOHFW in February 2009. Moreover, a new curriculum for existing nurse-­‐midwives was drafted by BNC and finalized for the pilot intervention. • Permission was given to the DGFP to start recruiting FWVs, though the recruitment process is yet to start. Current impasse on nurse recruitment has been unblocked and around 2,000 nurses are recruited, while recruitment of another 1,182 nurses is underway. The following actions were identified as the way forward : • EmOC centers need to be monitored for effective utilization and provision of quality services 24 hours a day, 7 days a week. • Existing strategy for C-­‐SBA training will be continued • Guidelines need to be developed and implemented to ensure standard monitoring and regulation of the C-­‐SBA training program for both public and non public providers. • Retention of trained human resources continues to be a challenge for providing EmOC services. • FWV training institutes should be reactivated. Neonatal and Child Health. The IMCI program has made substantial progress in implementing the prioritized action plan as well as overall improvement in child health status. The major achievements: • The Community-­‐IMCI program , which is implemented through GO/NGO partnership and incorporate essential new born care and sick newborn care management referral , was scaled up from 7 Upazilas in 2009 to more than 50 upazilas(13 districts), meeting the recommended APR 2009 target. In addition, the Facility-­‐IMCI program was expanded to 60 more upazilas; a total of 343 upazilas in 48 districts, including 40 district hospitals, are now providing IMCI services. New born care has been integrated within on-­‐going C-­‐IMCI and F-­‐IMCI, although service provision on the ground has just started. • Facility-­‐IMCI has been mainstreamed into the medical education curriculum and essential and sick newborn cares have been integrated within various training packages at both community and facility level. The Way Forward. The following actions were identified as the way forward: • Scaling up home-­‐based essential newborn and community case management of sick children, through provision of quality of services in high priority and deprived districts and focused facilities. final_report_hnpsp 55 •
•
Effective nutrition intervention packages within Community-­‐IMCI and Facility-­‐
IMCI services will be integrated in line with actions to be taken in mainstream nutrition. Quality of Community-­‐IMCI and Facility-­‐IMCI services and availability of trained personnel, essential drugs and commodities need to be ensured, with supportive supervision and strengthened monitoring mechanisms. Family Planning: The major achievements: Several measures were undertaken to increase use of long acting and permanent methods(LAPM) especially in the low performing areas of Chittagong and Sylhet Divisions. These included BCC activities, relaxation of social eligibility criteria for LAPM, client segmentation, formation of a LAPM strategy and advisory Committee, orientation and training workshops for service providers and religious leaders, use of satisfied No-­‐scalpel vasectomy clients as advocates, and a roving team approach to reduce geographical disparities in performance. The Way Forward: The following actions were identified as the way forward: • The focus of LAPM will be kept, especially in low performing areas, to reduce drop-­‐outs, continuity of supply of family planning commodities needs to be ensured to avoid stock outs which hamper the program’s ability to reduce unmet need. Contraceptive security is critical and requires continuous monitoring. • Effective coordination among different partners is very much needed for synergistic impact on family planning and reproductive health indicators. Performance of Long Acting and Permanent Method (LAPM). The performance of long acting and permanent method during the period 2005-­‐11 are given in table .The adoption of permanent methods namely tubectomy and vasectomy has increased consistently over the period. During 2005-­‐06, 62076 tubectomy were performed which more than doubled to 138381 in 2010-­‐11. The number of vasectomy performed increased to almost than 3 times from 5710 in 2005-­‐06 to 150881 in 2010-­‐11. The performance of IUD insertions exhibited a fluctuating trend but in the year 2010-­‐11 it increased to 307267. The performance of Implant exhibited much more fluctuations. In the year 2010-­‐11 it increased to 273677, compared to much lower figure in the preceding years. Such variations in performance of LAPM methods are cause of concern from programme point of view and deserve in-­‐depth investigation. The predominant cause appears to be supply shortage. final_report_hnpsp 56 Table 7.1.5 Physical Performance of Long Acting /Permanent Methods of Family Planning: 2005-­‐2011 Period: FY LA/PM Methods Tubectomy Vasectomy Total IUD Implant VSC Aug’05-­‐Jun’06 62076 51710 113786 248717 66366 2006-­‐07 100409 91291 191700 221694 13804 2007-­‐08 106053 92994 199047 237312 177648 2008-­‐09 115754 100646 216400 330709 86720 2009-­‐10 128768 162430 291198 226415 40348 2010-­‐11 138381 150881 289262 307267 273677 Source: MIS, FPCST/CATS Report, DGFP. Physical Performance of the OP on CCSDP: Table gives the physical performance of the OP on CCSDP. The target of performance of permanent method(Tubectomy and Vasectomy) has been achieved (99.74%). The performance of IUD insertions has been achieved by 87.25 per cent. The target of performing sub-­‐dermal Implants has been achieved by 89.27 per cent. The target of making 1500 UH&FWC as User’s friendly for VSC and Implant Services has been achieved. Table 7.1.6 Physical Performance of Operational Plan CCSDP : 2003-­‐2011(8 Years): Indicators Units of Benchmark measurement (Mid 2003) 2003-­‐11 Target Achievement Per cent Achievement VSC Number of 73325 1554375 1550282 99.74 (Tubectomy & VSC (FPCSTS/QATS, Vasectomy) performed in 2002-­‐2003 a Financial Year IUD Number of 171980 2339381 2041084 87.25 IUD inserted (FPCSTS/QATS, to users in a 2002-­‐2003 Financial Year Sub-­‐dermal Number of 61008 955912 854305 89.27 Implant Sub-­‐dermal (FPCSTS/QATS, Implant 2002-­‐2003 provided in a Financial Year Discontinuation % of eligible 48.6% 20% 56.5 Rate of couples aged BDHS (BDHS2007) Contraception 15-­‐49 years 1999-­‐2000 who discontinued use of (modern final_report_hnpsp 57 contraceptives methods) Making Number of No 1500 1500 100.00 UH&FWC as UH&FWC User’s friendly equipped & for VSC and furnished as Implant User’s friendly Services in ayear Source: DGFP Financial Performance of the OPs: The financial performance of the Operational Plans under the DGFP during the period 2003-­‐
2011 is given in table . The OP on FPFSD could utilize 87.68 per cent of the allocation. The CCSDP could utilize 82.66 per cent of the allocation. The financial performance of the OP on MC &RH is found to be 85.36 per cent of the allocation. The over all performance of this three OPs was 85.36 per cent. The financial performance of the other OPs of DGFP was 66.03 per cent. Out of a total allocation of Tk 351231 lakh, the DGFP could utililize Tk 294366 or 83.81 per cent. There is thus not only problem of availability of fund but efficient utilization of the available fund as well. Table 7.1.6. Financial Performance of Operational Plans Under DGFP: 2003-­‐2011(8 Years):(In Lakh Taka) Operational Budget Allocation Expenditure Plans(OPs) GOB PA Total GOB PA Total Expenditure (Project (Project as Per cent Aid) Aid) of Budget FPFSD 28098 165002 193100 25958 143173 169131 87.68 CCSDP 38556 27855 66411 33787 20811 54598 82.66 MC&RH 14823 48777 63600 10700 41368 52068 81.87 Sub-­‐total 81477 241634 323111 70445 205352 275797 85.36 Other OPs 16281 11839 28120 9610 8959 18569 66.03 Total 97758 253473 351231 80055 214311 294366 83.81 Source: DGFP Fertility, FP and Reproductive Health Services:1993-­‐2010 Fertility and Family Planning. Table__summarizes the level and trend of some major indicators in the fields of fertility, family planning and reproductive health services of Bangladesh in last two decades or so. The Total fertility rate(TFR) after remaining stalled at about 3.3 in the 1990s has declined to 2.7 in BDHS2007 and a further decline to 2.5 has been observed in the BMMS2010. Over the period CPR for any method showed an increasing trend up to UESD 2006 but in BDHS 2007 slightly lower value of 55.8 per cent was found. But in the USED2010 increased CPR of 61.7 per cent has been observed. The CPR for any modern method has also shown an increasing trend. But CPR for long lasting and permanent method(LAPM) in the last decade has been low and stagnant. In the BDHS2004 the CPR for any LAPM was 7.2 per cent and in UESD 2010 it slightly final_report_hnpsp 58 increased to 7.4 per cent. The field workers home visit has increased from 18.2 per cent in BDHS2004 to 21.0 per cent in BDHS2007. In the early nineties field workers home visit was as high as 43.0 per cent. The discontinuation rate of contraception has increased from49.4 per cent in BDHS2004 to 56.5 percent in BDHS 2007. We are experiencing hurdles in minimizing the contraceptive discontinuation rate. The BDHS 2007 indicates a higher discontinuation rate of 56.5 per cent while compared to BDHS 1999-­‐2000The unmet need for the use of contraception has increased from 11.1 per cent in BDHS2004 to 17.1 per cent in BDHS2007. The intention for future use of contraception was found to be 70.1 in BDHS2007. Reproductive Health Services. Compared to the decade of 1990s, antenatal care(ANC) has improved in the last decade. In the BDHS2004 as high as 50.5 per cent of women received ANC from medically trained provider. Since then it has been hovering about 54 per cent in recent years. For women in the lowest two wealth quintile, the use of ANC has increased from32.5 per cent in UESD2006 to 40.3 Per cent in UESD2010. An indication that more and more women from poor families are getting access to ANC. There has been lot of improvement in the percentages of deliveries attended by skilled personnel. It increased from 15.7 per cent in BDHS2004 to 26.5 per cent in BMMS2010. The deliveries attended by skilled personnel also increased for women in the lowest two quintile groups. It increased from 4.1 per cent in BDHS2004 to 11.8 per cent in UESD2010. The percentage of mothers who have been receiving postnatal care(PNC) increased form 19.3 per cent BDHS2004 to 22.4 per cent in UESD2010. The proportion of new born who received post natal care was similar to that of their mothers. It increased from 19.0 per cent in BDHS2004 to 22.7 per cent in UESD2010. Table 7.1.7 Fertility, Family Planning and Reproductive Health Services: 1993 -­‐2010 Indicators BDHS BDHS BDHS BDHS UESD BDHS UESD UESD BMMS 1993-­‐
1996-­‐
1999-­‐ 2004 2006 2007 2008 2010 2010 94 97 2000 CPR(%): Any Method 44.6 49.2 53.8 58.1 58.1 55.8 59.5 61.7 Any Modern Method 36.2 41.5 43.6 47.3 48.6 47.5 49.5 54.1 Percenatge of Women in long 11.4 10.6 8.9 7.2 7.1 7.3 7.2 7.4 lasting birth control method(IUD,Norplant, female sterilization, male sterilization) Field Worker’s home visit(%) 43.0 35.2 21.2 18.2 21.0 Discontinuation of FP method 47.8 46.9 48.6 49.4 56.5 within 12 months after beginning use(%) Unmet need for Family 19.4 15.8 15.3 11.1 17.1 Plannning(%) Future Intentions To Use 66.0 66.5 71.3 73.2 70.1 Family Planning(%) Antenatal Coverage: Percentage of last live births in 25.7 29.5 34.7 50.5 46.3 53.6 51.3 56.0 53.7 the three years preceding the survey for which women received at least one ANC from a medically trained provider(Total) Percentage of last live births in 32.5 30.5 35.4 40.3 the three years preceding the survey for which women final_report_hnpsp 59 received at least one ANC from a medically trained provider by two lowest wealth quintile Deliveries attended by Skilled Personnel(facility or home): Percentage of births in the three 9.5 9.1 13.0 15.7 years preceding the survey attended by skilled personnel (Total) Percentage of births in the three -­‐ -­‐ -­‐ 4.1 years preceding the survey attended by skilled personnel by two lowest wealth quintile Postnatal care: Percentage of last live birth in 19.3 the three years preceding the survey where the mother received PNC from a trained provider within 42 days of delivery Percentage of last live birth in 19.0 the three years preceding the survey where the child received PNC from a trained provider Fertility Total Fertility Rate (TFR) 3.4 3.3 3.3 3.0 Wanted TFR 2.2 2.0 Source and Note: BDHS, UESD BMMS . 17.9 21.2 21.4 26.0 26.5 7.6 7.3 8.0 11.8 16.5 23.4 18.1 22.4 18.0 23.7 18.6 22.7 2.7 1.9 2.52 Progress in MDG4 and MDG5. Indicators of MDG4 and and MDG5 are given in table . It appears that Bangladesh is well on track to achieve the MDG4: Achieving IMR 33/1000 and U5 mortality rate 48/1000 live birth by the year 2015. Regarding MDG5 of attaining maternal mortality rate of 144/100,000 live births in 2015 there appears to be some uncertainty. Given the maternal mortality rate of 194/100,000 live births in BMMS2010 Bangladeshi Policy makers have to express far more commitment and the implementors of the programme have to make vigorous effort to make the reproductive health programme far more efficient. Table 7.1.8 Progress in Maternal, Neonatal and Child Health, Family Planning, and MDG4 and MDG5 During HNPSP. Indicators and Targets IMR of 33/1000 and U5M final_report_hnpsp Expected Outputs and Results in HNPSP 1.Reducing IMR and U5M to Achieve MDG4 Progress during HNPSP 2003-­‐11 1. Bangladesh is on track to achieve MDG4 with 60 impressive decline in infant and Under-­‐five mortality 2. IMR declined from 65(2004) to 52(2007) 3. U5M declined from 88(2004) to 65(2007) Of 48/1000 by 2015 1.To decrease Maternal 2.Reducing maternal Bangladesh will be close to Mortality Rate from 322/ mortality to achieve MDG5 target MDG5 . 100,000 live births 1.Maternal Mortality Rate (BMMS 2001) to has decreased from 144/100,000 live births in 322(BMMS 2001) to 2015 194(BMMS2010): 2.To increase the proportion of births by skilled birth attendants from 13% (BDHS 2004) to 43% by 2011(APIR 2009) 2. Births with skilled attendance has increased from 15.7%(2004) to 26.5%(2010 BMMS) 1.To reduce TFR to 2.2 by 2011(APIR) 2. To increase Contraceptive Prevalence Rate of modern methods (CPR) and increase access to reproductive health services. 3. Reducing Fertility in line with the Population Policy which is to achieve replacement level of fertility i.e.TFR of 2.2. by 2010 1. TFR declined from 3.0(2004) to 2.7(2007) and 2.5 (2010 BMMS) 2. CPR (modern methods) increased from 47.3%(2004 BDHS) to 54.1%(2010 UESD). Source and Note: APR 2009. Targets from MDG Progress Report 2009. BDHS, BMMS, UESD Programme Performance: Strength and Weakness. In general the FP and Reproductive Health programme performed well. The programme has shown success in the following indicators: Ø The TFR remaining stalled or near stagnant for about a decade has started to decline in recent years. final_report_hnpsp 61 Ø The CPR for any method and for any modern method has started to increase in recent years. Ø Future intention to use contraception is also high (70.1%) Ø ANC coverage has shown increasing trend Ø PNC coverage has shown increasing trend Ø Deliveries attended by skilled personnel are on the increase Ø Postnatal care of mothers is on the increase Ø Post natal care of new born is also on the increase Ø Bangladesh is on track to achieve MDG4 (Infant and Under five mortality) Ø Bangladesh is likely to be close to achieving MDG5(Reducing Maternal Mortality) The programme needs to address the following short comings. Ø
Ø
Ø
Ø
Ø
Ø
Ø
Strong commitment from policy makers Dedicated field workers to their purpose CPR of LAPM methods are low and stagnant Discontinuation of Contraceptive methods is on the increase. Unmet need for family planning is on the increase Field Workers home visits is on the decline Stock out of Contraceptives Elaboration of some of the points are in order: Commitment and Leadership of Policy makers. Bangladesh has along history of Government supported Population control programme starting as early as 1960. After the creation of Bangladesh , Population control rogramme was attached priority in the first five year plan (1973-­‐78). Since then it has remain a priority topic in all the development plans. But there has been variation in commitment and leadership of policy makers over the last 4 decades or so. This has been depicted in the family Planning Programme Effort Studies conducted in 1999, 2004 and 2009. On the policy component the effort score of Bangladesh has decreased considerably over the period 1999-­‐2009. Stagnating Contraceptive use in recent years. The annual rate of increase of contraceptive use in recent years has been low or negligible. Major reasons for this are organizational weakness of the programme , low field workers home visits, no increase in the share of LAPM, high and increasing discontinuation rate and increasing unmet need for family planning. Funding and Its Utilization. There has been inadequate funding in the FP, Maternal and Child health and RH programme. However due to programme inefficiency, they have been unable to spend the fund allocated. Contraceptive Supply and Stock outs. Under the HNPSP, the procurement of goods and services were to be carried out in line with IDA and World Bank Guidelines. However , due to lack of experience on the part of DGHS and DGFP regarding IDA an World Bank procurement guideline, final_report_hnpsp 62 the procurement process caused a lot of delay. To address this problem USAID’s DELIVER(2007) projectprovided technical assistance to train the procurement staff of DGHS and DGFP. Some of the Observations of the DELIVER are given below DELIVER’s technical assistance support over the last few years has contributed toward a significant strengthening of the Bangladesh FP-­‐MCH supply chain. Notable improvements have been achieved in contraceptive procurement as well as in improved supply chain performance. However, there is a scope and need for further improvements, especially in attaining greater efficiency in these two areas. The investments made so far need to be protected and carried on further. In addressing future assistance in logistics and commodity security, the following areas merit consideration: Ø continuation of dedicated support for institutional strengthening and capacity building for public-­‐sector procurement presently conducted by the MOHFW through the DGFP and DGHS Ø use of private-­‐sector sources to support forecasting, monitoring and supervision, and training. The private sector could also be considered for executing public-­‐sector procurements selectively, especially for large bulk procurements Ø introduction and expansion, in phases, of appropriate approaches and state-­‐of-­‐the-­‐art technologies (e.g., bar coding) for supply chain efficiency improvements Ø capitalizing on the obvious benefits experienced by having a network of field-­‐based staff for problem solving and provision of on-­‐the-­‐job training and technical assistance to address the field needs Ø taking extra-­‐cautious steps in planning a realistic timeline when contraceptive procurement is done by the GOB, following the requirements of the lending agency, as delays may occur at any step of the process, resulting in stockout Ø improvement in donor coordination by using the existing Logistics Coordination Forum with analytical support in procurement and supply chain areas Ø making adjustments in the program as it matures by restructuring field program activities, redefining the role of field-­‐based Logistics Support Officers (LSOs) to continue as troubleshooters, and expanding LSO functions to include field-­‐based training below the upazila level and last mile logistics issues Ø identifying and increasing the capacity of young professionals in donor agencies, the GOB, NGOs, and in the private sector to function as champions for logistics and commodity security Ø understanding and emphasizing the need for having a clearly spelled out agreement in writing, through a Memorandum of Understanding with the MOHFW, that involves USAID or the donor consortium, to carry out the agreed-­‐upon activities on contraceptive security by setting up a high-­‐level policy task force Ø reviewing absorption capacity and timely processing of procurement activities of the MOHFW staff regarding the provision of procurement technical support, thus increasing effectiveness in ensuring timely procurement to avoid stock outs, and discussing and exploring alternative potential strategies. final_report_hnpsp 63 Some major challenges for DELIVER in the future: Ø Staff turnover at all levels within the MOHFW remains a major constraint. Changes in government makes policy shifts. These challenges have made capacity building a continuously shifting target. Ø There are emerging structures in the GOB—notably, cells for procurement and logistics monitoring at the MOHFW and DGFP levels—that need assistance to build GOB capacities. Ø The Central Procurement Technical Unit housed in the Ministry of Planning, mandated to provide technical support for procurement to ministries, needs technical and capacity building assistance. Ø There is a need to strengthen monitoring and supervision of the logistics system, which has remained the weakest link in the supply chain. The Monitoring Cell established in the DGFP needs to be strengthened and made functional. Ø Barkat et al (2010) in a study on Human and Economic Impact of RH Supplies Shortage & Stock Outs in Bangladesh made the following recommendations about supply problems of contraceptives: Ø ü Streamline procurement system and make the procedure simpler reduce steps of bureaucratic bottlenecks, cumbersome and time-­‐consuming formalities. ü Effect need-­‐based, bottom-­‐up procurement plan. ü Like the other issues, 'Population problem' should be focused as a major national ü issue. ü Encourage, promote/patronize for local production of quality FP-­‐RH commodities, particularly contraceptives such as pill, condom, injectables etc. in public and private sectors to procure it locally. ü Empower District FP Authorities to make local procurement of available RH commodities to meet shortages in the supply line/stocks urgently. ü Allocate fund from Revenue Budget of the government for procurement/production of RH commodities to reduce donor-­‐dependence with the objective of achieving self reliance and sustainability. ü Establish a sound monitoring system, a forecasting mechanism of procurement and supply. ü Ensure training and re-­‐training of field functionaries to build up their work skill (motivation, service-­‐delivery, record-­‐keeping, reporting, monitoring etc.) and meet the discrepancy of the govt. report and the field reality. ü Permanent contraceptives methods should be encouraged to get rid of irregular supply system. ü Undertake basic studies to develop contraceptives suitable for use by the ever growing population of Bangladesh. ü Carry out separate study on ‘Reasons of irregular supply of FP items at the service delivery points’. ü Expand and equip storage facilities to have a capacity for at least 24 months stocks in stores at different levels (regional/local). ü Increase manpower at the field level to regularize home visit and proper service delivery near the door steps of clientele. ü Alternatives/options to increase manpower in the field should be seriously examined, pilot tested and adopted, if found economically-­‐socially suitable/viable. ü Utilize the services of NGOs in service delivery and monitoring where there is shortage in manpower to strengthen home visit and service delivery. final_report_hnpsp 64 ü Strengthen FP programme by professional people (population-­‐FP) of the Department (cadre) to get the best out of present day bureaucracy, democratic culture and specialization. In view of the findings of the study and recommendations by Programme Managers, Service Providers and Clients, the study team suggest to institute a full-­‐fledged Project Resource Mobilization and Awareness (PRMA) Unit for effective monitoring of procurement and supply activities of RH-­‐FP commodities. PRMA may also be given the responsibility of advocacy at various levels. The study team also suggests a time-­‐bound implementation plan for implementation of all feasible recommendations for the greater interest of the nation. final_report_hnpsp 65 OP ON SERVICE DELIVERY-­‐ MOHFW 7.2.A Operational Plan On : NNP Summary The achievements of NNP are drawn from the available records and based on comparisons between 2004 to and 2010. The mean height of all ever-­‐married women aged 15-­‐49 yrs showed no change since 2004. The data indicate a slight improvement in women’s nutritional status as measured by the BMI. Since 2004 the mean BMI have increased from 20.2 to 20.6; consequently, the proportion of women with a BMI below the cutoff point of 18.5 showed a change from 34 percent to 30 percent, between 2004 and 2009. Moreover, obesity among women has increased slightly, from 9 percent in 2004 to 12 percent in 2007. Severe under weight (<2 SD) children showed reduction from 25% in 2004 to 9.4% in 2010. Moderate underweight improved by 5.1% in 2010 than 2004. Households using iodized salt have increased by 10% from the figure existed in 2004. Pregnant women weighing remained static. Night blindness prevalence rate showed 0.04%, Vitamin A capsule coverage among 1-­‐5 year children was 99.7% in 2008, Vitamin A capsule coverage among postpartum mothers was 35.0% in 2006, De–worming (Tab. Albendazole) distribution rate 2008 in 99.3%. Prevalence of stunting among children under 5 years of age BDHS, every 3 yrs showed a reduction from 43.2% in 2004 to 38%in 2007 (BDS, 2007). Prevalence of underweight among children under 5 years of age was 41.0% in 2004 improved to 33% in 2007. Infant feeding status up to 6 month improved from 43% in 2004 to 42% 2007. Infant and young child feeding (IYCF) was appropriate by 41.5% as shown in BDHS 2007 survey. Every year two rounds of vitamin A capsules supplementation to children aged 12 to 59 months showed a coverage of 20 million of children. The current coverage rate is about 99%. Along with the vitamin A supplementation, anti-­‐helminthes tablet, albendazole (400 mg) are also administered to 86% children aged 24 to 59 months. According to NNP MPR 2004, the proportion of Severe malnutrition was 13% and Moderate malnutrition was 23% among <2 years children. The Severe malnutrition was significantly reduced in old NNP areas. Supplementary feeding continued for the target groups of supplementary feeding are under two children from ultra poor families and pregnant women with BMI <17.0. In 2004, the coverage of pregnancy weight monitoring was 94%. Pertaining to this indicator, the overall performance of the ABCN has been improved in old Upazilas increased over the years. Adolescent girls and newly married women were also given iron and folic acid tablet to prevent pre-­‐pregnancy anaemia, in a dose of two tablets per week. 98.9% pregnant women, 96.4% Lactating women were given Iron Folate tablet and 92.4% Lactating Mother were given vitamin A capsule. In order to reduce the night blindness among postnatal mothers, a high dose Vitamin A capsule was given to the mother immediately after childbirth during the home visit by CNP. With the financial support from UNICEF, multiple micronutrient powder (MNP) supplementation for <2 years children was piloted in seven NNP Upazilas. The Child and Mother Nutrition Survey 2005 showed by BMI of the non pregnant adult mothers had Grade I CED (17 to 18.4) 3.7%, Grade II CED (16 to 16.9) 7.4%, Grade III CED (<16) 21.2%,Total (<18) 32.2%. Malnutrition rate in under was 41 (WHO 2008). Data on pregnancy weight gain is lacking. EmOC have showed improvement in delivery service. 10.7% <2 yrs. children of ultra poor families were brought under supplementary feeding. Of the total registered children, 8.9% were brought under SF in old Upazilas and 17% in new Upazilas. With the reduction of the rate of severe malnutrition, the supplementing feeding rate gradually reduced to 8.9% in 2010. Underweight in under 5 children reduced from 72 (1980) to 41 (2008). Stunting was 48.3% in 2000 it was 43.0% in 2008; wasted percentage also has with gone up from 12.0 in 2000 to 17.0 in 2008. Iodine nutritional status was 38.6% in 2005 in general population. Household consumption of iodized salt was 45%. MIS-­‐DGHS 2010 shows almost hundred percent lactating woman received Vitamin A capsule and iron tablet from June 2005 till June 2009. Feeding colostrums improved final_report_hnpsp 66 to 100.0% . The Child and Mother Nutrition Survey 2005 showed by BMI of the non pregnant adult mothers had Grade I CED (17 to 18.4) 3.7%, Grade II CED (16 to 16.9) 7.4%, Grade III CED (<16) 21.2%, and total (<18) 32.2%.Though information on household gardening is lacking yet iodine consumption, iron and folic acid distribution have contributed to improve maternal and child nutritional status from HNPSP. NNP could utilize 70.8% of the budget, but appreciable improvement was achieved in nutrition scenario of country particularly to the vast majority of rural people of the country. Background Bangladesh is an endemic home of malnutrition. Government of Bangladesh lounged BINIP in order to reduce malnutrition in 1995 in 40 upazilas and subsequently the project was revised to cover 60 Upazila by 2002. From July 2002, the BINIP project continued under the National Nutrition Project (NNP) and was integrated to HNPSP in 2004. The present NNP coverage continued in 232 Upazillas till 2011. The scope of services provided by the implementing NGOs under the supervision of NNP were social mobilization, management at field level, training of field workers, field level supervision, keeping liaison with relevant Govt. officials at sub-­‐national level, supporting in implementation of ABCN components of NNP. Objectives The overall objective is to achieve sustainable improvements in the nutritional status of the population, particularly children and women, through adoption of new behaviors and appropriate use of nutrition services increasingly managed by local communities. The specific objectives to be achieved by 2011 were: • To reduce the prevalence of low birth weight (<2,500 g) from 36% to 20% or less. • To reduce the prevalence of underweight (WAZ <-­‐2 Z-­‐scores) in children <5 years from 48% • (2000) to 36% (@ 2% reduction/ year). • To reduce the prevalence of stunting (HAZ <-­‐2 Z -­‐scores) in children <5 years from 43% to 37% (@ 1% reduction/year). • To maintain the prevalence of night blindness among children aged 12-­‐59 months below 0.5%. • To reduce the night blindness among pregnant women below 5%. • To reduce the prevalence of anemia in < 5 years children, from 49% to 40%, adolescents from 30% to 20%, and in pregnant women from 46% to 30%. • The reduce the prevalence of iodine deficiency (UIE <100 ug/L) from 43% to 23% of all school children. • Pregnancy weight gain more than 9kg or more in 50% of pregnant women • To increase household food & nutrition security through homestead food production final_report_hnpsp 67 Estimated Cost: (Taka in Lakh) Original Approved cost for 1st Revised Approved Cost 2nd Revised Proposed Cost 2003-­‐2006 for for 2003-­‐2010 2003-­‐2011 GOB PA Total GOB PA Total GOB PA Total 1020 1340 2360 1150 1540 2690 619 422 1,041 Estimated Costs and Expenditures of HNPSP for National nutrition programme (In Crore TK.) Name of the Estimated cost PIP (2003-­‐11) Estimated Expenditure (2003-­‐
% fund Operational 11) utilized Plan (OP) GOB PA Total % of GOB PA Total Total National 143.4
1107.0 1250.5
7.55 86.24 799.1
885.36 70.8 nutrition 3 8 1 2 programme Components of the Nutrition sub-­‐sector under HNPSP: The Programme consists of two components: A Service Component and the Programme Support and Institutional Development Component. The Service Component comprised of two sub-­‐
components: (i) Area-­‐Based Community Nutrition and (ii) National Level Nutrition Services. The Programme Support and Institutional Development Component comprised of three sub-­‐
components: (i) Programme Management and Institutional Development (ii) Monitoring, Evaluation and Operations Research and (iii) Training and Behavioral Change communications. National level include activities (i) Behavior change communications for appropriate caring and feeding practices for nutrition intervention target groups. (ii) Breast feeding protection, promotion and support and (iii) Micro-­‐nutrient supplementation fortification of appropriate food with micronutrients Methodology The Evaluation method used for this report is from available documents of ministry of Health Family Welfare, Word Bank documents. The relevant personnel implanting particular the operational programme were also consulted. final_report_hnpsp 68 Findings with relevant sources. Table 7.2.1: Year wise Progress Report in some core service indicators based on MPR (APIR -­‐ 2010) SL. Indicators 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Pregnant Women Weighed Pregnant Women Received SF <2 Children Received SF Pregnant Women Received ANC Pregnant Women Received Iron Tablet Lactating Mother Received Iron Lactating Mother Received Vitamin A Fed colostrums Exclusive Breast Feeding up to 6 m HH using Iodized Salt New born Weighed Low birth Weight. Severe under Weight. (<2 children) Moderate under Weight. (<2 children) NNP Sept. Baseline 2004 2004 (%) (%) -­‐ 96.7 June 2005 (%) June 2006 (%) June 2007 (%) June 2008 (%) June 2009 (%) June 2010 (%) 97 96.6 97.4 97.6 98 96.4 -­‐ 21 24.2 17.6 13.7 10.7 9.1 8.3 -­‐ 8.0 13 8.7 0.10 6.4 5.4 9.9 52.8 60 74.5 80 88 95.2 97 88.3 43.4 87.8 93.4 73 95.7 96 98 55.9 97 82 97 -­‐ 45 99.8 100 100 98 99 73.8 8.1 99.0 98.7 99.9 100 98 99 100 98 96 93.3 46 99 99.7 99.9 99.8 100 99.6 9.9 53.2 48 52.7 61.2 64.1 65.7 71.9 99 69.0 61.0 82 84.7 86 93.9 91.8 92 -­‐ -­‐ 95 95 94 96 95.7 96.3 97 20.7 18 14.2 10.1 8.9 8.2 8 7.8 25.2 24 19.1 15.6 14.2 10.6 10.1 9.4 24.6 26 24.6 23.5 23.8 22.1 21.6 20.9 Iodine nutritional status was 38.6% in 2005 in general population. Household conjunction salt iodized salt more than 45%. Both the 2004 and 2007 BDHS surveys included anthropometric measurements of all ever married women age 15-­‐49. In previous BDHS surveys, only women who had children less than five years of age were selected for anthropometric measurements. Hence, the comparisons are confined to the 2004 and 2007 BDHS surveys. The mean height of all ever-­‐married women age 15-­‐49 has not changed since 2004. The data indicate a slight improvement in women’s final_report_hnpsp Dec 2010 (%) 69 96 10 8.6 21 nutritional status as measured by the BMI. Since 2004 the mean BMI has increased from 20.2 to 20.6; consequently, the proportion of women with a BMI below the cutoff point of 18.5 has decreased from 34 percent to 30 percent. Moreover, obesity among women has increased slightly, from 9 percent in 2004 to 12 percent in 2007. Table 1 show that low birth remained above 90%. Severe underweight (<2 SD) children has showed edit action from 25% in 2004 to 9.4% in 2010. Moderate underweight improve by 5.1% in 2010 that in 2004. House hold using iodized salt increased from 61.0% to 92% in 2009. Night blindness prevalence rate 2005 in 0.04%, Vitamin A capsule coverage among 1-­‐5 year children 2008 in 99.7%, Vitamin A capsule coverage among postpartum mothers 2006 in 35.0%, De –worming (Tab. Albendazole) distribution rate was 2008 in 99.3%. Prevalence of stunting among children less than 5 years of age BDHS, every 3 yrs 43.2%, BDHS 2007 in 38%. Prevalence of underweight among children under 5 years of age BDHS, every 3 yrs 41.0%, BDHS 2007 in 33%. Infant feeling status up to 6 month 43%, BDHS 2007, 42 % children of 6-­‐23 month fed with appropriate Infant and Young Child Feeding (IYCF) practices 41.5%, BDHS 2007. Comments There is substantial improvement in all parameters mention in the Table 1 except supplementary feeding of pregnant women decreased in 2010. Supplementary feeding in under 2 children increased by 1.9% from 2004 to 2010. Iron tablet was received by pregnant women showed a decreased in 2010. Low birth rate, severe and moderate underweight children of less than 2 years children showed a decline. Table 7.2. 2: Facility Health Information System Percentage of CNCs by their facility health information system, according to NGOs, 2009 Registers/Forms All Registers maintained for: <2 children 94.2 Preg./lactating 91.8 mother BCC 88.5 Newly-­‐wed 94.7 Adolescent 97.1 girls Adolescent 86.5 boys Husband forum 81.3 Father-­‐in-­‐Law 93.8 forum Mother-­‐in-­‐Law 93.3 CNCMC 77.4 /Regulation book Inspection 64.9 CNP note book 73.6 Stock register 81.3 Household 84.1 survey Other 0.5 All registers 40.4 Type of protocol/forms available BCC poster 86.5 final_report_hnpsp 70 Flip chart Flash card Booklets CNC monitoring chart Growth monitoring charts Household survey chart CNP work plan List of ultra-­‐
poor families Birth registration forms Logistic forms Referral slips Other All protocols/forms N 95.7 100.0 58.7 74.5 82.2 72.1 62.0 67.8 25.0 23.6 62.5 0.5 8.2 208 Comments From the above table it is shown the types of Health education material and use in community clinics along with its performance studied by NGOs. Health education materials was righty used for the overall improvement of NNP performance. Table 7.2. 3: Mother and Children indicators of NNP. (APIR 2010) Indicator(s) Unit of Benchmark Achievement Measurement (Data Source) 2008 2011 Prevalence of women with BMI % of women 38% 33% 28% <18.5 (HKI 2003) Prevalence of Low Birth Weight % of new born 36% (<2500 gm) <2500 gm (BBS/UNICEF 2003-­‐
26% <20% 04) Under weight (<2Z) reduction % of children 48% 40% 36% in under 5 children (<5y) (BDHS 2004) Stunting (<-­‐2Z) reduction % of children 43% 40% 37% in under 5 children (<5y) (BDHS 2004) Severe Underweight in under 2 % of children 11.4% children (WAZ<-­‐3) (<2y) (NNP Baseline, 8% <5% ICDDR’B 2004*) Moderate Underweight in under 2 % of children 29.3% children (WAZ>-­‐3 to -­‐2.01) (<2y) (NNP Baseline, 25% <20% ICDDR’B 2004*) Prevalence of anemia among Hb% 38.8% 35% 30% Pregnant women (NSP, HKI-­‐IPHN 2004) Prevalence of anemia among Hb% 39.7% 25% 20% adolescent girl (NSP, HKI-­‐IPHN 2004) Prevalence of anemia among Hb% 67.9% 48% 40% children 6-­‐59 months of age (NSP, HKI-­‐IPHN 2004) final_report_hnpsp 71 Vitamin A supplementation in newly delivered women postpartum % of newly delivered women % of HH 3.4% (NSP, HKI-­‐IPHN 2003) 50% >90% Deduction of critical food insecure 24% 21% 18% Households (HH) (NSP, HKI-­‐IPHN 2001) Comment The Table 3 showed percentage of women low BMI decreased by about 10% from 2003. Prevalence of low birth weight showed a decline of about 16% from 2004 to 2011. Underweight in less than 5 declines from 2004 to 2011 by 20%. Stunting of under 5 children decline by 6% in 2011. Severe underweight decline by 5%. Moderate underweight in under 2 children decline by 9.3%. Prevalence of anemia among pregnant women decline by 8.8%. Prevalence of anemia among adolescent girl decline by 19.7%. Prevalence of anemia among children 6-­‐59 months of age decline by 27.9%. Supplementation in newly delivered women postpartum showed decline. Deduction of critical food insecure household reduced by 6%. Every year two rounds of vitamin A capsules supplementation to children aged 12 to 59 months are done. Around 20 million of children are covered. The current coverage rate is about 98% to 99%. Along with the vitamin A supplementation, anti-­‐helminthes tablet, albendazole (400 mg) are also administered to children aged 24 to 59 months. About 86% of the children who receive vitamin A fall into this age group, who received albendazole in the past rounds. The coverage was 98% to 99%. Coverage of vitamin A to under-­‐1 year children has been continuing to improve. The last available data shows a coverage rate of 94% in 2008 from a figure of 85% in 2007. It is stated that coverage of postpartum mothers with vitamin A was 35% in 2007. Table 7.2.4 : Prevalence of malnutrition among the under <5 children (Year 2000 to Year 2008) MIS-­‐DGHS 2010 Source and Year Location Stunted% Wasted% Child Nutrition Survey 2000 Urban 37.5 10.9 Rural 50.2 12.2 National 48.3 12.0 Child & Maternal Nutrition Survey 2005 Urban 32.5 10.8 Rural 44.9 13.1 National 42.4 12.7 UNICEF 2000-­‐2006 National 43.0 13.0 Bangladesh Demographic & Health Survey Urban 14.4 36.4 BDHS-­‐ 2004 Rural 18.2 45.0 National 43.0 17.0 WHO 2008 National 43.0 17.0 Table shows that stunting was 48.3% in 2000 it has risen to 43.0% in 2008, wasted percentage also has with went up from 12.0 in 2000 to 17.0 in 2008. Comment Stunting decreased from 48.3% to 43.0% in 2007. Wasted rate increased by 5% from 2000 to 2007. Table 7.2.5 : Coverage of pregnancy care MIS-­‐DGHS Year Weighed woman Pregnant needed Pregnant received
ANC Supplementary feeding iron tablet final_report_hnpsp 72 2004 96.7% 21.0% 43.4% 52.8% 2004-­‐Sep 97.0% 24.2% 87.8% 60.6% 2005 96.6% 17.6% 93.4% 74.5% 2006 97.4% 13.7% 73.0% 80.0% 2007 97.6% 10.7% 95.7% 88.0% 2008 98.0% 9.1% 96.0% 95.2% 2009 0.0% 0.0% 98.0% 97.0% This Table shows that pregnant women were given good care like weight taking, supplementary feeding, given iron tablet, received ANC in a satisfactory status. But from a figure 13.5 of MIS-­‐DGHS 2010 shows almost hundred percent woman lactating woman received Vitamin A capsule and iron tablet from June 2005 till June 2009. Table 7.2.6 : Coverage of Newborn and young children services from (Years 2004 to 2009) Year Newborn weighed Low birth weight Newborn fed Exclusive colostrums breastfeeding up to 6 months 2004 95.0% 20.7% 93.3% 9.6% 2004-­‐Sep 95.0% 18.0% 40.0% 53.2% 2005 94.0% 14.2% 99.0% 38.0% 2006 96.0% 10.1% 99.7% 52.7% 2007 95.7% 8.9% 99.9% 61.2% 2008 96.3% 8.2% 99.9% 64.1% 2009 0.0% 8.0 100.0% 95.0% This Table 6 showed that newborn weighing have stated in NNP and continued till 2008. Low births weight children came down to 8% in 2009 from 20.7% in 2004. New born fed colostrums rose to 100% in 2009. Exclusive breastfeeding up to 6 months showed a tremendous increase from 9.6% in 2004 to 95.0% in 2009. Figure 13.5 of the MIS-­‐DGHS 2010 showed that household using iodized salt from 68.0% in 2004 to 92.0% in June 2009. Comment New born care is adequately given in NNP. There is a fall of low birth weight rate by 16.7% in 2009 from 2004. Table 7.2.7 : Prevalence of anemia in Bangladesh MIS-­‐DGHS 2009 Population group Prevalence (%) Pres-­‐school aged children 49% final_report_hnpsp 73 Pregnant women 46% Non pregnant women 33% Adolescents in country 23-­‐29% Adolescent in the Chittagong Hill Tracts 43% This Table showed that prevalence of anemia existed in pre school children by 49%, pregnant women 46%, non pregnant 23% , adolescent girl in the country 23-­‐29% and adolescent in the Chittagong hill tracts 43%. Anemia situation in pregnant and children is a nutritional problem in Bangladesh. The Child and Mother Nutrition Survey 2005 showed by BMI of the non pregnant adult mothers had Grade I CED (17 to 18.4) 3.7%, Grade II CED (16 to 16.9) 7.4%, Grade III CED (<16) 21.2%,
Total (<18) 32.2%. Strength of the NNP As per Completion Report -­‐ National Nutrition Program (NNP) 2004-­‐2011 Description of the key indicators: Registration of population: The CNP registered the target groups of the very beginning of the program activities and then updated every month. As of December 2010, total population of 167 upazilas was recorded as 45467038, of which 1910030 were<2 years children, 493046 were pregnant women, 380506 were lactating mothers, 288537 were newly married women and 2139195 were adolescent girls. Growth monitoring: The health promotion was done through counseling the mother about feeding, caring and eating practices of the child. As of December 2010 Total number of under two children registered in 157 upazilas were 19,10,030. Among which 1200897 were in 110 Upazilas and 709133 in new 57 Upazilas. Monthly growth monitoring coverage was 94.7%. In 2004, NNP started with 1135327 registered <2 children which by June 2010 became 19,10,030. Weight monitoring coverage was 94% in 2004 which was increased to 97% in 110 Upazilas, but it was 92.5% in new 57 Upazilas started in March 2010. Status of malnutrition among <2 yrs. children: In 110 upazilas 8.6% children were found as severely malnourished and 21% were moderately malnourished. Whereas in new upazilas 28% children were severely malnourished and 24% moderately malnourished (Fig-­‐1). According to NNP MPR 2004, the proportion of Severe malnutrition was 13% and Moderate malnutrition was 23% among <2 years children. The Severe malnutrition was significantly reduced in old NNP areas, whereas in new upazilas, it is almost same as it was in the beginning of old upazilas. Prevalence of moderate malnutrition in old upazilas showed a slow downward trend over the years. Fig 1 : Status of malnutrition among <2 yrs. children final_report_hnpsp 74 Pregnant women and <2 Children under supplementary feeding: The purpose of supplementary feeding is to demonstrate parents the substantial and rapid gain in nutrition status through feeding a small additional quantity of food. The food supplement consisting of powdered rice and pulse mixture with molasses and oil are used both for children and pregnant women. The target groups of supplementary feeding are under two children from ultra poor families and pregnant women with BMI <17.0,10.7% <2 yrs. children of ultra poor families were brought under supplementary feeding. Of the total registered children, 8.9% were brought under SF in old upazilas and 17% in new upazilas. The supplementing feeding rate was 23.5% in 2004. With the reduction of the rate of severe malnutrition, the supplementing feeding rate gradually reduced to 8.9% in 2010. Out of 493046 registered pregnant women, 11% were brought under supplementary feeding program in NNP areas. In old upazilas the proportion of pregnant women under SF was 8.6% and in new upazilas 18% (Fig-­‐2). Adequate weight gain during pregnancy was only in 4.5% of pregnant women. Fig 2 : Pregnant Women under SF Fig 3 : <2 yrs. children SF Low Birth Weight (LBW): In 2004, LBW was found 18%. With pregnancy weight monitoring, effective IPC, Social mobilization and creation of awareness in the community along with the women empowerment final_report_hnpsp 75 helped to reduce the incidence of LBW. LBW in old Upazila was 7.9% and in new Upazilas 35% (Fig-­‐4). Total 214079 live births were registered in all Upazilas, out of which 203258 new born babies were weighed. The coverage was 89.5%. LBW in NNP areas has reduced gradually over the years. Fig 4 : LBW Pregnancy weight monitoring: As of December 2010 about 493046 pregnant women were registered 94.6% pregnant women were weighed coverage was 97.8%. Coverage in old Upazilas was 97.2% and in new upazilas was 92.9% (Fig-­‐5). In 2004, the coverage of pregnancy weight monitoring was 94%. Pertaining to this indicator, the overall performance of the ABCN has been improved in old upazilas slightly over the years. Fig 5 : Pregnancy Weight Monitoring Antenatal Care (ANC) 81.6% pregnant women were referred for ANC to the health centers. Among them 82% in old upazilas and 74% in new upazilas were referred (Fig-­‐6). Increased proportion in old upazilas indicates assurance of health services in CNC, effective BCC activities and social awareness. Fig 6 : % of Pregnant Women referred for ANC Micronutrient supplementation: final_report_hnpsp 76 A daily dose of iron and folic acid tablet was given to pregnant women throughout the pregnancy and to lactating mothers for three months after delivery. Adolescent girls and newly married women were also given iron and folic acid tablet to prevent pre-­‐pregnancy anaemia in a dose of two tablets per week. 98.9% pregnant women 96.4%, Lactating women were given Iron Folate tablet and 92.4% Lactating Mother were given vitamin A capsule. In order to reduce the night blindness among postnatal mothers, a high dose Vitamin A capsule was given to the mother immediately after childbirth during the home visit by CNP. Multiple Micronutrient Supplem In seven NNP upazila 7 Upozila managers and 41field supervisors (FS) were given training of trainers (TOT). 152 CNOs and 1606 CNPs were trained at the field level who provided MNP packets to the mothers of the <2 children. IYCF: IYCF encompasses breast feeding and appropriate complementary feeding practices. It was one of the important activities of NNP which included both area based and national level nutrition service. NNP had a significant role in improving breast feeding and complementary feeding in NNP areas. 99% babies were received colostrums in old Upazilas and 89.4% in new Upazilas. About 69% babies in old Upazilas and 54.3% in new Upazilas was exclusively breast fed until 6 months and 95% babies in old and 88.9% in new Upazilas fed with complementary food (Fig-­‐7). The exclusive breast feeding and complementary feeding practices had a remarkable improvement in NNP areas, which in 2004 was 53.2% and 64% respectively. In the year, 2007-­‐09, 15 upazilas were selected to form mother support group in order to improve their EBF & CF rate. 15 upazila managers and 81 field supervisors were given training of trainers (TOT) who subsequently trained 307 CNOs and 5972 CNPs. These CNO/CNPs, at the CNC level formed 5972 Mother Support Groups (MSG) and 24988 MSG members. In the year 2010, another two upazilas was included. Thus 2 Upazila managers and 19 field supervisor were trained as trainer and 73 CNOs and 734 CNPs were trained who thereafter oriented 5872 mother support group members to form 734 mother support groups. From 2007-­‐10, total 17 upazilas was brought under MSG training where 17 upazila managers, 100 field supervisions, 380 CNOs and 6706 CNPs were trained on breast feeding and 30860 community people were trained on breast feeding to form 3862 mother support groups in 3862 CNCs. Fig 7 : EBF, CF & Colostrums feeding rate in NNP Areas There is improvement in comparison to 2004 in ANC, lactating mother received iron tablet, mother received Vitamin A, fed colostrums, exclusive breast feeding weight taking of the new born. Rest of the parameters showed declining tendencies. Underweight in under 5 children improved from 72 (1980) to 41 (2008). Protein energy nutrition as stunting was 48.3% in 2000 it has risen to 43.0% in 2008, wasted percentage also has with went up from 12.0 in 2000 to 17.0 in 2008. Iodine nutritional status was 38.6% in 2005 in general population. Household conjunction salt iodized salt more than 45%. The pregnant woman taken good care like weight taking, supplementary feeding, given iron tablet, received ANC in a satisfactory status. Almost hundred percent woman lactating woman received Vitamin A capsule and iron tablet from June 2005 till June 2009. The newborn weighing has started NNP and continues. Low births weight children came down to 8% in 2009 from 20.7% in 2004. New born fed colostrums always final_report_hnpsp 77 around 100.0% June to 2004 to 2009, except a drop in Sep-­‐2004. Exclusive breastfeeding up to 6 months showed a tremendous increase from 9.6% in 2004 to 95.0% in 2009. The household using iodized salt from 68.0% in 2004 to 92.0% in June 2009. The Child and Mother Nutrition Survey 2005 showed by BMI of the non pregnant adult mothers had Grade I CED (17 to 18.4) 3.7%, Grade II CED (16 to 16.9) 7.4%, Grade III CED (<16) 21.2%,Total (<18) 32.2%. Malnutrition rate in under 5 is 41 (WHO 2008) where as it was 72 in 1980. Data on pregnancy weight gain is lacking. EMOC have showed improvement in delivery service. A. Key factors affecting implementation and outcomes: Frequent changes of leadership and turnover of staff-­‐ From 2004 to 2011, several Executive Directors were posted at different time. Most of the officers were deputed from different departments and lack of technical skills to fulfill their terms of reference. Frequent changes in position delayed implementation process. New officers take time to familiarize themselves with the project activities. Lengthy procurement procedure: From getting approval of World Bank and MOHFW to complete the procurement process, it took about 3-­‐6 months or more, which caused the program implementation slow and created doubt about continuity of the program. There was a delay in contracting NGOs due to issues regarding transparency in procurement of NGO services, shifting responsibility of contracting NGOs by MSA. Short term NGO contracting-­‐ Since 2004, the NGOs were contracted out at different time for a short period and most of the time, half of the implementation period passed away to get the approval for World Bank and MOHFW. Delay in contract with NGOs hampered the continuation of service delivery which in turn negatively influences the impact of the program. Delays in approval and clearance-­‐ Some essential activities could not be completed as per planning because of not obtaining Government or World Bank’s approval or clearance in time. Field level training, IQUAG are the example. Delay in supply of logistics to the field: Delay in procurement of goods, retender, delay in supply from central office, end of contract period with NGOs and delay in extension sometimes caused delayed supply of logistics and thus, there was a lack of medicine or MIS materials in the field. Lack of Technical expertise: Technical positions of NNP were blocked with non-­‐technical persons, which denied the project technical expertise. Provision of appointing specialists or consultants was not utilized. Conclusion: There is steady in progress nutrition scenario from the inception of HNPSP programme. For example -­‐ Maternal malnutrition has lowered though ANC. Iron and folic acid distribution status to the pregnant and adolescent girls is yet inadequate. More household gardening as a means of food security is yet to show marked improved in nutritional situation of the most vulnerable section of community. BCC activities are contributing as a definite role in improving nutrition scenario to the rural areas of the country. During the last decade, Bangladesh showed an overall decline in malnutrition and achieved MDG in reducing child mortality rate. Though NNP had a lot of programmatic and managerial challenges, integration of nutrition progressed in HNPSP achievement goals. final_report_hnpsp 78 Only one fifth of the total population was covered by NNP, It is necessary to expand nutrition intervention throughout the country to address malnutrition. Urban and hilly areas an also needed to bring under nutrition services. Recommendation The NNP programme has stated creating impact on nutrition of the larger section of the population (women and children) recommended to be strengthened and be continued. Adequate and trained manpower should be employed for nutrition activities at all levels. Fund procurement and disbursement should be timely for effective delivery of the service. Behavioral change communication (BCC) should be strengthened at all level. IEC material should be developed keeping in mind that vast majority people can be benefited from IEC. Information and communication between consumer and provider may contribute to words improved men of nutrition status by self help. OP ON SERVICE DELIVERY-­‐ DGHS 7.2 : B) Essential Services Delivery Summary The evaluation data were collected by reviewing available secondary sources and consulting with appropriate and concerned officials. Major component of ESD OP showed an improvement in HNPSP period and is good step forward for achievement of essential services delivery. Reproductive health as a part of ESD showed that deliveries attended by skilled personnel increased from 15.5% in 2004 to 18% in 2007 (BDHS) and 26% in 2010 (USED 2010). EmOC helped 43.23% pregnant to receive complete ANC, 10.8% birth took place in public facilities and 55.5% birth attended by trained birth attendants. After economic intervention birth attended by skilled personnel rose by 43%, institutional birth rose by 25% and PNC coverage went up by 20%. MMR reduced to 194 from 322, complete maternal care reached to 48%from 19% respectively. For poor rural pregnant women unable to bear expenditure for delivery related cost, maternal health voucher scheme pays the cost as in the scheme. LBW rate reduced from 18 to 7.8. This achievement can be explained by mass awareness increased in the beneficiaries’ and availability of service facility close to the home. Complete immunization coverage went up, improved IMCI service, and increased Vitamin A coverage, lowering of low birth weight children and reduction of protein energy malnutrition in children are markedly improved in HPPSP period. Training on clinical management for doctors and paramedics, supply of essential drugs, and logistics availability have contributed to successful in implementation of these ESD component. The logistics procurement and empathy of providers have increased from July 2008 to June 2009 than July 2009 to June 2010. The common illnesses diagnosed by trained provider in < 5 children have contributed towards utilization of service from UHC and UHFWC from nearby Government health facilities. Due to ongoing national TB control program TB detection and cure rate increased from 2004 to 2009. Besides 35 urban dispensaries and 23 school health clinics are offering out patients’ facility. Under HNPSP this program is a compliment to urban primary care service provided by final_report_hnpsp 79 ministry o local government. Medical waste management run by CMMU of the Ministry of Health and Family Welfare dug 76 pits in UHC and UHWCs in Upozilas. Officials of 34 districts and 108 Upozilas received training as trainee, IEC materials developed and used for control of Hospital infections in respective Upozilas. Violence against women and girls are an important public issue and nearby health care facilities are ready to treat such injuries. Overall ESD is contributing effective management of consumers-­‐mostly women and children in rural areas more than ever before. ESD have utilized 84.4% of budget for effective delivery. Background Essential Service Delivery (ESD) is a priority in health care delivery service in Bangladesh, because this service is needed at any time by vast majority of the population, of the country. Moreover, the availability of service and cost of health is increasing for every one particularly for poor rural women and children. Components of ESD ESD is composed of the following components: 1. Reproductive Health 2. Child Health a. Expanded Programmed on Immunization (EPI) b. Control of Acute Respiratory Infections (ARI) c. Control of Diarrheal Diseases (CDD) d. Integrated Management of Childhood Illness (IMCI), and e. School Health Programmed 3. Limited Curative care 4. Urban Health Services 5. Health Care Waste Management, and 6. Support Services & Coordination The objectives, targets and strategies are described under in each components/components sub components. 1.
Reproductive Health i. Objectives /targets The government had taken up several initiatives in redressing the high burden of maternal mortality and morbidity through supporting efforts in strengthening the service delivery system. A joint initiative titled “ accelerating progress towards Maternal and Neonatal mortality and morbidity reduction” popularly known as MNH program was taken to achieve MDG & 5 funded by DFID and EC. This program was jointly be implemented by the GOB and UN agencies. It was envisaged that enhancing the capacity of health managers to plan, implement and effectively monitor maternal and neonatal health care services, with particular emphasis on reaching the poor and vulnerable populations would lead to achievement of the followings: i.
Increased capacity of Health personnel at all level to plan, coordinate, monitor and Maternal and Neonatal Health services with community participation. ii.
Implement improved family and community awareness and actions on appropriate Maternal & Neonatal Health practices. iii.
Increased rates of skilled attendance at delivery, both at community and facility level. iv.
Reduction in the delays in recognizing maternal and neonatal complications and deciding to seek care v.
Reduction in the time taken by women and babies to reach EMOC facilities for care. final_report_hnpsp 80 vi.
vii.
viii.
ix.
Reduction in the delay that women and babies experience in receiving appropriate quality care in facilities. Increased accountability of the Health care providers. Nurture social movement for reduction MMR as Women’s right and improved management of Violence against women Improve the Nutritional status of women and children. final_report_hnpsp 81 Estimated Cost: (Taka in Lakh) Original Approved cost for 1st Revised Approved Cost 2nd Revised Proposed Cost 2003-­‐2006 for for 2003-­‐2010 2003-­‐2011 GOB PA Total GOB PA Total GOB PA Total 8180 55600 63780 32710 237170 269870 47,891 237,354 285,245 Estimated Costs and Expenditures of HNPSP for Essential service delivery (In Crore TK.) Name of the Estimated cost PIP (2003-­‐11) Estimated Expenditure (2003-­‐
% fund Operational Plan 11) utilized (OP) GOB PA Total % of GOB PA Total Total Essential service 478.9 787.2 2373.5
17.22 368.09 2038.8
2406.97 84.38 delivery 1 2 4 8 Management of Implementation: The point raised in MTR 2008 that EmOC can contribute to reduce maternal mortality by availability of health providers and health facility at the time of need and it may in future contribute to reduction of home delivery. Dots programme was intensified for TB control. Medical waste management for prevention of infection was prioritized. In APIR 2010 main point raised to increase capacity of health personal, to improve community awareness, to make available the skill birth attendant for delivery, reduction in delay for maternal and neonatal complication for treatment, reduction of time to reach EmOC facility, to increase accountability of the health personnel, to nurture social movement on woman’s right and improved management of violence against woman, to improve nutritional status of the children. Methodology The Evaluation method used for this report is available documents of ministry of Health Family Welfare and related documents of Word Bank documents. The relevant personnel implementing the operational programme were consulted. The findings of review with sources are as follows-­‐ Table 7.2.8 : Utilization of Essential Service Delivery (UESD) Survey 2010 Indicators BDHS UESD BDHS UESD UESD 2004 2006 2007 2008 2010 Antenatal Coverage Percentage of last live births in the three years preceding the survey for which women received at least 50.5 46.3 53.6 51.3 56.0 one ANC from a medically trained provider Deliveries attended by skilled personnel (facility or home) Percentage of births in the three years preceding the 15.7 17.9 21.2 21.4 26.0 survey attended by skilled personnel Utilization rate of ESD of the two lowest income quintiles a) Percentage of births Total 15.7 17.9 21.2 21.4 26.0 attended by skilled By two lowest quintile 4.1 7.6 7.3 8.0 11.8 personnel (by wealth quintiles) b) Percentage of ANC by Total 50.5 46.3 53.4 51.3 56.0 medically trained providers By two lowest quintile 32.5 30.5 35.4 40.3 final_report_hnpsp 82 (by wealth quintiles) TT Coverage Percentage of mother age 15-­‐49 with a live births in the three years preceding the survey and whose last birth was protected against neonatal tetanus Postnatal Care Percentage of last live births in the three years preceding the survey where the mother received PNC from a trained provider within 42 days of delivery Percentage of last live births in the three years preceding the survey where the child received PNC from a trained provider within 42 days of delivery CPR with proportions for method mix Any method Any modern method Pill IUD Injection Condom Female Sterilization Male Sterilization Norplant Any traditional method Percentage of women on long lasting birth control methods (IUD, Norplant, female sterilization, male sterilization ) Vitamin A coverage Percentage of children (9-­‐59 months) receiving vitamin-­‐A capsules in the 6 months preceding the survey Vaccination Coverage Percentage of children age 12-­‐23 months who received specific vaccines at any time before the survey All vaccines BCG DPT3 Polio3 Measles -­‐ -­‐ 90.7 86.9 91.3 19.3 16.5 23.4 18.1 22.4 19.0 18.0 23.7 18.6 22.7 58.1 47.3 26.2 0.6 9.7 4.2 5.2 0.6 0.8 10.8 58.1 48.6 27.3 0.9 11.2 3.0 4.7 0.4 1.1 9.5 55.8 47.5 28.5 0.9 7.0 4.5 5.0 0.7 0.7 8.3 59.5 49.5 27.8 0.8 10.5 4.0 4.5 0.6 1.3 10.0 61.7 54.1 29.7 0.9 12.5 4.4 4.6 0.6 1.3 7.6 7.2 7.1 7.3 7.2 7.4 81.8 85.2 88.3 87.9 82.6 73.1 93.4 81.0 82.3 75.7 20.3 75.6 96.2 86.6 88.4 82.5 26.4 81.9 96.8 91.1 90.8 83.1 37.1 83.1 96.8 91.2 91.6 84.6 33.7 82.1 97.8 91.2 92.7 85.3 38.0 Treatment for ARI Percentage of children under five years of age with symptoms of ARI seeking care from a trained provider Treatment for Diarrhea 74.6 81.1 81.2 70.6 Percentage of children under five years of age with diarrhea’s treated with ORT (ORS or homemade solution) ANC coverage is good and showed a rise from 50.5 in 2004 to 53.6 in 2010. Deliveries attended by medically trained providers three years preceding the survey was 15.7 in 2004 increased to 26 in 2010.Utilization rate of ESD of the lowest income quintiles are-­‐ a) Percentage of birth attended by skilled personnel by lowest two quintile was 4.1 in 2004 rose to 11.8 in 2010 final_report_hnpsp 83 82.7 b) Percentage of ANC by medically trained providers (by wealth quintile) was 50.5 in 2004 increased to 56 in 2010 c) Total birth attended by skilled personnel was 15.7 in 2004 increased to 26 in 2010 d) By two lowest quintile utilization rate of ESD was 32.5 in 2006 increased to 40.3 in 2010. TT coverage showed a rise from 90.7 to 91.3 in 2010. Post natal care received from trained providers within 42 days of delivery a showed rise from 19.3 in 2004 to 22.4 in 2010. Percentage of last live birth in 3 years preceding the survey where the received PNC from a trained provider within 42 days of delivery was 19 rose in 2004 to 22.7 in 2010 Contraceptive prevalence rate with proportion for any method mix Contraceptive prevalence rate with proportion for any method showed a rise from 58.1 in 2004 to 61.7 in 2010. Any modern method users have showed a rise from 47.3 to 54.1 from 2004 to 2010. Inject able contraceptive use showed a rise 0f 0.2% from 2004 to (4.2) in 2010 (4.4), while pill users increased to 2.1% in 2010. Condom user remained same in this period. Male sterilization showed a rise of 0.5% from 0.8 in 2004 to 1.3 in 2010.. Norplant Percentage of women on long lasting birth control method (IUD, Norplant, female sterilization, male sterilization) was 7.2 in 2004 increased to 7.3 in 2010. Vitamin A coverage of children of 9-­‐59 month in 6 month preceding the survey showed a rise from 81.8 to 88.3 in 2010. All vaccination covered to children aged 12-­‐23 months from 73.1 in 2004 to 81.9 in 2010.Children who received specific vaccine at any time before the survey showed a rise in HNPSP period. BCG was highest 97.8%, DPT 3 dose (91.1) was second, polio3 (90.8) was third and measles (83.3%) ranked fourth in 2010. Percentage of children under five years of age with symptoms of ARI seeking care from trained provider rose from 20.3 in 2004 to 37.1 in 2010, Percentage of children less than five years of age with diarrhea treated with ORT (ORS or homemade solution) was 74.6% in 2004 it went up to 82.7% in 2010. Comment Major components of ESD showed an improvement in HNPSP period and is good way forward of programme under taken by operational plan for essential service delivery. The next two tables deal with utilization of reproductive health service. Table 7.2.9 : Emergency obstetric care facilities in 2009, DGHS-­‐MIS Medical District Upazila NGO Private UN Process Indictor College Hospitals Health facilities clinics/ Total Hospitals (n=61) Complexes (n=30) hospitals (n=567) (n=13) (n=401) (n=62) ANC services (N) 94,426 104,104 431,637 95,910 272,450 998,527 Normal delivery (N) 31,314 44,751 113,342 10,403 48,527 248,337 Cesarean section (N) 34,960 26,181 19,420 6,515 105,354 192,430 63,617 68,144 131,402 17,258 154,081 434,502 Still births (N) 4,836 4,481 4,709 341 2,316 16,683 PNC services (N) 32,255 59,499 168,829 25,412 127,532 413,527 Maternal death (N) 716 400 87 11 93 1,307 Newborn deaths (N) 1,428 193 285 112 367 2,385 Table shows that distribution of reproductive services at different level hospitals. Medical College Hospital utilized by 9.46% women for ANC, District Hospitals by 10.42%, Upazila health complex 43.23%, NGO facilities 9.60%, and Private clinics/hospitals by 27.29%. Post natal service utilization was more from UHC, then District Hospital and Medical College Hospitals respectively. final_report_hnpsp 84 Normal deliveries are conducted more in UHCs than District Hospital and medical college hospitals respectively. Deliveries by Caesarean was had done more in medical college hospital than district and UHC. Live birth was more in UHC than medical college hospitals and district hospitals. Stillbirths were more in medical college hospitals than any other place of deliveries. Post natal care was utilized more from UHC than district hospitals and medical college hospitals. Maternal death occurred more in medical college hospitals than districts and UHCs Neonatal death occurred in decreasing order from medical college hospitals, the district hospitals and UH complex. From USED survey 2010 it appeared that live births in the three years preceding of the survey are as follows-­‐ public facility of the 10.8%, private facility 11.0%, NGO facility 1.9%, Home 75.9% and others 0.4%. The same survey showed that percent distribution of live births in the three years preceding the survey found that doctors assisted 17.3%, Nurse/midwife 8.6%, CSBA 0.1%, traditional birth attendant 12.6%, Community birth attendant 55.4%, Unqualified doctor 0.2%, Relatives and friends 5.5% and others 0.2%. The same survey showed that percent distribution of live births in the three years preceding the survey, public facility 41.5%, private facility 42.1%, NGO facility 7.2%, home 8.5% and others 0.7%. The table below showed that the percent distribution of live births in the three years preceding the survey delivered by C-­‐section or normal delivery. Table 7.2.10 Types of birth-­‐MIS DGHS 2010 Type of delivery Place of birth Public Private health NGO facility Home Other Number health facility of facility women C-­‐section 27.4 64.5 7.3 0.0 0.0 382 Normal 8.3 2.9 1.1 87.2 0.4 2550 Total 10.8 11.0 1.9 75.9 0.4 2932 From table it is clear that C-­‐section in Public facility was less utilized than private health facility. Only 8.3% normal deliveries were conducted in public health facility and the vast majority of normal birth took place at home. From 2932 deliveries, 75.9% delivered at home, 11% at private and 10.8% in public health facilities. Comments Reproductive health as a part of ESD showed that deliveries attended by skilled personnel increased from 15.5% in 2004 to 18% in 2007 (BDHS) and 26% in 2010 (USED 2010). This can be explained by as mass awareness is working for acceptance of skilled birth personnel mostly by rural women. Table 7.2.11 : Economic Evaluation of some ESD indicators (APIR 2010) Indicator Intervention Control Improvement All birth attended by skilled staff 70% 27% 43% Institutional deliveries 44% 19% 25% Had at least 3 ANC 58% 34% 24% Had PNC within one month 41% 21% 20% Time to prepare referral 33 minutes 53 minutes -­‐ In comparison to control economic interventions showed improvement in selector parameters like birth attended by skilled staff (43%), institutional deliveries (25%), at least 3 ANC (24%), PNC within one month (20%) HNPSP indicators showed better performance after intervention. Demand side financing through maternal mother voucher scheme. The MOHFW conducted an innovative programme to encourage the pregnant women to seek ANC, PNC and delivery care from skilled medical personnel, the programme is known as final_report_hnpsp 85 Demand side Financing (DSF). The programme started in 2006. From this programme a pregnant mother can reimbursable incurred expenditure by maternal health voucher scheme if her care was given by related skilled medical personnel or health facilitator in the programme area. The women receive a financial benefit worth of Tk. 750.00 for a normal delivery. If there is a complication, such as forceps delivery, manual removable of placenta, dilation of curettage or vacuum extraction of body, she receives another 1000 taka. For management of ecelamsia there is a provision of Tk. 1000.00 For a case requiring C-­‐ section an amount of Tk. 6000.00 is given. In 2009, DSF covered 33 Upazilas, which has been expanded to 35 Upazila. Table 7.2.12 : Status of DSF used by permanents Year No. of beneficiary pregnant received DSF 2006-­‐07 12,166 2007-­‐08 109,689 2008-­‐ 09 146,287 2009-­‐10 139,120 It is clear that DSF is popular in rural poor women for reproductive health delivery Comment The findings in selected parameters of ESD showed substantial improvement. Table 7.2.13 : Progress in Implementation by training of staff and by service delivery: July 2008 to June 2009 July 2009 to June 2010 Training: Training: 13 Doctors trained on EOC (One year), 29 07 Doctors trained on Emergency Obstetric FWVs trained on EOC (Six month), 235 FWVs Care (One year), 16 FWVs trained on trained on Midwifery (Six months). Emergency Obstetric Care c (Six month), 18 83 Doctors & 167 FWVs trained on VIA & CBE FWVs trained on Midwifery (Six months). methods. 37 Doctors & 119 FWVs trained on VIA & CBE Services: methods. ANC-­‐ 3,71,974 Services: PNC-­‐ 77,226 ANC-­‐ 3,68,459 Delivery-­‐ 47,791 PNC-­‐ 84,068 C. Section-­‐ 10,938 Delivery-­‐ 51,797 <5 Child Care-­‐ 3,46,229 C. Section – 12,673 CSBA – 955 <5 Child Care-­‐ 2,54,801 Others: CSBA – 1224 28 MCWCs upgraded from 10 to 20 beds. Others: UH&FWC: 500 centers upgraded (under process). MCWC: 28 centers upgraded from 10 to 20 beds. This Table shows that the training was given to indifferent in categories in staff was more from July 2008 to June 2009 than July 2009 to June 2010. The service rendered are almost same for ANC but PNC increased, delivery increased, C section increased, < 5 child care decreased from July 2008 to June 2009 than July 2009 to June 2010, CSBA increased in July 2008 to June 2009 than July 2009 to June 2010, UH&FWC 500 centers upgraded, MCWC 28 centers upgraded from 10 to 20 beds. final_report_hnpsp 86 Table 7.2.14 : Priority activities and overall progress of IMCI (MIS-­‐DGHS 2010) Component-­‐wise Planned Priority Activities Component-­‐wise Progress in Implementation July 2008 to June 2009 Clinical Management Training (CMT) for Implementation of F-­‐ IMCI in 100 Upazilas has Doctors & Paramedics started Ensure Supply of essential drugs and logistics 350 doctors & 1070 paramedics has been trained Follow-­‐Up visit after CMT Essential drugs has been supplied in all Upazilas of the country and logistics supplied Development and distribution of Student in the IMCI Upazilas manual in 48 medical colleges Follow Up after IMCI training has been conducted in 15 Upazilas Implementation of c-­‐ IMCI in 15 Upazilas has started Implementation has started in 48 medical colleges July 2009 to June 2010 Clinical Management Training (CMT) for Implementation of F-­‐ IMCI in 60 Upazilas & 40 Doctors & Paramedics district hospitals has started 430 doctors & 1074 paramedics has been Ensure Supply of essential drugs and logistics trained Essential drugs has been supplied in all Development of Counseling package for C-­‐
Upazilas of the country and logistics supplied IMCI Expansion of C-­‐IMCI in 50 Upazilas Counseling package for C-­‐IMCI service Development of ANC, ENC & PNC package has providers has been developed and TOT & been training completed. developed ANC, ENC & PNC package has been developed Development of Opinion leaders package & TOT conducted and training started Development of Village doctor’s package C-­‐IMCI Opinion leaders, Village Doctor’s & Development of Basic Health Worker’s ANC, ENC & PNC package developed and in the Package process of contracting out to NGOs. Adopted student manual and teaching Review of Student manual and preparation of guideline for teachers has developed teaching guideline for teachers. Priority activities and overall progress for Integrated Management Childhood Illness management packages developed and list of clinical training was conducted between 2009 & 2010 are shown in this Table. Comment Training on clinical management patients for doctors and paramedics and ensure supply of essential drugs and logistics and for implementing IMCI components and the logistics procurement have increased July 2008 to June 2009 than July 2009 to June 2010, contributing improved IMCI. Table 7.2.15 : The achievements in reproductive and limited curative care (MDG targets and indicators, MIS-­‐DGHS 2010) Target Indicator Achievement 67.0 (MICS 2009) 53.84 (SVRS 2008) Reduce by two thirds the <5 year mortality rate/1,000 live births 65.0 (BDHS 2007) mortality rate among children Infant mortality rate/1,000 live births 45.0 (MICS 2009) under five 41.26 (SVRS 2008) final_report_hnpsp 87 Reduce by three quarters the maternal mortality ratio Achieve, by 2015, universal access to reproductive health 1 year old children immunized against measles (%) Maternal mortality ratio/100,000 live births Births attended by skilled health personnel (%) Contraceptive prevalence rate (%) Adolescent birth rate Antenatal care coverage (at least one visit) (%) Antenatal care coverage (at least four visit) (%) Unmet need for family planning (%) 52.0 (BDHS 2007) 82.8 (BECES 2009) 83.1 (BDHS 2007) 290.0 (MTR 2008) 24.4 (MICS 2009) 18.0 (BDHS 2007) 55.8 (BDHS 2007) 33.0 (BDHS 2007) 52.0 (BDHS 2007) 20.4 (BDHS 2007) 17.1(BDHS 2007) Halt & begin to reverse the HIV prevalence among population aged <0.1 (HSS 2006) spread of HIV/AIDS 15-­‐24yrs (%) Achieve, by 2010 universal access to treatment for HIV/AIDS for all those who need Halt & begin reverse the incidence of malaria & other major diseases Population with advanced HIV infection 100.0 (NASP 2009) with access to ARV drugs (%) Malaria incidence rate 1,000 population Malaria death rate (%) Children U-­‐5 sleeping under insecticide-­‐treated treated bed nets (%) TB incidence rate 100,000 population TB prevalence rate% TB death rate (Per 10,000 population) TB case detection rate (%) TB cure rate (%) with DOTS 0.63 (DGHS 2009) 0.032 (2007) 100.0 (WHO 2009) 79.0 (2010) 45 (WHO 2009) 74.0 (NTP 2009) 92.0 (NTP 2009) This Table shows that prevalence mortality rate in <5yr children almost achieve the target, maternal mortality achieved target, HIV/AIDS began reverse among population aged 15-­‐24 in percentage is <0.1 (HSS 2006), population with advanced HIV infection with access to ARV drugs achieve 100% NASP in 2009, malaria incidence rate per 1,000 population is 0.63 DGHS 2009, malaria death rate in percent children, U-­‐5 sleeping under insecticide treated bed nets is 0.032 (2007). TB incidence rate per 100.000 population was 100.0 (WHO 2009). TB prevalence rate reduced to 79.0 (2010), TB death rate (Per 10,000 population) was 45 (WHO 2009), TB case detection rate 74.0 (NTP 2009), TB cure rate in percentage with DOTS improved to 92.0 (NTP 2009). Comment Limited curative care contributed significantly during the HNPSP period. final_report_hnpsp 88 Table 7.2.16: Improvement in Reproductive health: BMMS – survey 2010 Maternal Mortality BMMS 2001 Maternal Mortality Ratio (estimated from verbal autopsy) 322 Maternal deaths per 100,000 live births Pregnancy related Maternal Mortality Ratio estimated from household 382 deaths Pregnancy related deaths per 100,000 live births 400 Pregnancy Related Maternal Mortality Ratio estimated from sibling history 20.2 Proportion of adult female deaths due to maternal causes Antenatal Care Percentage of last live births in the three years preceding the survey of 47.6 which women received at least one ANC visit from any provider 40.1 Percentage of last live births in the three years preceding the survey of which women received at least one ANC visit from a medically trained provider 11.6 Percentage of last live births in the three years preceding the survey of which women received 4 or more ANC visits Skilled Assistance at Delivery Percentage of births in the three years preceding the survey attended 12.0 by medically trained provider 9.2 Percentage of births in the three years preceding the survey delivered at a health facility 2.6 Percentage of births in the three years preceding the survey delivered by C-­‐section Postnatal Care Percentage of last live births in the three years preceding the survey of 10.62 which mother received postnatal care checkup within 2 days of delivery Complete Maternal Care Percentage of last live births in the three years preceding the survey of 4.8 which mother Received at least one ANC visit, delivery care and PNC visit from a medically trained provider2 Care Seeking for Complications final_report_hnpsp BMMS 2010 194 201 257 14.21 71.2 53.7 23.4 26.5 23.4 12.2 22.5 19.0 89 Percentage of last live births in the three years preceding the survey 52.7 that had complications for which women sought any care Percentage of last live births in the three years preceding the survey 24.9 that had complications for which women sought care from a medically trained provider 15.6 Percentage of last live births in the three years preceding the survey that had complications for which women sought care in a health facility 1 Includes one late maternal death 2 PNC from a medically trained provider within 42 days of delivery 67.9 36.4 28.5 This Table 8 shows that there is change towards better reproductive health service for women from 2001 to 2010. Maternal mortality ratio improvement from 322 in 2001 to 194 in 2010, along with improvement of proportion of adult female deaths due to maternal causes ( from 20.2was lowerede 2001 to 14.2). Percentage of births in the three years preceding the BMMS was more than double (from 12 in 2001 to 26.5). Postnatal care also improved from 10.6 in 2001 to 22.5 in 2010. Complete maternal care improved from 4.8 in 2001 to 19 in 2010. Care seeking for complication also raised from 52.7 to 67.9 from 2001 to 2010. Comment Bangladesh Maternal Mortality and Health care survey of 2010 showed a clear indication that ESD service under this programme dramatically improvement. Table 7.2.17 : Disease pattern in children aged 0 to 59 months as a part of IMCI, (MIS-­‐
DGHS-­‐2010). Diseases 0-­‐28 29-­‐59 2-­‐12 1-­‐5 Total days days years Male 333426 70840 321503 538323 964092 Female 25998 58368 3009911 495209 880566 Very Severe 27382 46472 35351 57335 166540 disease Pneumonia 0 0 92461 143340 235801 No 0 0 178458 301340 479798 pneumonia Diarrhea 10196 22620 85531 171902 290249 Fever-­‐
0 0 13296 27133 40429 Malaria Fever-­‐ No 0 0 102461 197592 300053 Malaria Measles 2357 6238 19544 33245 61384 Ear problem 2417 6844 36088 72937 118286 Malnutrition 5074 13718 33590 65382 117764 Others 20458 41789 137967 286826 487040 Refer 2642 5995 32544 63533 104714 This Table shows that that diarrheal disease, pneumonia, undiagnosed severe disease, measles, ear problem and measles are leading cause in children in under five children of Bangladesh. This is also an indication improvement in IMCI and limited curative service for those who needs quick service delivery. Comments final_report_hnpsp 90 These are the common illness in < 5 yrs. children. Integrated management of childhood illness is a priority in public health, these children can avail treatment from the nearby Government health facilities, which are always ready to treat all these problems. Treatment of common illness is a part of ESD operational plan services are available at UHC, UHWC and in community clinics. Table 7.2.18 : HNPSP priority objectives achievements (APIR 2009). HNPSP Priority Units of Measurement Achievement with Objectives reference period & source Reducing % of underweight children age 6 to 46.3 (BDHS 2007) Malnutrition 59 months (weight-­‐for-­‐age Z-­‐score < -­‐2) % of severely underweight children 10.9 (BDHS 2007) age 6 to 59 months Reducing infant Infant deaths per 1,000 live births 52 (BDHS 2007) and Under-­‐ five Deaths in children under 5 per 1,000 65 (BDHS 2007) Mortality live births Table shows achievement in malnutrition reduction and infant and underfive mortality status in 2007 as per BDHS Urban health Urban primary Health care in Bangladesh is virtually provided by Ministry of Local Government, Rural Development and Cooperative (MoLGRD) through City Corporation and municipalities. These local bodies run number health facilities. Under HNPSP, there is a program for Urban Health to compliment urban primary care services provided by MoLGRD. School health Twenty three school health clinics located usually in Municipal Corporation and municipalities are rendering out patient service for school students since fifties. Medical waste management The waste management function for the health facilities at upazila and below level has been entrusted with the operational plan of essential services delivery (ESD). The components of the program are: (i) construction of pits (for infectious, sharps, general and recyclable waste) in the upazila health complex; (ii) procurement and regular supply of logistics for collection and transportation of waste and the safety materials for the waste handlers; (iii) training and orientation of the health personnel on proper waste management; and (iv) community awareness on medical waste, its management and individual responsibility. In FY 2007-­‐08, 131 pits were constructed to deposit medical wastes. The Construction Management and Maintenance Unit (CMMU) of the Ministry of Health and Family Welfare undertook a project to construct pits in 76 Upazilas. Officials of 34 districts and 108 Upazilas received training as trainer to orient other health personnel and workers on medical waste management. IEC materials were developed for the upazila hospitals and logistics were supplied to the respective upazila health complexes in FY 2008-­‐09. Comment Medical waste management are run by the Ministry of Health and Family Welfare dug pits in 76 Upozilas. Officials of 34 districts and 108 Upazilas received training to be served as trainer. IEC materials developed and are used. final_report_hnpsp 91 Violence against Women Violence against Women and girls is a pandemic problem. One out of every 3 women armed the world has been beater, coerced into sex, of other size abused in her life time. A population study dune by ICDDRB confirms the high rates of domestic violence and also confirms that it will remain a major public health problem in Bangladesh. Husbands are the greatest perpetrators of violence against woman. Nearby public health facilities are ready to treat such physical injuries. Observations: There is substantial improvement in ESD 11 indicator parameters. MIS-­‐DGHS 2009 showed that the ESD services have good acceptance in terms of IMCI parameters and women’s reproductive health services. There are good of acceptance of ANC, PNC and are increased from 5% in 2001 to 19% in 2010.There are slow but steady increase in post natal services (BMMS 2010). The met need for EOC was 42.3% in Rajshahi division, 59.3% in Sylhet, 48% for Khulna, 55.3% for Dhaka, 43.1 for Barisal and 37.5%for Chittagong division respectively and as a whole for Bangladesh it was 47.2% (MIS-­‐DGHS 2009). Case fatality rate was 0.6 for the country, being highest (0.9%) in Barisal and Rajshahi and lowest (0.4%) in Khulna. Rates of newborn and maternal death in emergency obstetric care facilities by division showed that in Barisal there was 2.2% neonatal death and 0.6% maternal death. While corresponding rates for Chittagong was 0.7% and 0.3%, 0.7% and 0.2% for Dhaka, in Khulna it was 0.2% for both rates, 0.4% and 0.3% in Rajshahi and for Sylhet it was 1.3% and 0.6% respectively. BDHS survey-­‐2007 and WHO survey 2008 confirmed that 41% of children of under 5s are under weight. Delivery by trained providers increased from 12.2% in2001 to 26.5% in BMMS 2010.Deliveris by C-­‐section increased by almost 5 times in the last 10 years from2.6 to 12.2%. Deliveries in health facilities are 7 times more used by richest than poor between 2001 and 2010. Anemia is prevalent in currently pregnant and for that matter iron and folic acid tablet along with supplementary feeding is contributing for reduction of anemia. Pit for disposal of waste were constructed in 133 Upazilas along with procurement of logistics. Hands on training were completed. Behavior change communication material is developed and used to reduce hospital infection. TB and leprosy admission had increased curative rate is showing good results after introduction of HNPSP Strength of the programme The ESD programme has added improvement of the existing primary care health services. The staff and facilities existed for implementation activities were highly acceptable by the beneficiaries. The ESD service delivery by the budgeted of 2822.45 million taka could expend 2406.9 million taka, so 84.38% money was utilized for most needed aspect of essential health service delivery. There is appreciable participation from pro poor rural women and children contributing to create an impact in health care delivery. Weakness of the programme The construction of various public health hospitals are completed, but many of them yet to function because of shortage of furniture, equipment and recruitment of necessary manpower. There was lacking in service provider orientation, delay of procurement of the logistics due to fund release difficulties. There is dearth of logistics in terms of hospital equipments and furniture’s. Availability of emergency fund was virtually non existence. The service coordination between the various levels of service providers was not conducive to effective service delivery at functional levels. Conclusion ESD of HNPSP created impact on the mother and child patient’s welfare. The service utilized by mother and children explains that rural poor women and their children have utilized this out patient’s service facility from the UHC, USWC and MCWC. Health Education plus Behavioral change communication have aroused awareness for availing Govt. Health service along with the health education activities rendered by NGOs as it evident from availing this service by the rural population. final_report_hnpsp 92 But constraints exist in terms of service delivery by trained health manpower, adequate drug supply at the time of need and laboratory service in many UHWC. Physical facilities are lacking in almost all UHWC. Recommendations 1. Trained/skilled manpower in Govt. Health facilities should be available all the time for effective service delivery. 2. Adequate drugs should be available as and when needed by visiting patients and prescribed by the visiting physician 3. Auxiliary facilities in terms of ambulance service, water and electricity supply can ensure better service delivery. 4. In service and orientation training may be arranged at a regular interval for service providers better delivery. Attempt should be geared up for involving local allied for their cooperation 5. Physical facilities of the upgraded UHWC/UHFWCs should be as per requirement, as and when needed. Empowering local authority by allocating for utilizing a defined budget for combating emergency need is recommended. 7.2
C) Improved Hospital Services Management Summary There is gradual increase in number of patient attendance at Upazilla Govt. Health facilities. The bed occupancy at district hospitals is highest and hospital death rate is highest in specialized postgraduate teaching hospitals. Outpatient attendance is highest in medical college hospitals. In the public health facilities 54,713,781 patient seen in OPDs constituting 54% all of patients ( MIS-­‐DGHS Jan-­‐Dec 2009), of them 35% were seen in primary care hospitals, 5% in secondary care hospitals, and 1% seen in post graduate teaching hospitals respectively. Special purpose hospitals seen 2% OPD patient and Bangabandhu Sheikh Mujib Medical University Hospital seen 2% of the total out-­‐door patients. During this period a total of 2,938,865 were admitted in different hospitals. Death rates in Hospitals are a-­‐bit more for males than females. Registered hospitals and clinics are 2,501 and in these facilities beds are 7,107 among them 1,593 are free beds. Many privately managed hospitals like Heart Foundation Hospital, Kidney Hospital, Eye Hospital, Diabetes hospital and Mental Hospital are reporting MIS-­‐DGHS about specialized rendered through hospitals. Twelve Urban dispensaries reported to have rendered our door service to 493,886 patients, 19 school health clinics rendered outdoor health service to 655,059 outdoor patients. There is no change of the health manpower from 2008 to 2010. Various training program, research were conducted to improve service delivery. Research conducted and reports are published journals. The BSc nursing curriculum developed and revision completed for diploma nursing and midwifery curriculum. Related documents developed used for improved hospital clinical service delivery and their status from 2008 to 2010 was good in terms of recording and reporting to the concerned authority. About 89% patients utilized public health facilities situated at Upazilla and below, indicate public health facility is being popular to the poor rural women and children. Construction for up gradation and new hospitals building already done, many of these facilities are yet to function for public service, because of unavailability of physical facilities and manpower. Only 44% of health posts are filled up by doctors, among the doctors 26.6 % are female doctors. Operational Plan Activity Summary Sheet prepared by improved hospital services management, DGHS showed expenditure from July 10-­‐June 11 was 96.8%. Out of the total budget the total utilization of the fund is 71.14% from 2003 to 2011 final_report_hnpsp 93 Background Bangladesh hospitals provide primary, secondary and tertiary level health care. The secondary and tertiary hospital services are the most visible utilized area of clinical delivery. The public hospitals offer the best accessibility for economically challenged and vulnerable population, so improved hospital services management was an integral component in HNPSP. Objectives/Targets of the Program: Ø To ensure the accessibility of hospital services to women, children and especially to the poor. Ø To reduce the maternal mortality and morbidity by strengthening existing the EOC activity. Ø To introduce structured hospital referral linkage for the improvement of the patient care. Ø To strengthen and upgrade secondary and tertiary level hospital services for improvement of patient care. Ø To equip secondary and tertiary level hospital for provision of the expected range of services with quality of care. Ø To introduce Standard waste management (Phase wise) practices in collaboration with MOLGR&D for the reduction of the diseases amongst the service providers and community people and also to improve the hospital environment. Ø To provide the operational cost of the hospitals beds running under developmental budget. Ø To transform the existing primary, secondary and tertiary level hospitals women friendly hospitals for improving the accessibility of women and also improving the quality of health care. Ø To improve the patient care in the private sector by strengthening the regulatory frame work and also providing others support. Ø To improve the quality of care and client satisfaction by introduction of the different component on clinical governance. Ø To reduce the hospital based infection rates as a part of quality care by implementing Infection prevention and control activities, specially hand washing. Ø To strengthen the emergency management by developing capacity of the service providers on poisoning management. Ø To provide access for the poor to specialize clinical service i.e. Reconstructive surgery. Ø To improve hospital based eye care by GO and NGO collaboration. Ø To improve the quality of care for the private sector and NGOs hospitals/Clinics/Laboratories through monitoring/supervision and also strengthen the regulatory frame work. Purpose and Outputs The purpose of the Improved Hospital Services Management Programme has been stated as “Appropriately equipped hospitals at all levels will provide efficiently the expected services with quality of care and equity of access.” The corresponding outputs during HNPSP will be: •
To strengthen and upgrade secondary and tertiary-­‐level hospitals for improvement of patient care. •
To equip all hospitals appropriately at all levels for provision of the expected range of services with quality of care and equity of access. •
System development with requisite capacity building to improve quality of care. •
To ensure the accessibility of hospital services to children, women, and poor. •
To improve stakeholder participation and expand coverage of the services. •
To improve the quality of care of the private sector and NGO hospitals, clinics and laboratories through monitoring, supervision and a strengthened regulatory framework. final_report_hnpsp 94 •
•
Improve emergency services in respect of poisoning management. Reduction of hospitals based infection rate by practicing standard infection prevention and control system. Major Activities during 2003-­‐2011 Ø
Public Sector Hospital Services • Institution rollout from HPSP • Contingency Plan / IDA credit • Up gradation of Comilla MCH 250 to 500 bed • Up gradation of Khulna MCH 250 to 500 bed • 250 bedded TB Hospital at Shyamoli, Dhaka • 500 bedded General Hospital at Khilgaon, Dhaka • 500 bedded General Hospital at Mirpur, Dhaka • 100 bedded General Hospital at Chittagong Port area • Demand from different Institute • 25-­‐Bedded Children Hospital at Jhenaidah • Establishment of CCU at Jessore General Hospital • Establishment of CCU at 200-­‐250 bedded Hospital (9 DH) • Establishment of ICU & Casualty Unit at 4-­‐MCH • Establishment of 10-­‐bedded ICU at 49-­‐District Hospital • Up gradation of 100 bedded Hospital to 250 bed (10 DH) • Up gradation of Mymensingh MCH 500 to 1000 bed • Up gradation of Rajshahi MCH 500 to 1000 bed • Up gradation of Sher-­‐E-­‐Bangla MCH, Barishal 500 to 1000 bed • Up gradation of MAG Osmani MCH, Sylhet 500 to 1000 bed • Establishment of 250 Bedded specialized Sheikh Abu Naser Hospital at Khulan. • Establishment of Institute of Tropical Medicine & infection diseases, Faujdarhat, Chittagong • Establishment of Institute of Neuro-­‐science • Up gradation of District Hospital from 50 to 100 bed. Ø
Capacity development of IH Services (Operational cost) Ø
Capacity Development and Strengthening of Kidney Foundation Ø
Support to 500 Bedded Dinajpur Medical College Hospital Ø
Capacity Development and strengthening of National Cancer Institute Ø
Introduction of Standard WM Practice at secondary & tertiary level hospitals Ø
Piloting and Roll-­‐out of Referral Procedures Ø
Hospital Accreditation & Medical Audit Ø
Action plan for hospital based EOC & Gender sensitivity Ø
Strengthening of the Baby & Women friendly hospital. Ø
Specialized Clinical services (Reconstructive surgery)-­‐DMCH Ø
Strengthening of existing artificial Limb replacement workshop at NITOR. Ø
Strengthening of National Control of Rheumatic Fever and Heart Diseases Ø
National Electro-­‐medical workshop (NEMEW) Ø
Strengthening of TEMO Ø
Establishment of Central Medical Gas pipe in Different medical facilities. Ø
Strengthening of Postmortem Service at District Level Hospital Ø
Strengthening of Maternal and Neonatal Health at Secondary and Tertiary Level Hospital Ø
Improved Poisoning management at Secondary and Tertiary Level Hospital Ø
Infection prevention and control program (Hand washing) at Secondary and Tertiary Level Hospital Ø
Support to Orobindo Child Hospital, Dinajpur. final_report_hnpsp 95 Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Ø
Hospital Based Eye Care (SS) (this activity to be implemented by NIO and different district hospital) WHO BAN Program Hospital Improvement Initiative (HII) Red Crescent Hospital at Jessore National Heart Foundation, Mirpur, Dhaka Strengthening of BSMMU, Dhaka Support to Ahsania Mission Cancer Hospital. Shishu Hospital Khulna Establish Shishu Bikash Kendro at all (14) Govt. Medical College Hospitals. Budget and sources of funding st
Original Approved cost for 1 Revised Approved Cost 2003-­‐2006 for 2003-­‐2010 GOB PA Total GOB PA Total 15430 35330 50760 36380 93670 130040 (Taka in Lakh) 2nd Revised Proposed Cost for 2003-­‐2011 GOB PA Total 44908 78722 123,630 Estimated Costs and Expenditures of HNPSP for Improved hospital services management (In Crore Tk.) from 2003-­‐2011. Name of the Estimated cost PIP (2003-­‐11) Estimated Expenditure (2003-­‐
% fund Operational Plan 11) utilized (OP) GOB PA Total % of GOB PA Total Total Improved Hospital 449.0 787.2 1236.3
7.46 224.06 655.51 879.57 71.14 Services Management 8 2 0 Management of Implementation Main point raised on Improved Hospital Management Services in MTR 2008 and APIR 2010 are as follows: The Line Director for Improved Hospital Management Services (IHMS) coordinates a wide range of activities, relating both to the functioning and reform of hospitals and a number of research institutions, both public and private in Bangladesh, e.g. cancer hospital, rheumatic fever research institute, etc. The main reform areas the IHMS are coordinating include commissioning of hospital services, accreditation of health facilities and hospital autonomy. Current problems with the commissioning of new public health facilities is that separate Government Orders (GO) are given to sanction allocation of funds for infrastructure, equipment, creation of staff establishment, recurrent costs, etc. The IHMS have advocated that one GO should cover the whole budget for commissioning and recurrent costs, this would allow for better coordination and synchronization of inputs. The IRT noted that current expansion of hospital services in Dhaka are planned, three 500 bedded hospitals, this is a concern given that there is no overall coordination of urban health services and there are already considerable strain on the provision of appropriately trained human resources. A Hospital Autonomy Bill was prepared by last the Government but there has been little progress so far. Some initiatives towards decentralization have taken place but limited to responsibility for looking after ambulances, and some local financing initiatives, e.g. patient visitor levy final_report_hnpsp 96 scheme. The IHMS feel that the Bill may need revising, giving current thinking and experience, especially in relation to delegation of financing and financial control. Delegation of financial responsibility to hospital management will be essential if the proposed hospital autonomy strengthening pilot in six district hospitals and 14 Upazila health complexes is to work. The Clinic Ordinance 1982 sets out the regulations for registration and accreditation of health facilities, both public and private. As the number of new hospitals and clinics increase, currently 2,104 in the private sector alone, and the number of diagnostic centres are also increasing (currently 4,492) there is need to orientate the owners and managers of these facilities to the regulations set out in the Ordinance. The Ordinance provides for the setting up of a National Accreditation Council. The Council is setting criteria for the registration of hospitals and diagnostic centers, currently the accreditation system is on a one to five star award based on a set of criteria. During the IRT field visits the Civil Surgeon reported that private facilities were award of the accreditation system but were slow to apply for accreditation, currently there does not seem to be any sanction for not applying, once a facility has registered with their designated authority they have no other obligations. The IHMS programme reported the same constraints as other programmes regarding the implementation of their OP, lack of human resources, procurement delays, funds release, particularly for IHMS the synchronizing of release of development and recurrent budgets so that they can phase inputs appropriately, i.e. infrastructure, equipment, staff, recurrent costs. Methodology The Evaluation method used for this report is from available documents of ministry of Health Family Welfare and Word Bank documents. The relevant personnel responsible for this operational program were consulted. The findings of review with sources are as follows-­‐ According to Management Information System (MIS), Directorate General of Health Services (DGHS), Health Bulletin 2010, the following tables shows number of patient attended and bed occupancy rate at different hospitals. Table 7.2. 19 Upozila Health Complexes by Bed occupancy rates from 2005 to 2009 (MIS-­‐DGHS 2010) Bed Y2005 Y2006 Y2007 Y2008 Y2009 Occupancy% No. % No. % No. % No. % No. % at UHWC Total Upazila 343 100.00 357 100.00 361 100.00 404 100.00 408 100.00 Health Complexes There is gradual increase in number of patient attendance at Upazilla Govt. Health facilities with bed occupancy at 100% from 2005 to 2009. Table 7.2.20 Average daily attendance and bed occupancy Secondary and Tertiary Level Hospitals. Type of health facility Average Length Bed Hospital Average Daily Average of Stay (day) Occupancy Death Rate Admission Daily OPD Rate (%) (%) (N) Patients (N) Specialized Postgraduate 9 96.04 5.18 33 232 Teaching Hospitals Medical College Hospitals 5 86.3 4.44 158 1179 final_report_hnpsp 97 Direct Hospitals 3 112.63 2.24 49 Infections Disease Hospitals 18 109.14 5.76 2 Chest Clinics/Hospitals 48 63.96 3.52 1 TB Segregation Hospitals 42 76.53 3.25 -­‐ Leprosy Hospitals 41 53.64 0 1 This table shows that bed occupancy at district hospitals is highest and hospital death rate is highest in specialized postgraduate teaching hospitals. Out-­‐patient attendance is highest in medical college hospitals. final_report_hnpsp 366 35 -­‐ 14 98 Table 7.2.21 : Number of admissions, deaths and out-­‐patient visit in different types of health facilities (Health Bulletin 2010, MIS-­‐DGHS) Facility type Dat
a fro
m num
ber of facil
ities 1 No. of admissions No. of hospital deaths No. of OPD visits Male Female Total Male Femal
e Total Child Male Female Total 14,589 24,986 39,575 680 492 1,172 -­‐ 474,481 438,873 6 66,390 24,032 90,422 2,936 1,158 4,094 75,634 101,810 163,214 913,35
4 340,65
8 14 317,27
8 349,44
8 300,262 617,540 26,02
2 17,17
1 202,557 277,377 828,645 11,61
8 8,362 146,684 479,197 14,40
4 8,809 738,674 939,788 1,273,902 739,018 3,928 8,525 12 6 18 4,511,58
3 27,161 6,049,46
3 91,344 8,057,874 2,036 1,339,74
7 3,752 4,597 2 600,72
9 1,716 5 2,540 1,850 4,390 184 48 232 51,072 66,436 72,714 5 3,206 3,337 6,583 24 12 36 87,960 86,974 135,852 Drug Addiction Treatment Center Leprosy Hospital TB Hospital 2 -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ 10,398 32,040 43,998 310,78
6 86,436 3 520 104 624 -­‐ -­‐ -­‐ 1,206 3,180 2,332 6,718 12 2,366 921 3,287 7,426 100 85,292 93,872 23 5,406 Government Employees’ Hospital Mental Hospital TB Center TB Clinic 1 -­‐ -­‐ -­‐ -­‐ -­‐ 56,24
2 -­‐ 1,326 5,104 2,996 9,426 1 592 154 746 2 2 4 6,398 1,302 23,566 41,266 1 43 -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ 23,358 428,087 12,812 607,698 20,700 724,340 Union Sub-­‐
center Urban Dispensary Rural Health Center School Health Clinic Secretariat Clinic -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ 9,171,80
9 136,102 10,899,083 12 6,708,75
9 120,288 14 1,534 2,020 3,554 18 12 30 111,609 131,182 141,544 19 -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ 149,999 216,479 288,581 1 -­‐ -­‐ -­‐ -­‐ -­‐ -­‐ 23,142 29,854 33,816 56,870 1,760,1
25 26,779,
651 493,88
6 384,33
5 655,05
9 86,812 Tot
al= 1,360,9
08 1,577,95
7 2,938,86
5 31,74
0 25,66
4 57,40
4 13,279,5
80 18,455,7
07 22,978,494 University Hospital Postgraduate Teaching & Specialized Hospital Medical College Hospital District & General Hospital Upazila Health Complex 31-­‐bed Health Complex Infectious Disease Hospital Labor Hospital 62 421 626,61
8 2,952,3
64 18,618,
920 164,86
9 190,22
2 46,364 237,496 final_report_hnpsp 99 54,713,
781 Comment In all public health facilities OPDs 54,713,781 patients reported to have seen in Jan to Dec 2009. Primary care hospitals have seen 35% patients, secondary care hospital have seen 5% patients and 1% seen in post graduate teaching hospital. Special purpose hospitals have seen 2% OPD patients. Bangabandhu Sheikh Mujib Medical University Hospital has seen 2% of the total out-­‐
door patient. During this period a total of 2,938,865 patients were admitted in different hospitals. Death rates in hospitals are more in males than in females. Table 7.2.22: Progress in manpower indicators APIR 2010 Sl. Name of Status Status 2010 Indicators 2008 1. No. of Doctors. 2510 2510 2. No of Technologist. 1010 1010 3. No of Medical 650 650 Assistant There is no change of the health manpower from 2008 to 2010. Table 7.2.23 : Progress in Training and research (IHM) APIR 2010 Name of Status Target Status Indicators 2008 2009 2010 2009 2010 National Trained 100 100 50 00 health Professionals Research 6 6 100% 100% Dissemination Conducted. Journals 2 published. This Table 4 shows that various training programme was undertaken, research activities carried out and the results are published in journals. The strengthening of the quality of clinical practice through in service training done and related documents developed and their status is 100% in 2010. Table 7.2.24: Progress in capacity building indicators Sl Name of the Indicators Status Target Status 2008 2009 2010 2009 2010 Development of Basic 01 -­‐ -­‐ -­‐ -­‐ 1. BSc Nursing curriculum Revision of Diploma 01 -­‐ -­‐ -­‐ -­‐ 2. Nursing and Midwifery curriculum Development of job 01 -­‐ -­‐ -­‐ -­‐ 3. description /guide line for hospital service management Strengthen the quality of 05 Hos. 02 02 01 01 4. clinical practice through attached in service training. Nis Develop and Introduce 05 02 02 01 01 final_report_hnpsp 100 5. 6. 7. QA system in nursing services, education and practices. Develop, piloting scale up client centred model ward. Develop and strengthen nursing management information system (MIS) Capacity building of DNS personnel 03 Hospitals 02 02 01 -­‐ 01 -­‐ -­‐ -­‐ -­‐ 8. Status of progress in nursing quality service shown in table number 5, and development of BSC nursing & domestic revision done. Quality of clinical training done in 5 hospitals. MIS and QA system in nursing services, education developed and practiced. Table 7.2.25 : Distribution of OPD patients in different health care facilities. DGHS-­‐MIS, Health Bulletin 2010 OPD NO. % Primary Care (USC, UHWC TB Clinic) 19,168,124 35 Out patient care centre (UHWC) 29,832,403 54 Secondary level hospital (District) 2,952,368 3 Specialized hospital do880,260 2 University hospital 913,354 2 Tertiary level hospital 626,618 1 P G Hospital 340,658 1 From this Table 6 it is clear that 89% out patient is at the health facilities situated at Upozilla and below. This is a clear indication that OPD services Govt. health facilities are used by poor, rural population most of these patients are women and children. Table 7.2.26: Number of Sanctioned, filled up and vacant posts ( MIS-­‐DGHS 2010) Sanctioned Male Female Total Vacant Class I Doctor 20,234 8,921 2,379 11,300 44% Non doctor 466 168 50 218 53% Class II 1,611 406 719 1,125 30% Class III 65,079 32,936 20,549 20,549 18% Class IV 24,912 14,603 5,354 19,957 20% Total 112,302 57,034 2,905 86,085 23% This Table 7 shows that 44% of health posts are filled up by doctors, among the doctors 26.6 % are female doctors. Operational Plan Activity Summary Sheet prepared by improved hospital services management, DGHS showed expenditure from July 10-­‐June 11 was 96.8% Observations: The Operational Plan indicators progress smoothly and sustainable for eg more than 98% of patients utilized Upazila and district health facilities. With the help of reports from public sector hospital records data the disease profile is prepared by MIS-­‐Health and published in Health Bulletin,2010 (Table 3). Table 5 showed that the number of doctors, number of Technologist, number of Medical assistants are steady from 2008 to 2010. There is no substantial improvement in awareness workshop for quality improvement of the service personnel. Table 6 final_report_hnpsp 101 and Table 7 shows that research dissemination conducted has little progress. Table 8 shows that nursing services have not improved enough. According to Ministry of Health and Family Welfare, Human Resources Development Unit 2011 the currently total number of nurses available in country is 15023. 35% of the registered doctors (43537) are serving in public hospitals. The number of patient attendance is shown Table 9. At primary and secondary level percentage of attendance is about 89%. This clearly indicated that patients largely attended by the poor, women and children patient. But 11.76% of the sanction posts are filled up by female doctors (Table 10). The construction of health facility is going but human resources employment is almost stand still. Bangladesh Health Facility Survey conducted by World Bank 2009 found to ranked service quality of providers by patients chronologically as-­‐ 1. Cleanliness: UpHFWCs, MCWCs, UnHFWCs, UHCs, DHs 2. Wait not long: UnHWCs (both types),UHCs, MCWCs, DHs 3. Providers Showed respect: Un HFWCs (both types), MCWCs, UHCs, DHs Only about a third of DHs, 10% of MCWCs and 15% of UHCs are able to provide Obstetric first aid. Comprehensive EmOC are provided at primary and secondary care centers. At DHs and UHCs provides 19% and 2% at MCWCs. The method followed for bio-­‐medical wastes was burn and bury at DH, UHC, and MCWC but lower level facility used bury without burning. Only 5-­‐7% reported collecting and storing the waste to move offsite at a later date. Strength of the OP implementation Health facilities have been constructed and still continued from tertiary level to grass level is good. Various level training and research are in progress. The availability of trained and skill manpower at Upzila level have been raised. The laboratories are in various related facilities are of developed for effective delivery of improved hospital services. Ambulance and power generator for electricity is available. Weakness Allocated fund for procurement for necessary goods and furniture’s was always late, physical facilities are in bad shape. Necessary repair of day to day used instruments are not adequately cared for. Ambulance service, electric supply and water supply are fur less than adequate. Because of inadequate fund allocated for continuity of services are often disrupted. There is no recruitment of doctor’s by Public service Commission for long. Enough in service and orientation training was not held. Trained man power was not available because only 44% of the sanctioned posts are filled up and majority of the doctor’s are male, (88%) than female so gender equality is fur reach to maintain gender equality. Frequent change of line director was a constraint in implementation of the OP, yet hospital utilization are more than ever before. Conclusion: OP on improved hospital management showed achievements of substantial degree with utilization of 71.14% of the budget. There are one physician for 2,785 populations and one nurse for 5,782 populations. Emergency obstetrical and IMCI have substantially improved to deliver MCH care. The hospital services are increasingly utilized (e.g. In 2009 there were 2,767,183 hospital admission at this country). These findings indicate that hospitals are increasingly utilized by public particularly from rural areas. In 2009-­‐10 MIS-­‐Health data depicts that 13,507 training/workshops held for professionals for improved clinical service delivery. In the same time training on emergency obstetric emergency care was held for 488 participants. HNPSP have contributed to the development of hospital delivery services. final_report_hnpsp 102 Recommendation Ø The World Bank Health Facility Survey 2009 observed that for public facilities at the district level there appears to be no serious shortage of physicians if the sanctioned numbers of physician positions are considered. However, the distribution of sanctioned positions among the various types of facilities is not appropriate. Therefore, a careful redistribution of physicians should make the system much more efficient and effective. Ø Unlike physicians, nurses and other support staff are in short supply in all the facilities. Overall, number of support staff in health facilities is less than half of what would be needed. Therefore, the number of nurses, FWVs, and other non-­‐physician providers and supporting personnel should be increased. Ø The wide gap that exists between the sanctioned and filled positions at the health facilities appears to be a system-­‐wide problem. The administrative mechanism of filling the sanctioned positions should be evaluated carefully. Ø Most facilities are not ready to provide obstetric first aid because of the lack of the three injections in the facilities. Only 55% of DHs and 38% of UHCs reported having no oxytocin. Magnesium sulfate is the most constraining obstetric first aid item; only 42% of DHs, 23% of UHCs and 10% of MCWCs reported having the injection in the facility for use. Ø Essential drug availability is quite poor in almost all public health facilities. The essential drugs which are missing in many DHs and these are: tuberculosis drugs, Benjathine Penicillin injection, cotrimazole cream, acyclovir tablet, fluconazole tablet and chloroquine. Drug availability at the UHCs appears to be much better than that in the DHs. Ø Ambulances are available in most DHs, UHCs and MCWCs. In UHCs, about a quarter of ambulances were not in working condition. Moreover, more than 50% of UHCs reported that the use of ambulance remained restricted due to lack of funding. Maintenance of ambulance at the UHCs appears to be a significant problem. Policy planners should also identify mechanisms to improve fund availability for operation and maintenance of the ambulance. final_report_hnpsp 103 OPs ON SUPPORT SYSTEM -­‐ 7.3 Operational Plans On : Human Resource Management and Capacity Development Summary: I. OPs on Human Resource Management 1. HNPSP had 3 OPs on Human Resource Management (HRM) : One with DGHS, one with DGFP and the other one with MOHFW. Capacity development provisions were spread over 16 OPs (out of 38 OPs in HNPSP). 2. Major HR issues which constrain availability and quality of health service like creation of posts, filling of vacancies, deployment and retention of manpower, their performance evaluation or their career leader etc. all fall within the purview of Revenue budget and could not, therefore, be addressed by HNPSP OPs which are financed out of Development budget. This water-­‐tight division of public resource sharply reduced the scope of activities under the HRM-­‐OPs. 3. OP of HRM-­‐MOHFW financed only 2 activities: training and strengthening the office of the HRD Unit in the Ministry. Other activities in the OP like preparation of HR Master Plan and the setting-­‐up of a comprehensive HR data base through the establishment of a HR Data cell could not progress beyond planning or initial processing stage. Post-­‐MTR revision of the OP in 2008 saw its allocation reduced by 33%-­‐ from a total of Tk 15.30 crore to Tk 10.13 crore. However at the end of HNPSP, only 45% of that reduced allocation could be utilised by this OP. 4. OP on HRM DGHS had 65% of its allocation for training/ workshop and 20% for perchase of office machinery, even though the write-­‐up of the OP included as components HR issues which fall within the ambit of the Revenue budget. By the end of HNPSP, 81% of its allocation of Tk 6.44 crore were utilised. This OP had the lowest budget out of the 3 HRM OPs, even though DGHS had the largest manpower! 5. OP on HRM -­‐ DGFP had 92% of its budget of Tk 25.48 crore for training and 90% of this training budget was for foreign training. During the 2008 mid-­‐term revision, the allocations for this OP was revised downwards from Tk 32 crore to Tk 25.48 crore, partly as a result of conversion of the short foreign trainings to local training Only 79% of this allocation was utilised till the end by HNPSP. The average percentage of funds utilised for the 3 HRM OPs was 69.32% whereas the average for all OPs in HNPSP has been estimated at 81.73% HNPSP appeared to pay limited attention to the importance of HR in service delivery and within its total programme. II. OPs on Capacity Development 6. 16 OPs had budget for training while 89% of their training budget was accounted for by 4 OPs : (i) In-­‐service Training, (2) NNP, (3) HRM-­‐DGFP and (4) Sector-­‐wide Management -­‐ MOHFW. There was widespread misapprehension about the appropriateness of utlisation of the large training fund. At the request of the 'pool fund' funders the World Bank final_report_hnpsp 104 appointed a well-­‐ known international consultancy company to look into the matter. The Oxford Policy Management examined the trainings funded between 2005-­‐2006 to 2007-­‐
208 and cane up with their findings in 2009. The training cost for those 3 years was $53 million. The studI findings were on the whole positive, to the surprise of those who commissioned it. it found that the selection of courses and the trainees were made by a decentralised system under the guidance of a central committee located in the Ministry. The choice of subjects reflected ''a reasonable balance between systems strengthening, public health and infections diseases, and the newly arising requirements for diagnostic and curative services.'' There was some evidence of duplications of training the same individual but complains of waste of training due to early movement from their posts was not confirmed by the Survey. It noted substantial spending on short overseas programmes for management training and for short clinical attachments but doubted their value. It suggested to build up on inventory of local providers and make greater use of local resources assisted, where necessary, by external specialists. The Report come to the conclusion that the Survey ''revealed much evidence of good practices in human resource management associated with training.'' It made a number of recommendations to strengthen and improve the training system. 7.3.1. Human Resource Management and Capacity Development 7.3.1.1 There is little doubt that service delivery programme in a sensitive and critical area like health is largely dependent on the availability and quality of human resource. This is dramatically demonstrated in case of Bangladesh where health infrastructural facilities have been created to cover Upazillas and Unions and even below, while the service suffers due, among others, to the absence of some service providers in certain areas like hard-­‐to-­‐ reach rural areas or due, in part, to their presence in inadequate numbers or with inappropriate skill-­‐mix. The challenges generally faced in human resource management include the following: 1. the absolute shortage in numbers of all categories of service providers (e.g. doctor, nurses, technicians etc.) 2. mal-­‐distribution of staff, 3. skill-­‐mix imbalance, 4. negative work environment, and 5. weak knowledge base . These challenges have been found valid for Bangladesh (Bangladesh Health Watch, 2007 Report). 7.3.1.2. How did HNPSP address these issues? There were 3 OPs directly addressing HR issues: Ø Human Resource Management under MOHFW Ø Human Resource Management under DGHS Ø Human Resource Management under DGFP However it is necessary to recognise that there were in built limitations in the structure of HNPSP which did not allow it to deal with crucial issues like creation of posts, recruitment for filling up vacancies, deployment of manpower to service delivery points, their performance evaluation or their career ladder-­‐-­‐ all of which fell within the purview of the Revenue budget, while HNPSP-­‐-­‐ inspite of its claim as a sector programme-­‐-­‐ could, in reality, deal only with those final_report_hnpsp 105 issues which could be funded from the Development budget. So none of those mentioned issues could be handled by the 3 HRM OPs in HNPSP. The administrative arm of the Government was responsible for taking related actions and decisions on those issues. This reflects the divide in Bangladesh government activities into two water-­‐tight compartments of Revenue and Development budget. HNPSP was a 'development' programme, while most of the challenges faced in Human Resource Management were of 'administrative' rather than 'development' nature. So the 3HR related OPs in HNPSP dealt with a limited set of activities and accordingly had small budgets. 7.31.3. HRM OPs and budgets: The following table gives a consolidated picture of budget allocation for the 3 HRM OPs in HNPSP. Table-­‐ 7.3.1 Budget allocation for HRM OPs (in crore taka) Name of OPs Budget Allocation % of total HNPSP 2003-­‐2011 outlay 1. HRM-­‐DGHS 6.44 0.04 2. HRM-­‐DGFP 25.48 0.15 3. HRM-­‐MOHFW 10.13 0.06 Source: (Strategic Plan for HPN Sector Development Programme (2011-­‐2016), April 2011, Planning Wing, MOHFW (Annex 7.4-­‐Table 1A) It is relevant to note that the total allocation for all programmes under the HNPSP was 16,566.47 crore taka whereas the three HRM OPs together had a share of only one quarter of 1 per cent of that allocation (0.25%)! This reflects the importance HNPSP attached to the issue of human resource management within its overall development strategy. Moreover, the budget allocation was not consistent with the size of manpower under the two Directorates. The allocation for HRM-­‐DGFP was 4 times larger than the of HRM-­‐DGHS, whereas the size of manpower in DGHS is many times more than that in DGFP. So there appears to be no rational basis for budget allocation among the HRM OPs. 7.31.4 HRM OPs and utilisation of allocated funds: Table-­‐2 provides the picture of estimated expenditure for the three HRM OPs for 2003-­‐2011: Table -­‐7.3.2 Estimated Expenditure by 3 HRM OPs (in crore taka) Name of OPs Estimated cost PIP Estimated % fund utilised 2003-­‐2011 expenditure 1. HRM-­‐DGHS 6.44 5.20 80.75 2. HRM-­‐DGHP 25.48 20.13 79 3. HRM-­‐MOHFW 10.13 4.54 44.82 Source : Strategic Plan for HPN Sector Development Programme 2011-­‐2016, April 2011, Planning Wing, MOHFW (Annex 7.4 : Table 1A) The average percentage of funds utilised for the 3 OPs was 69.32% whereas the average for all the OPs under HNPSP has been estimated at 81.73% in the quoted source. Considering the poor share of HRM OPs in the HNPSP allocations, the performance of utilisation of funds makes a dismal picture indeed! final_report_hnpsp 106 7.3.1.5. Contents of the HRM OPs and performance. The rate of utilisation of allocated funds for the HRM OPs is an indication of the implementation of the activities planned for under those 3 OPs. All the 3 OPs were designed along the strategic objectives identified in the 2003 HR strategy: Workforce Planning, deployment, performance management, HRMIS, Capacity building and HR Support Functions. However, as we have pointed out earlier at para 2, most of these functions were within 'administrative' rather than 'development' jurisdictions and therefore the bulk of the activities which were implemented under these OPs involved training of personnel of one type or another. Thus for OP on HRM-­‐MOHFW, only 2 major activities were financed, as the APR 2009 had noted: (1) involving training and (2) strengthening the office of the HRD Unit within MOHFW -­‐-­‐
the training component accounting for 60% of the funds utilised. Other priority activities like the preparation of a HR Master Plan covering HR needs for different categories of health and family planning personnel upto 2030 or the setting up HR Data cell for developing a comprehensive HR data base for the whole sector, drawing on the information available with the personnel sections of different Directorates and agencies under MOHFW etc. had remained on the planning or processing stage. The progress of implementation of activities under this OP (HRM-­‐MOHFW) was so slow that during the last revision of this OP following the MTR in 2008, its allocation was reduced by 33% from 15.30 crore taka to 10.13 crore taka. However, it could achieve less than 45% of that reduced allocation at the close of HNPSP! Similarly, for OP on HRM-­‐DGHS, 65% of its allocations was for training and workshop and 20% for purchase of machinery, computer and furniture etc. , even though the OP identified the same six 'strategic objectives' mentioned at the beginning of para 1.5 and included those as major components of HRM. One can clearly notice that while the write-­‐up of the OPs raised issues of strategy and objective, the actual activities which were implemented revolved mainly round training and workshops. The picture of OP on HRM-­‐DGFP shows a similar pattern: 92% of its budget of 25.48 crore taka (revised downwards during RPIP 2008 from the original allocation of 32.00 crore taka) was for training. However in this case, 90% of the training budget was for foreign training! During the OP revision process in 2008, the HNPSP Steering Committee-­‐ which was the approving authority for OPs-­‐halved the number of the short term training programmes and converted them into short local training only. Allocation was also made for conducting 3 Accountability surveys at District, Upazilla and Union levels but these were never conducted. Similarly the OP planned as one of its activities 'engaging professionals and staff association in a constructive manner' for creating good working conditions, but it remained a pious wish and no step was either taken to develop a 'code of conduct' for mutual engagement either. A similar activity was also included in OP on HRM-­‐MOHFW, with similar no output. 7.3.1.6 HR indicators in the Results Framework 7.3.1.6.1 The Project Appraisal Document (PAD) of the World Bank had an elaborate annex on Results Framework (RFW) with 62 indicators covering all the components of HNPSP for purposes of programme monitoring. This was prepared in March, 2005 and predated the OPs which were finalised after the approval of HNPSP by ECNEC in June 2005. The RFW mentioned two indicators for human resources, neither of which had direct bearing on the HRM OPs or for that matter, any other OP in HNPSP! 7.3.1.6.2 HR indicators included in the RFW: The first indicator was the establishment of a HR Task force with ToRs in year 1 of HNPSP and then making it operational over the subsequent years of HNPSP. The second indicator related to putting in place performance -­‐ linked staff incentive system in place. final_report_hnpsp 107 This required conducting an incentive study and consultation process in year 1 of HNPSP, leading to piloting Action Plan in year 3 and its introduction from year 4 of HNPSP. 7.3.1.6.3 Achieving the HR indicators: Steps were taken by MOHFW towards implementing the steps indicated by both the indicators, even though at different speed and urgency than required by the RFW. A Health Workforce Strategy paper was drafted in 2007 but could not be finalised within the next 2 years. It was claimed that the Ministry's approval to that draft strategy was given in a meeting chaired by the Additional secretary, MOHFW. It is not clear whether the HR strategy received approval of the Secretary or of the Honourable Minister, MOHFW. Whatever the case may be, no concrete follow up step appears to have been taken so far to make the Health Workforce strategy operational. As for the other indicator, a consultancy was contracted to prepare an incentive study in 2009 which submitted its findings and recommendation for piloting a scheme of personnel incentive systems. No follow-­‐up steps had been taken by MOHFW on those recommendations. 7.3.1.6.4 Revised indicators in RPIP The indicators in the RFW were revised in 2008 following the Mid-­‐term review of HNPSP and reduced to 32 indicators from the 62 indicators in the original RFW, 2005. The revised indicators, now part of RPIP, did not contain any indicator for monitoring HR! 7.3.1.6.5 HRM OPs and indicators: The HRM OPs had little to do with HR indicators mentioned in the RFW 2005, while the revised indicators of 2008 did not include any reference to Human Resource. So there was no built-­‐in monitoring system for evaluating the HRM OPs with the help of assigned indicators. This is one example, among others, of OPs and indicators in the RFW not matching with each other. In order to avoid such a disconnection between OPs and indicators, there is clearly a need for setting indicators for each OP which are closely aligned to the goals / objectives of those programme. Hopefully this would be done in the next sector programme from the very beginning. 7.3.1.7. Lessons learned from HRM OPs. i)
The limitation of the sector Programme as a 'development' programme should be kept in view while the details of activities to be included in the OP are drawn up. This would help avoid including activities which fall within the purview of revenue budget and are of non-­‐development in nature and therefore not acted upon. ii)
Three OPs on HRM were drawn up separately under three different agencies e.g. MOHFW, DGHS and DGFP, with budgets disproportionate to the size of the human resources under them. Such irrational resource allocation can be avoided if care is taken to examine the related OPs more carefully during their processing and inconsistencies are reconciled before approval of the OPs. iii)
Both DGHS and DGFP introduced Personal Data sheet (PDS) for recording service details of their employees, but each was using different format and each was processing the PDS differently. Similarly, each was trying to develop personnel MIS (PMIS) using different formats, making it impossible to have common data base for use by MOHFW. Common guideline and mentoring by MOHFW could have avoided such fractious outcome and could have led to creation of more consistent and user-­‐
friendly employee data base. final_report_hnpsp 108 iv)
v)
HNPSP underestimated the need for and the value of dealing with Human Resource as a crucially important input for supporting an effective and efficient service delivery system. It was during the MTR in 2008 that the subject received considerable attention and yet the implementation progress was dismal to the end, reconfirming the neglect with which the planners of HNPSP had designed the HRM OPs. This lapse needs to be corrected in the next Sector Programme, so that more substantive and meaningful activities are implemented to improve human resource management in MOHFW. Indicators for monitoring the performance of OPs on HR need to be defined in the next Programme in a way which are closely aligned to the goals/objectives of the Programme and realistically assess OP performance. 7.3. 2. Capacity Development and Training 7.3.2.1. Programmes and activities of capacity development of health and family planning personnel through training were spread over a large number of OPs in HNPSP. The OP on In-­‐
service Training in DGHS, and the OP on NIPORT for DGFP were meant only for in service training for personnel under DGHS and DGFP respectively. The Directorate of Nursing and the Directorate of Drug Administration had separate training provisions in their respective OPs for their personnel. OP on NNP had large provisions for training-­‐ both local and foreign, even though they had only a dozen officers to manage the Programme. OP on HRM-­‐DGFP had also considerable number of long term and short-­‐term foreign and local training facilities. Many other OPs had provisions for short-­‐term training, workshops and educational tours and visits. By the end of HNPSP, a large amount was spent on training account. There was a widely held apprehension about the usefulness and justification for the training programmes, the method of trainee selection or their replacement, their deployment courses to their jobs etc. The need for an investigation into the investment being made by the 'pool fund' of HNPSP for improving capacity building was cited during the Mid-­‐term review in 2008 and was made a part of the Action Plan for Human Resources for that year. As a follow up the World Bank, as the fund manager of the HNPSP 'pool fund' (worth over $800m), selected a well-­‐known British consulting company the Oxford Policy Management-­‐ to undertake the review. The ToR of the study mentioned a number 'weaknesses' in then existing capacity building practices: ''inadequate training needs assessment, poor selection of courses, arbitrary candidate selection, elaborate and complex approval processes and poor follow-­‐up''. 7.3.2.2. Findings of the OPM study: The review was conducted between Nov. 2008 and February 2009 and identified 16 OPs (out of total of 38 OPs, in HNPSP) having budget for training. The study covered the period from 2005-­‐2006 to 2007-­‐2008 and estimated the value of the training-­‐ as approved by the World Bank to be worth $53 million till then. Around 89% of the training budget for the three years was accounted for by just 4 OPs: In-­‐service Training, NNP, HRM-­‐DGFP and Sector-­‐wide Management-­‐MOHFW. The majority of the training courses were located outside Bangladesh (with 14% inside Bangladesh) while the number of people trained in Bangladesh was many times higher than those trained overseas, largely because of the number trained in-­‐country by the NNP. It was also found that the majority of the training-­‐ 91% of the cases involving 86% of budgeted allocation-­‐was for short term, lasting less than 9 months. Most of this training (84%) had a duration of less than 15 days. The training programmes were not centrally controlled by the Ministry, even though it had a central Training Committee, which usually concentrated on issuing policy guideline but directly dealt with long-­‐term foreign training. Each L.D. had annual training plan for his OP and the choice of candidates and the choice of training course were influenced by the programme final_report_hnpsp 109 managers under him. Such a decentralised approach appeared natural in a large programme like HNPSP. The study concluded that ''the overall targeting of use of funds seems to strike a reasonable balance between systems strengthening, public health and infectious diseases, and the newly arising requirements for diagnostic and curative services.'' Complains of waste of training due to early movement from their post by the trainees was not confirmed by the survey. However there was some evidence of duplication of training and of attendance on multiple courses by the same individual. There appeared to be no overall policy regarding balance between long and short-­‐term training as it varied between different OPs. The survey noted substantial spending in short overseas programmes-­‐ on management training and study tours and felt that short courses of management training was unlikely to provide value for money. Similar doubts were expressed about the efficacy of short clinical attachments. It also noted that there was no process of systematic evaluation of the quality and impact of training, even though such capacity existed ('in NIPORT and probably elsewhere'). The Survey suggested to build up an inventory of local providers and an assessment of their capabilities alongwith feedback to decision makers on the quality of courses attended and incorporating records of training in personnel data bases. The findings of the survey ''provided clear evidence that the impact of training was greater where there was an active involvement of the supervisor/ manager in both the preparation of the trainee before the programme and in back-­‐to-­‐work activities associated with the training''. The OPM report felt that there was 'substantial evidence of scope for greater utilisations of national training providers, both government and non-­‐government', while suggesting partnership with international faculty where this assists capacity strengthening. The survey 'revealed much evidence of good practices in human resource management associated with training ', (conclusions in the OPM Report 2009). On the whole, the overall negative perspective reflected in the TOR (quoted at section 2.1) was not substantiated in the survey findings. The Report however made a number of recommendations to avoid the noted shortcomings and weaknesses to be able to strengthen the role of training in capacity building in health sector in Bangladesh. final_report_hnpsp 110 7.4 Operational Plans on: Improved Financial Management, Procurement, Logistics and Supply Management. A. Summary of Improved Financial Management OPs on Improved Financial Management in MOHFW, DGHS and DGFP The need to improve the financial management to support the proper implementation of HNPSP was recognized from the beginning of the programme. The Ministry of Health and Family welfare has responded positively to improve the financial management system in past years. The Government has been preparing two types of budget; (a) Development Budget prepared on the basis of the Annual Development Plan (ADP) and (b) Non-­‐development Budget or Revenue Budget. The Development Budget transforms the ADP into budget format to seek legal approval for grants and appropriations. The expenditure classification under the revenue budget is completely independent /different. The process of budget preparation is complete when the two budgets as well as the Re-­‐ appropriation Bill are approved by the Parliament. With the broad objective to improve the financial capacity of the line Ministries in the field of allocation and utilization of resources, monitoring and evaluation of the budget, accumulation and generation of accurate financial reports, the Government of Bangladesh (GOB) initiated comprehensive reforms in public financial management from the early 1990s. . In FY 2005-­‐06 Medium Term Budget Framework (MTBF) was piloted in four Ministries. MOHFW has been following the MTBF process for both the revenue and development budgets since FY 2006-­‐07. Preparing budget separately had a number of disadvantages. It did not help to prepare need based budget planning and to inefficiency. For preparing budget Line Directors did not provide inputs in time rather after budget was approved by the MOHFW. The procedure for preparation and approval of development budget under the SWAP is different from that of individual development projects. For HNPSP one block allocation for development budget is provided for MOHFW for the whole sector covered by the PIP and the Ministry has full authority to distribute these funds to the different Line Directors (LDs) as per their approved Operational Plans (Ops).The Ministry appoints LD for implementation of the OPs. SWAP-­‐ Funding Mechanism of HNPSP The Ministry of Health and Family Welfare implemented the Health and Population Sector Programme (HNPSP) with the help of Development Partners (DPs) apart from GOB assistance under Sector Wide Approach Programme (SWAP). HNPSP budget (2003-­‐2011) by sources of financing: ` Revised cost of PIP of HNPSP had been approved to be implemented within the timeframe of 2003 –2011 and the approved cost had been estimated at tk 3738411.05 lakh out of which programme cost was taka 1656646.53 lakh as development expenditure and taka 1026734.71lakh as Project Aid from Development Partners which was administered by IDA. final_report_hnpsp 111 Financial Monitoring Report / Accounting Flow and Reconciliation. Accounting: Pool Fund was channeled through the existing mainstream accounting system of the GOB. Accounting followed the system of Comptroller General of Accounts. Under the system FMAU of MOHFW continued to receive and record financial information both for GOB and Pool Donors funds following CGA system and would be responsible for maintaining the sector accounts. FMAU was also responsible for receiving expenditure statement from the Line Directors and reconciled the SOE with CGA information. The non-­‐pool donors used different mechanisms for making funds available to the programme. Reconciliation Respective Line Directors were expected to reconcile the expenditure with CAO. No FMRs were acceptable to FMAU if they were not reconciled to the CAO. Financial performance report of HNPSP was needed to be sent to WB in duly filled up FMRs. 38 FMRS for 38 operational plans needed to be sent altogether to get the quarterly fund release from World Bank. Financial Reporting GOB & DPs had agreed to accept a single set of Financial Monitoring Reports (FMRs). FMAU was responsible for consolidating financial information from all cost centres, preparing variance analysis for actual expenditure and reconciled information with Quarterly financial Statements (FMRs). Performance Based Financing (PBF) Disbursement of funds from this category was made only if the performance became satisfactory. Performance fully depended on financial achievements required to be proved through submission of duly filled in FMRs. Fund Release from World Bank Based on Annual Performance Review of HNPSP, MOHFW and DP by April 15th of each year estimated the financing share for both GOB and Pooled Donors for the following fiscal year for all disbursement categories. On the basis of monthly expenditure, GOB drew funds from the Forex account to its consolidated fund. At the end of the quarter, DP were to replenish the FOREX account on the basis of FMRs including a statement on funds required for the next six months. Better Traceability of Fund Better traceability of fund depended on good governance in all the offices under MOHFW. Weaknesses in internal control had resulted in increased auditing. Following the special Financial Review in 2007, initiatives were implemented to strengthen the internal audit function, contracting out to independent institution to carry out internal audit. Procedural simplification & traceability of fund a) The present procedure of budget preparation suffered from data feedbacks from district level to the Directorates under MOHFW. This was simply a constraint for the Directorate to give appropriate data and information to the Ministry in time. It might be recalled that there were already existing system of data entry at District and sub-­‐district level. final_report_hnpsp 112 But a system of flow of collated and systemized data and information from district and sub-­‐district level was yet to be properly developed. Availability of data and information would act as a catalyst for procedural simplification of budget preparation. REPORT ON IMPROVED FINANCIAL MANAGEMENT UNDER HNPSP The need to improve the financial management to support the proper implementation of HNPSP was recognized from the beginning of the programme. The Project Appraisal Document (PAD) assessed the fiduciary risk as high and set out a number of actions for improvement of financial management. The Ministry of Health and Family welfare has responded positively to improve the financial management system in past years. Historically the Government has been preparing two types of budget; (a) Development Budget prepared on the basis of the Annual Development Plan (ADP) and (b) Non-­‐development Budget or Revenue Budget. The ADP is prepared by the Planning Commission. In the ADP, the projects/ programmes are arranged sector-­‐wise showing the allocations for all the projects (Capital expenditure and revenue expenditure, sources of funds e.g., GOB and Project aid).. The Development Budget transforms the ADP into budget format to seek legal approval for grants and appropriations The expenditure classification under the revenue budget is completely independent /different. And this makes it difficult to bring the revenue and development expenditure into one single format and thereby show the Government resources allocated to same activities/ programmes under the two budgets. The process of budget preparation is complete when the two budgets as well as the Re-­‐ appropriation Bill are approved by the Parliament. With the broad objective to improve the financial capacity of the line Ministries in the field of allocation and utilization of resources, monitoring and evaluation of the budget, accumulation and generation of accurate financial reports, the Government of Bangladesh (GOB) initiated comprehensive reforms in public financial management from the early 1990s. In the meantime two projects viz. Reforms in Budgeting and Expenditure Control (RIBEC) and Financial Management Reforms Project (FMRP) had already been implemented by the GOB under the stewardship of the Finance Division of the Ministry of Finance. In FY 2005-­‐06 Medium Term Budget Framework (MTBF) was piloted in four Ministries. MTBF was expanded to ten Ministries including the MOHFW as part of the reform process under the FMRP with a view to improving the efficiency and effectiveness of public expenditure. MOHFW has been following the MTBF process for both the revenue and development budgets since FY 2006-­‐07. Ministry of Finance is now implementing Strengthening Public Expenditure Management Project (SPEMP) as a successor project to the Financial Management Reform Programme (FMRP). SPEMP has included a number of components to develop Public Financial Management (PFM) capacity in line ministries. It will provide a supportive framework for the improvements in Financial Management proposed for MOHFW. For effective coordination The Finance Division asked all Ministry/Division including MOHFW to establish a budget management branch/wing combining the officers both from administration and planning side but such branch/wing was not established. Preparing budget separately had a number of disadvantages. It did not help to prepare need based budget planning and lead to inefficiency. For preparing budget Line Directors did not provide inputs in time rather after budget was approved by the MOHFW. It was also observed that due to top down approach budget amount was always less than planned amount and at the same time LDs failed to spend their budgeted fund within the time frame. In the absence of adequate information from the ground level officers final_report_hnpsp 113 Departments/Agencies prepared their own estimation based on past experience. As a result, expenditure in priority areas sometime remained unattended. The procedure for preparation and approval of development budget under the SWAP is different from that of individual development projects. For HNPSP one block allocation for development budget is provided for MOHFW for the whole sector covered by the PIP and the Ministry has full authority to distribute these funds to the different Line Directors (LDs) as per their approved Operational Plans (Ops).The Ministry appoints LD for implementation of the OPs. At present there are 38 OPs under the HNPSP and one LD is responsible for one OP. The OPs are prepared by the LDs with inputs from the Programme Managers for each sub-­‐programme/programme. The draft Ops are examined by the Planning Wing of the Ministry and submitted for consideration of the HNPSP Steering Committee headed by the Hon’ble Minister for Health and Family Welfare. After finalization of the OPs as per recommendation of the Steering Committee and the proposed development budget by the BMC, these are forwarded to the Planning Commission and the Finance Division. In Bangladesh, present Planning & budgeting system are shown as under. Present Planning Procedures National Strategy for Accelerated Poverty Reduction (NSAPR) Sector Programme Sector-­‐Wide Approach Investment Project Figure-­‐-­‐-­‐8 T.A Project As usual the Steering Committee approved the revision. After approval of the Steering Committee, the Planning Wing of the Ministry had to issue Administrative approval in favour of each OP by July of the concerned fiscal year. Simultaneously the FM&D Wing of the Ministry issued GO for ADP allocation under HNPSP according to economic code. SWAP-­‐ Funding Mechanism of HNPSP The Ministry of Health and Family Welfare implemented the Health and Population Sector Programme (HNPSP) with the help of Development Partners (DPs) apart from GOB assistance under Sector Wide Approach Programme (SWAP). Process of getting Fund • Approved Operational Plans (2003-­‐2011) • Annual Development Programme / Revised Annual Development Programme • Mid Term Budgetary Framework (MTBF) HNPSP budget (2003-­‐2011) by sources of financing: final_report_hnpsp 114 ` Revised cost of PIP of HNPSP had been approved to be implemented within the timeframe of 2003-­‐2011 and the approved cost had been estimated at tk 3738411.05 lakh out of which program cost was taka 1656646.53 lakh as development expenditure and taka 1026734.71lakh as Project Aid from Development Partners which was administered by IDA. Total cost of the programme for the period of 2003—2011 and break up for financing is shown as under: Summary of Approved budget for HNPSP (2003-­‐2011) by sources of financing Table -­‐=7.4.1 Taka in Lakh Area Of 2003-­‐08 2008-­‐11 Total % of Total Expenditure GOB Revenue 977395.00 1104369.52 2081764.52 55.69% GOB 257721.82 372190.00 629911.82 16.85% Development Sub-­‐total of GOB 1235116.82 1476559.52 2711676.34 72.54% Project Aid 407497.48 619237.48 1026734.71 27.46% Sub-­‐Total of 665219.05 991427.48 1656646.53 44.31% Dev(GOB+PA) Total (Rev+Dev) 1642614.05 2095797.00 3738411.05 100% Development Partners support for HNPSP: An amount of taka 95746.95 lakh had been received from Development Partners for 2003-­‐06 for HNPSP. An amount of Taka 955987.76 lakh of Development Partners support was committed for the HNPSP of MOHFW from 2005-­‐
2011. Forex Accounts -­‐-­‐ Fund Flow Pooled DPs Quarterly IDA and FMRS Multi Donor Trust Fund from MOHFW to DPs Forex Account Held By GOB On the Basis of GOB’s Budget system FMRs (including GOB Resources) Figure-­‐-­‐9 MOHFW Operational Plan wise allocation are attached at Annexure-­‐-­‐F Expenditure Financial Monitoring Report Accounting Flow and Reconciliation. final_report_hnpsp 115 Accounting: Pool Fund was channeled through the existing mainstream accounting system of the GOB. Accounting followed the system of Comptroller General of Accounts. Under the system FMAU of MOHFW continued to receive and record financial information both for GOB and Pool Donors funds following CGA system and would be responsible for maintaining the sector accounts. FMAU was also responsible for receiving expenditure statement from the Line Directors and reconciled the SOE with CGA information. The non-­‐pool donors used different mechanisms for making funds available to the programme. Sometimes they made funds available to the programme by making direct payment to the contractors-­‐suppliers and consultants under bilateral agreements with the Government Non pool donors also disbursed funds to Line Directors for specific programme expenditure. Reconciliation Respective Line Directors were expected to reconcile the expenditure with CAO within 10 days after the end of respective quarter before sending it to FMAU. No FMRs were acceptable to FMAU if they were not reconciled to the CAO. Financial performance report of HNPSP was needed to be sent to WB in duly filled up FMRs. 38 FMRS for 38 operational plans needed to be sent altogether to get the quarterly fund release from World Bank. Financial Reporting GOB & DPs had agreed to accept a single set of Financial Monitoring Reports (FMRs). FMAU was responsible for consolidating financial information from all cost centres, preparing variance analysis for actual expenditure and reconciled information with Quarterly financial Statements (FMRs) which included the following reports: • Consolidated statements and uses of funds statements • Sources and uses of funds of Pool Donors • Sources and uses of funds of Non-­‐Pool Donors • Uses of Funds by Project components/activities as per Operational Plan • USD Forex Account (Health Account) Performance based Financing (PBF) Disbursement of funds from this category were made only if the performance became satisfactory. Performance fully depended on financial achievements required to be proved through submission of duly filled in FMRs. final_report_hnpsp 116 Quantity FMRs MOHFW to DP Fund Release from World Bank Based on Annual Performance Review of HNPSP, MOHFW and DP by April 15th of each year estimated the financing share for both GOB and Pooled Donors for the following fiscal year for all disbursement categories. On the basis of monthly expenditure, GOB drew funds from the Forex account to its consolidated fund. At the end of the quarter, DP were to replenish the FOREX account on the basis of FMRs including a statement on funds required for the next six months. Fund Flow Arrangement Pooled Fund IDA and Trust Fund held at Forex Account held by GOB On the basis of FMRs (MOF) GOB budget system (Including GOB Resources) (Including GOB Resources) G MOHFW Expenditure Figure-­‐-­‐10 Better Traceability of Fund Better traceability of fund depended on good governance in all the offices under MOHFW. Weaknesses in internal control had resulted in increased auditing. Following the special Financial Review in 2007, initiatives were implemented to strengthen the internal audit function, contracting out to independent institution to carry out internal audit, however, their TOR covered only to the audit of HNPSP expenditure, leaving non-­‐development expenditure (and expenditure of development projects) to other means. The Transparency implied that budget allocations should be spent for the purpose for which provision were made and accounts were properly maintained. It must be accessible and statements made available when asked for the purpose of external or internal audit by auditors or for purpose of monitoring as required. But these were nominally achieved during the implementation of HNPSP. The HNPSP result framework was revised and all operational plans were more or less linked to result framework. Two management Information systems under HNPSP DGHS & DGFP final_report_hnpsp 117 increased the number of operational computers in the periphery. Service statistics and logistics of DGHS & DGFP were in operation partially during HNPSP. There were scopes for improvements regarding the of quality health information at Peripheral and central level as decision making tools. Data would hardly be used for planning purposes which had poor reflection in output, monitoring and reporting at operational level. Procedural simplification & traceability of fund b) The present procedure of budget preparation suffered from data feedbacks from district level to the Directorates under MOHFW. This was simply a constraint for the Directorate to give appropriate data and information to the Ministry in time. Consequently, Budget Working Group (BWG) failed to act appropriately to prepare draft papers to meet the requirements of Budget Management Committee (BMC). Due to these limitations, the Directorates in the absence of data availability at their end prepared unreliable estimates based on their experience and assumptions. This led a gap and mismatch between resource allocation and resource requirements in budget process. It might be recalled that there were already existing system of data entry at District and –sub-­‐
district level. But a system of flow of collated and systemized data and information form district and sub-­‐district level was yet to be properly developed. c) Availability of data and information would act as a catalyst for procedural simplification of budget preparation. d) Similarly transparent data and information availability at all levels through computerized system would be instrumental to better traceability of funds and expenditure tracking which would led to bring about consistency with overall financial planning. Table 7.4. 2 Summary of Approved budget and Expenditure Statement of HNPSP (2003-­‐2011) Development budget expenditure (HNPSP) Out of total development fund of HNPSP budget Taka 16566.35 lakh including PA of Taka10267.35 lakh, fund utilization is Taka 13540.92 including PA of Taka 8156.03. Percentage of total fund utilization is 81.73% while for PA it is 79.42% And for GOB it stands at 85.48%. OP wise expenditures are shown at Annexure-­‐-­‐-­‐G Approved Cost of PIP Estimated Expenditure % of Fund (2003-­‐2011) (2003-­‐2011) Utilization GOB PA Total GOB PA Total 6299.12 10267.35 16566.47 5384.80 8156.03 13540.92 81.73% Analysis of Operational Plans on Improved Financial Management 1. Name of OPs: A. Improved Financial Management-­‐ MOHFW. final_report_hnpsp 118 B. Improved Financial Management-­‐ DGHS. C. Improved Financial Management-­‐DGFP. 2. 3. Objectives: -­‐ Financial Management is an important area of Sector Wide Management that needs strengthening in the course of HNPSP. Improved Financial management in the Ministry of Health of Family Welfare (MOHFW) and the two Directorates, DGHS and DGFP are brought under OP’s for improved Financial Management. LD designated in the Ministry and in the two Directorates was responsible for their respective OPs. The FMRP and other reform Programmes supported by Donors is a continuous process to improve public expenditure management and financial accountability. Improved Financial Management was a component of HNPSP. This included the control system, financial reporting, expenditure monitoring by components and sub components, resource tracking, technology transfer, analyzing financial information, settlement of audit observations raised by Foreign Aided Projects Audit Directorate (FAPAD), Compilation of Financial Monitoring Reports (FMRs), and reimbursement of funds & preparation of withdrawal applications as requested under the Development Credit Agreement (DCA)with World Bank & other Development Partners. Programme Contents:-­‐ a) Institutionalizing the Improved Financial Management:-­‐ i)
Accounting:-­‐Govt and the DPs agreed to accept a single set of FMRs. The reports were compiled by FMAU by using a computerized Management Accounting Consolidation System (MACs) developed to reflect the sector financing and expenditures. MACs were implemented in the Ministry from the 2nd quarter of FY 2007-­‐2008 on a parallel run basis. To introduce enhanced MACs for LDs for more informative reports for efficient use and transmitting data to the FMAU electronically for compilation of FMRs. A statement of expenditure format developed and provided to DPs for reporting DPA on a quarterly basis. This system required constant follow up with DPs. ii)
Internal Audit-­‐-­‐-­‐The Ministry formed “Core Internal Audit Teams” and “Spot Check” to carry out internal audit functions at regular intervals. In order to strengthen the internal audit functions it was agreed in addition to core internal audit teams and spot checks, the internal audit function would be outsourced to private audit firms. iii)
External Audit—FAPAD carried out annually the external audit. It was the responsibility of FMAU to coordinate in resolving the audit observations and report to the Donors the status of settlement of audit observations. An Audit Task Team was formed to maintain close liaison with the FAPAD for a prompt settlement of audit observations. b) Strengthening the Improved Financial Management:-­‐ Capacity building at the Ministry, Directorates and Field level was one of the main purposes of Improved Financial management. Link to HNPSP goals –The close monitoring of financial activities of the programme was expected to ensure funds were effectively and efficiently channeled in the light direction to achieve the pro poor goals of the HNPSP. 4. Targets (if any) / Indicators in original & Revised Result Framework. final_report_hnpsp 119 Indicator—Delayed settlement of external audit objection had been a concern. Prompt settlement of audit objections within the time frame indicated in the Result Framework, necessary arrangements and close follow up would be maintained during the implementation of HNPSP. 5. Budget allocation and Expenditure:-­‐ A) Improved Financial Management of MOHFW (Taka in Lakh) Original Approved cost for 1st revised Approved cost 2nd revised Approved Estimated 2003-­‐2006 for 2003-­‐2010 cost 2003-­‐ 2011 Expenditure 2003-­‐
2011 GoB PA Total GOB PA Total GoB PA Total GoB PA Total 130 860 990 360 2390 2030 408 2117 2525 300 1020 1320 B) Improved Financial Management of DGHS (Taka in Lakh) Original Approved cost for 1st revised Approved 2nd revised Approved Estimated 2003-­‐2006 cost for 2003-­‐2010 cost 2003-­‐ 2011 Expenditure 2003-­‐
2011 GoB PA Total GOB PA Total GoB PA Total GoB PA Total 80 50 140 250 60 310 193 148 341 83 145 228 C) Improved Financial Management of DGFP (Taka in Lakh) Original Approved cost 1st revised Approved 2nd revised Approved Estimated for cost for 2003-­‐2010 cost 2003-­‐ 2011 Expenditure 2003-­‐
2003-­‐2006 2011 GoB PA Total GoB PA Total GoB PA Total GoB PA Total 80 50 140 250 60 310 193 148 341 190 103 293 6. Management of Implementation: The APR2006 and APR 2007 and the Special Financial Review (SFR) in 2007 highlighted weak financial management and suggested to address the weaknesses. The main cause of financial management was the lack of qualified skilled and experienced finance staff at all levels of health system particularly at LD and cost centre level. Many reasons were identified at MTR 2008 for the low utilization rate, including human resource constraints, lengthy procurement procedures and delays in fund release particularly in the release of RPA. APR 2009 also recommended that the preparation of the revenue and development budgets needed to be brought under the coordination of a single wing of MOHFW. It was also stated at MTR 2008. Following the special Financial Review in 2007, initiatives were implemented to strengthen the internal audit function, contracting out to independent institution to carry out internal audit, however, their TOR covered only to the audit of HNPSP expenditure, leaving non-­‐
development expenditure (and expenditure of development projects) to other means. The HNPSP had objectives to make logistic system more effective and efficient through reducing distribution tiers, installing greater accountability and generating regular and reliable final_report_hnpsp 120 inventory transaction data. The reduction of cost was expected through accurate forecasting and proper storage. 7. Assessment of strengths / weaknesses. Strengths Following the special Financial Review in 2007, initiatives were implemented to strengthen the internal audit function, contracting out to independent institution to carry out internal audit. IT has developed substantially in MOHFW but the same is inadequate in the Directorates of Health or Family Planning or other subordinate offices. The HNPSP result framework was revised and all operational plans were more or less linked to result framework. Two management Information systems under HNPSP DGHS & DGFP increased the number of operational computers in the periphery. Service statistics and logistics of DGHS & DGFP were in operation partially during HNPSP. Weaknesses Lack of coordination in planning process and budget operation-­‐-­‐-­‐ The concern of co-­‐ordination in the Planning and Budgeting process at the MOHFW exists in manifold. Two sets of officers from two different cadres with different training and experience are posted in two wings. Presently Admn Section-­‐3, was looking after the budget preparation activities which was under Administration Wing. This Section acts as secretariat of the Budget Management Committee (BMC) for resource distribution purpose.
Estimation of non-­‐development budget for the Ministry was also being coordinated from this Section. On the other hand, estimates for the operational plans were being processed and coordinated by the Planning Wing. For effective coordination, the Finance Division asked MOHFW to establish a budget management branch/wing combining officers from both the services. Shortage of Trained man power in the Ministry to analyze the strategic objectives, policies and priorities of the Ministry and setting clearly defined measurable targets and Key Performance Indicators (KPIs) for the Departments/Agencies under the Ministry. Recommendation for future. i)
The PIP should contain national and sectoral strategies. The overall goals, objectives and implementation strategies have to be presented with yearly breakdown. The OPs may be developed showing yearly and cumulative targets as well as means of attainment. ii)
HNPSP strongly emphasized the need for internal audit to ensure periodic monitoring of financial and operational activities in the sector. It is therefore suggested that to make the system sustainable, the audit plan and follow up mechanism should be approved by MOHFW. For better traceability of fund an action plan may be developed and implemented in MOHFW. iii)
MIS unit in DGHS and DGFP should be geared up for programme monitoring (inputs and outputs) to give adequate feed back to M & E unit. iv)
Budget Management branch combining officers from both the services (Planning and Administration) should be put in place. v)
Existing trained manpower should be retained in the MOHFW and The Directorates. Proper training of manpower in the area of final_report_hnpsp 121 vi)
vii)
viii)
ix)
x)
planning/budgeting/implementation/Monitoring and auditing & accounting need to be improved in the next sector programme. The present procedure of budget preparation suffers from data feedbacks from district level to the Directorates under MOHFW. This is simply a constraint for the Directorate to give appropriate data and information to the Ministry in time. For the purpose of procedural simplification in budget preparation and improved basis of programme monitoring, it is recommended that a computerized system preferably LAN / WAN backed by trained manpower needs to be developed for the next SWAP. The improved computerized system would help the Directorates and BWG of the MOHFW to get timely data and information. In turn, BWG would be in a position to prepare analytical position paper for the BMC meetings in time. Recruitment or deployment of qualified finance staff is essential to finance positions both at the centre and at operational units at LD and cost centers level. It is recommended that contractual arrangement for internal audit services should be continued for the next sector programme of MOHFW. final_report_hnpsp 122 7.4. B. Operational Plan on Procurement and Logistics : Summary of OP on Procurement, Logistics and Supply Managment in DGHS and DGFP
Procurement & logistics are Integral to the delivery of health services. Funding for goods represents a significant proportion of overall expenditure in the Bangladesh health sector at about 30% and yet full benefits from this are not seen. These Issues are long standing in the MOHFW sector programme from the very beginning. The budgets for procuring goods & services rest with Line Directors as does the technical responsibility for identifying the quality & type of items required for various procurement plans. Various procurement entities were responsible for aggregating the requirements into lots and carrying out the tendering exercise. Most items were procured by CMSD and DGFP. There were also following other operational units on a smaller scale to undertake procurement activities. The HNPSP had objectives to make logistic system more effective and efficient through reducing distribution tiers, installing greater accountability and generating regular and reliable inventory transaction data. The reduction of cost was expected through accurate forecasting and proper storage. Procurement & storage under the Directorate of General Health Services-­‐Commonly known as central Medical Stores Depot (CMSD), was established with the objective of timely procurement and supply of the necessary drugs, equipment and supplies to the end users. Main objectives of the Programme were as follows:-­‐ -­‐-­‐To improve the operational capability of CMSD. -­‐-­‐To maintain utility services of CMSD. -­‐-­‐To procure goods requested by all Line Directors of DGHS in time. -­‐-­‐To ensure proper distribution of the goods and proper storage of goods. -­‐-­‐To ensure proper handling of goods and proper storage of goods. -­‐-­‐To keep ware house equipment, office equipment vehicles, etc of CMSD operational so as to perform adequate services. -­‐-­‐To keep Electro-­‐medical Equipment of Govt. Hospitals operational by repairing as and when reported. -­‐-­‐To ensure legal issues by appointing legal advisor, consultants and Bio-­‐Medical Engineers. Procurement Storage and Supply Management of DGFP would undertake greater responsibility for procurement and delivery of the contraceptives and essential drugs to provide maternal, child and delivery of the contraceptives and essential drugs to provide Family Planning Services to the Service Delivery Points throughout the country. Objectives of this OP were listed as follows: -­‐-­‐Continue logistics support for implementation of reproductive health (RH) programme. -­‐-­‐Ensure timely procurement of commodities required for Family Planning Programme. -­‐-­‐Ensure timely shipment and distribution of commodities. -­‐-­‐Ensure proper storage of the commodities. -­‐-­‐Build up capacity for procurement. Civil Surgeons were authorized to procure Standard Package of medicines and supplies for DGHS facilities up to and including district Hospitals. CMSD-­‐ procured medical equipment, final_report_hnpsp 123 office equipment, imported drugs and medical supplies and carried out emergency procurement. DGFP was responsible for the centralized national and international procurement for the Family Planning Wing including contraceptives and DDS Kits (Drugs and Dietary Supplements). DGFP followed its own Distribution System. The HNPSP had objectives to make logistic system more effective and efficient through reducing distribution tiers, installing greater accountability and generating regular and reliable inventory transaction data. The reduction of cost was expected through accurate forecasting and proper storage. Meeting International Standards: All procurement of goods &services was governed by the Public Procurement Act 2006 and the 2008 Public Procurement Rules. It was observed that these had established a sound national procurement policy that had brought government procurement both national and international, in line with good international practices. Therefore, each procurement plan followed process containing necessary information in the schedule of requirement (SOR) with a list of items, quantities and their respective destinations. The World Bank reviewed every tender exercise some after they had been completed, and some at various stages before the tender packages was issued. Some after they had been completed. So the impact of the involvement of the WB in procurement had been an ongoing issue that was imposed. Procurement and Supply: Due to lack of efficient storage, inventory supply and distribution chain and utilization of logistics were limited. There was lack of proper coordination among the procurement groups and the Line Directors with adequate timing and proper planning of procurement and supply. In respect of approval of the revised Ops, fund release and procurement be simple which would facilitate implementation of the programme according to its plan. All the LDs considered the procurement of goods and services as one of the constraint in achievement of their activities as per plan. Sometimes they had to drop the procurement plan as it was not made in the stipulated time frame. Monitoring and Supervision As mentioned in many reports APRs, MTR, APRIs and different assessment that the reporting system of activities of operational plan are poor. The present reporting system and practice is not enough to capture and reflect the accomplishment, which need to be improved. Development budget expenditure (HNPSP) Out of total fund of HNPSP development budget Taka 16566.35 lakh including PA of Taka10267.35 lakh, total fund utilization is Taka 13540.92 including PA of Taka 8156.03. Percentage of total fund utilization is 81.73% while for PA it is 79.42% and for GOB it stands at 85.48%. All bulk procurement of DGFP was done by logistic & supports this under the control of DG on the basis of requirements of Different Directors. Logistic and Supply Unit of the DGFP functioned with a line Director at the top of the hierarchy comprised of different sections, such as Local Procurement, Foreign Procurement, Distribution and Management. final_report_hnpsp 124 Modest progress had been made in the procurement process. Some achievements were made during the period of HNPSP. A computerized procurement tracking software had been installed at CMSD. Ø Focal points of different procurement entities were identified. Ø Recommendation of medical equipments study was being followed up partially. Ø CMSD had taken important steps in improvement of bidding documents. The weaknesses of Procurement were faulty planning, centralization without capacity building, limited financial authority and rigidity in procurement processing by the World Bank. Distribution suffered from irregularity and shortage. The World Bank reviewed every tender exercise some after they had been completed, and some at various stages before the tender packages was issued. Some after they had been completed. So the impact of the role of the WB in procurement had been an ongoing issue that was imposed. Report on Procurement , Logistics and Supply Management Of DGHS & DGFP Procurement & logistics are Integral to the delivery of health services. Funding for goods represents a significant proportion of overall expenditure in the Bangladesh health sector at about 30% and yet full benefits from this are not seen. These Issues are long standing in the MOHFW sector programme from the very beginning. The budgets for procuring goods & services rest with Line Directors as does the technical responsibility for identifying the quality & type of items required for various procurement plans. Various procurement entities were responsible for aggregating the requirements into lots and carrying out the tendering exercise. Most items were procured by CMSD and DGFP. There were also following other operational units on a smaller scale to undertake procurement activities. The HNPSP had objectives to make logistic system more effective and efficient through reducing distribution tiers, installing greater accountability and generating regular and reliable inventory transaction data. The reduction of cost was expected through accurate forecasting and proper storage. Meeting International Standards: All procurement of goods &services was governed by the Public Procurement Act 2006 and the 2008 Public Procurement Rules. It was observed that these had established a sound national procurement policy that had brought government procurement both national and international, in line with good international practices. Therefore, each procurement plan followed process containing necessary information in the schedule of requirement (SOR) with a list of items, quantities and their respective destinations. Following the preparation of SOR tender documents were prepared, approved and published. After bid closure there was evaluation of bids and notification of awards. final_report_hnpsp 125 Procurement and Supply: Generally efficient and transparent procurement and distribution throughout the year prevented the stock out. But due to lack of efficient storage, inventory supply and distribution chain and utilization of logistics were limited. There was lack of proper coordination among the procurement groups and the line directors with adequate timing and proper planning of procurement and supply. In respect of approval of the revised Ops, fund release and procurement be simple which would facilitate implementation of the programme according to its plan. All the LDs considered the procurement of goods and services as one of the constraint in achievement of their activities as per plan. Sometimes they had to drop the procurement plan as it was not made in the stipulated time frame. Delay of procurement occurred due to the following reasons: -­‐-­‐-­‐-­‐-­‐-­‐Lengthy procedures and delay of getting no objection from World Bank (WB) -­‐-­‐-­‐-­‐-­‐-­‐Entertaining complain during the bid-­‐evaluation stage, -­‐-­‐-­‐-­‐-­‐-­‐Centralized procurement system, -­‐-­‐-­‐-­‐-­‐-­‐New rules/conditions for packaging, land acquisition, rehabilitation etc. for works procurement. -­‐-­‐-­‐-­‐-­‐-­‐Delay in the approval process in the Ministry. There were lack of coordination among procurement planners, implementers and users which resulted in wrong packaging, specifications and sometimes reluctant to receive goods/services/works. Analysis of Operation Plans on Procurement, Logistics & Supply Management of DGHS AND DGFP 1. Name of OPs: Procurement, Logistics and supply Management (DGHS) 2. Objectives: -­‐ Procurement & storage under the Directorate of General Health Services-­‐
Commonly known as central Medical Stores Depot (CMSD), was established with the objective of timely procurement and supply of the necessary rugs, equipment and supplies to the end users. Main objectives of the Programme are as follows:-­‐ Ø To improve the operational capability of CMSD. Ø To maintain utility services of CMSD. Ø To procure goods requested by all Line Directors of DGHS in time. Ø To ensure proper distribution of the goods and proper storage of goods. Ø To ensure proper handling of goods and proper storage of goods. Ø To keep ware house equipment, office equipment vehicles, etc of CMSD operational so as to perform adequate services. Ø To keep Electro-­‐medical Equipment of Govt. Hospitals operational by repairing as and when reported. Ø To ensure legal issues by appointing legal advisor, consultants and Bio-­‐
Medical Engineers. 3. Programme Contents:-­‐Procurement of goods by CMSD under HNPSP followed the public procurement Act 2006 and public procurement Rules 2008. Major components of the programme are: 3.1-­‐ Logistic Management. 3.2-­‐ Procurement and clearance. 3.3-­‐ Storage & Distribution. 3.4 Repair & Maintenance. final_report_hnpsp 126 4. Targets (if any) / Indicators in original & Revised Result Framework. 4.1 Decentralization of procurement system & delegation of authority for procurement to the level of LDs 4.2 Delegation of authority at District level to procure locally available hospital commodities for day to day operation of hospitals. 4.3 Building capacity of personnel on procurement. 4.4 Providing Technical assistance including training to other LDs and the district level authorities to speed up their procurement. 4.5 Improving logistic Management Information Systems (LMIS) 5. Budget allocation and Expenditure: Tk in lakh st
Original Approved 1 revised Approved 2nd revised approved Estimated cost for
cost for 2003-­‐2010 cost for 2003-­‐2011 Expenditure 2003-­‐
2011 GOB PA Total GOB PA Total GOB PA Total GOB PA Total 6780 570 7360 16870 540 17410 31,234 871 32,105 45782 347 46029 1. Name of OP-­‐ Procurement, Storage and Supply Management-­‐DGFP 2. Procurement Storage and Supply Management would undertake greater responsibility for procurement and delivery of the contraceptives and essential drugs to provide maternal, child and delivery of the contraceptives and essential drugs to provide Family Planning Services to the Service Delivery Points throughout the country. Objectives of this OP were listed as follows: Ø Continue logistics support for implementation of reproductive health (RH) programme. Ø Ensure timely procurement of commodities required for Family Planning Programme. Ø Ensure timely shipment and distribution of commodities. Ø Ensure proper storage of the commodities. Ø Build up capacity for procurement. Ø Ensure timely delivery of contraceptives and drugs to the service centers/ outlets. Ø Monitor and establish accountability of logistic system. 3. Programme Contents: Ø Administration & Management Ø Procurement ü Foreign procurement ü Local procurement. Ø Capacity Building and Training Ø Improvement of warehouses Ø Improvement of Upazila stores Ø Commodity shipment (through public and private transport pre-­‐shipment and post shipment Inspection) Ø Logistics MIS final_report_hnpsp 127 Ø Conduct physical Inventory and Commodity Audit. Ø Technical Assistant. Targets (if any) Indicators in original & Revised Result Frame work. Ø All bulk procurement of DGFP is done by logistic & supports this under the control of DG on the basis of requirements of Different Directors. Ø Ware housing, supply & distribution rationalizing and upgrading. Ø Logistics Management System and logistics data networking. Ø Upgrading regional warehouse and Refixing the catchments area. Ø Automation of Upazila FP stores. Ø Contraceptives security. 5. Budget allocation & Expenditure. ( TK .in lakh ) st
nd
Original Approved 1 revised 2 Revised Approved Estimated cost for 2003-­‐2006 Approved cost for Cost for Expenditure 2003-­‐
2003-­‐2010 2003-­‐2011 2011 GOB PA Total GOB PA Total GOB PA Total GOB PA Total 5580 150 5730 9750 560 10310 10.349 545 10.895 5655 229 5884 6. Management of Implementation: Main points raised in Different APRs-­‐-­‐-­‐ DCA 2005 provided for setting up the introduction of new institutions Like PSO, MSA, PMA to address the difficulty involved in the new process of HNPSP. Only PSO was in operation since July 2007 & MSA was made Operational at the end of 2008. But PMA was not in operation during HNPSP period. If MSA & PMA were in place before undertaking any major new contracting activity, risk associated with more direct contracting approach could be avoided. The MTR 2008 however, reported that CMSD were now managing tender processes better and Line Directors getting better at completing their procurement plans in time. Also the APR 2009 reported that performance of the procurement agencies had improved when measured against two the indicators in the PAD, namely percentage of contracts awarded within bid validity( this had increased), and miss-­‐procurement (reduced). However opening letters of credit for international procurement remained a problem. According to the APR 2009, the technical procurement process was improving; various key issues that could be scaled up for the performance of the procurement and logistics system were not addressed including delegation of authority, and efficiency of approval process. According to APIR 2010 there was lack of coordination 7. Assessment of strengths & weaknesses: Strengths:-­‐-­‐ Modest progress had been made in the procurement process. Some achievements were made during the period of HNPSP. Ø A computerized procurement tracking software had been installed at CMSD. 5. Focal points of different procurement entities were identified. Ø Recommendation of medical equipments study was being followed up partially. Ø CMSD had taken important steps in improvement of bidding documents. final_report_hnpsp 128 Weaknesses:-­‐-­‐ The weaknesses of Procurement were faulty planning, centralization without capacity building, limited financial authority and rigidity in procurement processing by the World Bank. Distribution suffered from irregularity and shortage. There was no evidence of achievement in cost reduction. Delay in Procurement also delayed timely implementation. There were lack of coordination among procurement planners, implementers and users which resulted in wrong packaging, specifications and sometimes reluctant to receive goods/services/works. The World Bank reviewed every tender exercise some after they had been completed, and some at various stages before the tender packages was issued. Some after they had been completed. So the impact of the role of the WB in procurement had been an ongoing issue that was imposed. The decision making process in respect of approval of the revised Ops, fund release& procurement is complex and time consuming. If the procedure was simplified that would facilitate implementation of the programme according to its plan. Most of the LDs faced problems concerning procurement of goods, works & services and that prevented them to achieve their desired activities as per plan. Many time they had to drop their procurement plan as they could not accomplish them in stipulated time frame. Because of the centralized procurement system other entities were discouraged to procure goods as per their needs which delayed procurement for smaller entities. Recommendation for future Sector Programmes 1. For timely implementation of the programme according to plan, the decision making process for approval fund release and procurement should be made simplified. 2. WB procurement procedure and GOB public procurement regulations & rules should be simplified to avoid delay in completion of tender process. This will facilitate reduction of total average lead time in the procurement process. 3. The procuring entities were staffed by officers from deputation from other departments & they lacked specialized knowledge other than what they gain on the job & through desk level training. To avoid such situations it is recommended that retaining staff doing procurement functions should not be transferred at least 4-­‐5 years from the posts. 4. For Procurement & Logistics improvement, it is recommended that Technical Assistance should be obtained through the establishment of PLMC and engagement of TA for CMSD and DGFP procurement. 5. The future programme design for procurement it is suggested that more focus is needed on technical support rather than on reform issues. 6. A member of technical expert or PLMC needs to be present at the technical evaluation meeting to give technical assistance. 7. CMSD should evaluate functioning and planning of its post shipment inspections. Specific training on opening of letters of credit should be organized. 8. Accurate forecasting and proper storage should be improved for reduction of costs. final_report_hnpsp 129 Chapter 8 Findings on Field Survey and Investigation Summary : The summary Findings on field survey such as observation on health facilities, Opinion of service recipients, focus group discussions, opinion of service providers and key stakeholders are presented in this chapter. The topics appear as in the following sections. Section 8.1 : Findings from Observation on Health Facilities Section 8.2: Findings From Face To Face Interview With Service Recipients. Section 8.3: Findings From FGD Meetings With 7 Homogeneous Groups Section 8.4: Findings From The Consultative Meetings With The Service Providers and Key Stakeholders. Description of Sampling Design: The sampling design and respondents are given in Annex-­‐A and data collection instruments are at Annex-­‐ H. Findings: 8.1 Findings from Observation on Health Facilities In order to assess the status and maintenance of health facilities, the field investigators observed and verified documents for the following items: Availability of Ticket Counter, Presence of Outdoor Doctor, Presence of Pharmacist, Availability of Cleaners, Presence of Ward-­‐Boy, Percent of Bed Occupancy, Separate room of Out patients, Privacy in Counseling, Screen beside Patients Seat, Supply of Water, Toilet Facility for Out-­‐patients, Separate Toilet for Female, Separate Room for IUD/Delivery, Overall cleanliness of hospital. All The District hospitals studied had the affirmative maintenance of the facilities. But the situations in MCWC, UHC and UH&FWC had a lot of variations in situations with the availability. Equipments Availability and Functional Status: Information about availability and functional status of the following equipments were obtained through observation and document verification. Weighing Machine for Adults, Weighing Machine for Child, . Adult Stethoscope, BP Machiune, IUD Kit, Blood Transfusion Set, Microscope, Surgery Kit, O & G Kit, Tubectomy Kit, Vasectomy Kit, Autoclave, Refrigerator, Ligh in OT. Aircondition In OT. In this case the District hospitals and MCWCs had the equipments in functional condtions, but the situations inUHCs and UHFWCs was not that satisfactory. Obstetrics Services. Regarding Obstetric First Aid Services, All the 7 District hospitals and 7 MCWCs had Obstetric First Aid, 9 out of 14 UHCs has this service and 14 out of 28 UHFWCs had this service. About basic EMOC, all the 7 district hospitals, 7 MCWCs, 6 out of 14 UHCs and 8 out of 28 UH&FWC had this service. Regarding Comprehensive EMOC, all the 7 district hospitals and MCWCs, 6 out of 14 UHCs and 2 out of 28 UH&FWC had this service. Contraceptives Stocks. Presently all the designated contraceptive items; namely, Injectables, Implants, IUD, Contracptive Pills and Condoms were available in all the 7 district hospitals and 7 MCWCs. But there were shortage of some items in the UHCs and UH&FWCs. 8.2 Service Recipient. Socioeconomic and Demographic Characteristics: A total of 490 exit clients and beneficiaries of the catchment areas of District Hospitals, MCWCs, UHCs and UH&FWCs were selected through random sampling. Of the total clients of 490 interviewed, 126(35.7%) were male and the remaining 364(74.3%) were female. The mean age 130 of male patients was 36.7 and the mean age of female patients was 30.8 years. Regarding education of the respondents we find that as high as 40% had no schooling, 24.5% had education at grade 1-­‐5 and 27.1 % had education at grade 6-­‐10. Only 8.4% of the patients had education at H.S.C. level (grade 12) and higher level The average monthly household income was Tk 4650/-­‐ and mean landholding size was found to be 20 decimals. Both the indicators suggest that the patients visiting the health facilities are from poor households. The mean number of children ever born was found to be 2.6 per woman and the mean number of living child under 5 was 0.95. The mean age of the youngest living child was 42 months. Service Providers, Time Spent and their Behaviour. As high as 435(88.8%) of the patients reported that they were provided service by the MBBS doctors. And 35(7.1%) received services from SACMO and 16(3.3%) received services from FWVs. The mean waiting time of the patients was 30.7 minutes and the mean time taken by the service provider to issue medicine was 8.5 minutes. While examining patients privacy was maintained in 48.6% of the cases. Not satisfactory and 3.0% observed their behavior to be very unsatisfactory. Client Examination Prior To Treatment: As many as 260(53.1%) of the patients replied that they had their pulse rate examined by the provider, 100(20.4%) replied that their blood pressure was examined, in 226(46.1%) Stethoscope was used, and 111(22.7%) patients were examined for anemia. Opinions/Views On Improvement of Health Services. Highest responses to this question was for the supply of adequate medicine, followed by 289(59.0% for the regular attendance of the doctor, 221(43.1%) was for the placement of MBBS doctor, 137(28%) was for the availability of equipment Immunization Status of Under 5 Children and Treatment Seeking Behavior: Among the under 5 children 74.1% was fully immunized and 22.7% was partially immunized. Family Planning Services. Among the eligible couples surveyed 55.5% was currently using any family planning method. Regarding the health/FP worker’s home visitations, 35.7% indicated that they were visited by FP worker, 10.6% replied that they were visited by health worker and 32.2% replied that their houses were not visited by any health/FP worker in the last three months before the survey. Maternal Health. 22% of the respondents reported occurrence of birth during one year preceding the survey. Their deliveries was assisted by Dai(24.5%), Trained TBA/TBA(19.6%), SBA(43.1%), Relatives/neighbor(12.7%) and health center(6.1%). Among those who had delivery in the preceding year of the survey 26.9% had complications before delivery, 21.3% had complications during delivery and 19.4% had complications after delivery. Opportunity/Use Status of Services from Health Centres. The mean distance of the health centers from the patients house was found to be 1.6 Km. On a detailed inquiry on the kind of purposes for visiting health centers, it came out that treatment for common disease (46.6%) was the dominant response for visiting health centres, followed by children’s sickness (37.2%), Emergency health care (22.5%), Complications during delivery (14.5%) and side effects of FP methods (13.3%). 131 8.3 Focus Group Discussions. Notion about the implementation of HNPSP (2003-­‐2011): HNPSP programme has been highly commendable and practicable and common people have been HNPSP programme not properly rendered since 2003 and accountability has not yet been ensured and if ensured then only health services would be fetched by every house in the village. HNPSP programme very important and with dynamism and transparency the programme should be reached to every house of the rural Bangladesh People are benefited about health and nutrition awareness-­‐ these services could be improve if more supervisory supports are conducted every month Implementation of HNPSP activities are going smoothly The number of doctors, nurses and equipments has increased and environment has improved. Improvement in health service delivery in HNPSP when compared to before 2003: Quality of health services through UHC has much improved than what it was before 2003 UHC-­‐ health workers don’t duly render their responsibilities as such health services to the patients are almost the same as before the start of the programme in 2003 HNPSP services to the people are not yet apparent Health services have improved than what it was before 2003-­‐ except for administrative activities are not yet properly implemented. Health services have improved profusely due to recruitment of doctors and nurses in the UHC Scope of treatment to the patients has increased which is better than what was before 2003 How far HNPSP service delivery has been pro-­‐poor especially to women, children and the poor? More attempts should be taken to reach the health services to the door steps of the poor people especially the women and children. All essential drugs should be supplied to the patients through governmental efforts and steps should be taken that the patients do get the medicines. The health workers should be equipped with all needed facilities and supervision of their activities should be ensured to make health services more accessible to women and children Besides medical treatments, the supply of essential drugs to the patients especially to the women, children and the poor. Doctors and nurses at some places take money for drugs and medicine. If both the doctors and nurses work honestly and sincerity then this would be encouraging to the poor people to their services. Services to the women, children and poor people have much improved. Incidence of diarrhea has reduced and death of children from diarrhea diseases and death of mothers from delivery has fallen. Poor people awareness has increased to access health services from the hospital] Steps Needed in improve health services in future. 132 ü Doctors should visit the students (at schools) at least once in a month to ensure health service/cares and health awareness programme with them and they should be sincere and self-­‐motivated about this. ü Needed manpower to be posted in health centers ü Essential machines and equipments should be installed ü Supervisory supports to field workers to be ensured ü Bureaucratic poses and procedures should be curtailed ü Each field workers should be entrusted with targets to reach ü Health services should be extended and developed in all the Unions. . ü Teachers of educational institutions should be involved in this awareness programme. normal works of the health workers. ü Health services would be quality and improved if satellite clinics are arranged in the village every week. ü Regular supply of essential drugs should be ensured. Opening and closing of health center should be ensured at the right time. ü Modern equipments should be installed in the health center as the poor patients can not afford treatment cost for some of the major injuries at far off Rangpur Sadar Hospital 8.4 Key Stakeholders: Suggestions/Recommendations to improve the over all performance of HNPSP: ü For preparation of Design and formulation and implementation of OPs should be initiated through the concerted efforts of all concerned Ministries and Agencies/Cells and Sectors. They should often sit together to steer the needed steps to modify the ongoing OPs in terms of funds allocation, recruitment of human resources, procurement of equipments or any other related shortfalls or any set backings. ü Inter ministerial efforts and well coordinated and holistic approaches should be ensured within all the key persons involved in HNPSP design, formulation and implementation through forum and continuous meetings and feedbacks and sustained interactions ü All the concerned officials who are thoroughly experienced, more self-­‐motivated and with proven efficiency/expertise should be promoted to work as Line Directors for the concerned OPs. If situation demands-­‐ they may be contracted to work even after their retirement. ü Decentralization of administrative and financial authority should be entrusted with the local level officials ( CS, Directors and Deputy Director) to transfer or promote their field level staff on the basis of their respective field performances and they should also be authorized to purchase or procure furniture, drugs and other day to day hospital accessories and maintenance and repair works of hospital as well. ü For additional beds in the Hospitals the need for furniture, drugs, equipments and recruitment of medical professionals should be implemented through development fund of the Government -­‐ since allocation of fund from revenue head is time-­‐consuming and cumbersome as well. ü As often practiced/followed in developed countries for hospital management services-­‐ recruitment of non-­‐medical persons-­‐ highly motivated and smart graduates experienced 133 ü
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in human resources, accounts and financial management should be initiated by the Government. The MO HFW should be entrusted with the discretionary power to employ or recruit mid-­‐level Health and Family Planning personnel/workers with minimal level of concurrence from Ministry of Law, Ministry of Finance, Ministry of Public Administration and Public Service Commission. Some mechanism may be devised to make a coordinated efforts amongst the Public Division, PSC, Law Ministry, Finance Ministry and concerned MOHFW to speed up or smoothen the recruitment procedures on adhoc basis. There should be some consensus amongst all concerned Ministries to make a commitment to do their respective exercises in the formulation, approval and implementation of the programme through forum and committee meetings and consultations within themselves. To develop the in-­‐house expertise within the Planning Cell of MOHFW/ or under the jurisdiction of each of OPs-­‐ necessary funds should be released/allocated for conducting monitoring and evaluation of their respective areas on regular basis. And for unbiased evaluation and also due to work-­‐load-­‐ provision for budgetary release should be made to outsource the monitoring and evaluation of OP performances to experienced research firms of the country in collaboration with any donor agencies if needed. Budgetary allocation of funds for implementation of various OPs should not be strictly fixed rather it should be made flexible due to the price escalation and changes in the value of foreign currency to procure equipments and needed health accessories for Hospitals/health centers and also to keep up with the international standard of per capita health cost. Some budgetary arrangement should be made to render both gynecological and obstetric cares/services (caesarian delivery with OT facilities) are to be provided in the same UHC so that risky delivery by TBAs may be averted by the pregnant mothers. ü Improved health awareness programme should be targeted towards not only the curative aspects of treatment but also help people avoid common diseases (communicable and non-­‐communicable diseases) through preventive measures and basic health education. ü Non communicable diseases and conventional & non conventional urban health programme demand may be more emphasized in next programme. ü Coordination and Referral to upper health facility, ICC unit to secondary and tertiary health facilities, emergence and reemergence of new and old diseases and hospital autonomy to be included in the next programme. ü Doctors to have specialized training to handle machines and other computer based application (medical management information systems). ü The quality of nursing services should be upgraded up to international standard through advanced diploma courses for which the nursing colleges at Dhaka, Chittagong, Rajshahi and Bogra along with 2 other nursing colleges at private sector and nursing institutions 134 ü
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of the country should be manned with faculty members, qualified teachers/trainers. And also to increase the number of nursing professionals-­‐ all the medical colleges and hospitals of the country should provide nursing courses within their respective campuses. Nurses in our country work under low profile status-­‐ upgradation of their rank, status and salary supports-­‐ should be ensured despite some professional jealousy from doctors may crop up at the initial stage. Docs/Paramedics/FP workers, who are dedicated, self-­‐motivated and opted to serve the poor and disadvantaged people in the remotest health facilities at Union levels should be rewarded in the form of quicker promotion and financial incentives. Health and Family Services through CCs may be made reasonable more functional if regular supply of ESD and be manned with registered medical professional at least with SACMO. Both in-­‐service and refreshers courses should be made functional and be rationally imparted to all concerned Health and Family Planning personnel on nutrition, reproductive health, common CD and NCDs, MCH services Food safety issues are neglected-­‐ there are only 8-­‐10 food inspectors for 1.5 crores of people in Dhaka city-­‐ So food safety act may have to be in the health policy issue. Recruitment of medical professionals are a lengthy, cumbersome one and too many queries, papers submission in Public Division, Public Service Commission, Law Ministry and within the own Ministry are to be carried out. So some drastic measures have to be thought out to expedite the process of recruitment. Introduction The Findings on field survey such as observation on health facilities, Opinion of service recipients, focus group discussions, opinion of service providers and key stakeholders are presented in this chapter. The topics appear as in the following sections. Section 8.1 : Findings from Observation on Health Facilities Section 8.2: Findings From Face To Face Interview With Service Recipients. Section 8.3: Findings From FGD Meetings With 7 Homogeneous Groups Section 8.4: Findings From The Consultative Meetings With The Service Providers and Key Stakeholders. 8.1 Findings from Observation on Health Facilities Status of Health Facilities and Maintenance: In order to assess the status and maintenance of health facilities, the field investigators observed and verified documents for the following items: Availability of Ticket Counter, Presence of Outdoor Doctor, Presence of Pharmacist, Availability of Cleaners, Presence of Ward-­‐Boy, Percent of Bed Occupancy, Separate room of Out patients, Privacy in Counseling, Screen beside Patients Seat, Supply of Water, Toilet Facility for Out-­‐patients, Separate Toilet for Female, Separate Room for IUD/Delivery, Overall cleanliness of hospital. All The District hospitals studied had the affirmative maintenance of the facilities. But the situations in MCWC, UHC and UH&FWC had a lot of variations in situations with the availability. 135 Equipments Availability and Functional Status: Information about availability and functional status of the following equipments were obtained through observation and document verification.: Weighing Machine for Adults, Weighing Machine for Child, . Adult Stethoscope, BP Machiune, IUD Kit, Blood Transfusion Set, Microscope, Surgery Kit, O & G Kit, Tubectomy Kit, Vasectomy Kit, Autoclave, Refrigerator, Ligh in OT. Aircondition In OT . In this case the District hospitals and MCWCs had the equipments in functional condtions, but the situations inUHCs and UHFWCs was not that satisfactory. Obstetrics Services. Regarding Obstetric First Aid Services, All the 7 District hospitals and 7 MCWCs had Obstetric First Aid, 9 out of 14 UHCs has this service and 14 out of 28 UHFWCs had this service. About basic EMOC, all the 7 district hospitals, 7 MCWCs, 6 out of 14 UHCs and 8 out of 28 UH&FWC had this service. Regarding Comprehensive EMOC, all the 7 district hospitals and MCWCs, 6 out of 14 UHCs and 2 out of 28 UH&FWC had this service. Contraceptives Stocks. Presently all the designated contraceptive items;namely, Injectables, Implants, IUD, Contracptive Pills and Condoms were available in all the 7 district hospitals and 7 MCWCs. But there were shortage of some items in the UHCs and UH&FWCs. Observation Regrading Financial Matters Table: 8.1.1. Observation Regarding Financial Matters at Health Centers ( Zila Hospital / MCWC / UHC and UHFWC) : Financial Matters Zila MCWC UHC UHFWC Hospital n=7 n=14 n=28 n=7 Yes No Yes No Yes No Yes No 1. Whether Fee is Taken from Out 07 -­‐-­‐ 1 6 09 05 04 24 Patients 2. Any Guideline for Service Fee 07 2 5 12 02 04 24 3. Whether Poor get free service -­‐-­‐ 07 4 3 09 05 12 16 4. Difficulty to use Ambulance for 07 -­‐-­‐ 0 7 05 11 04 24 Fund 5. Limited Use of Generator for -­‐-­‐ 07 3 4 05 11 07 21 short of fund 6. Whether Service Fee is Deposited -­‐-­‐ 07 3 4 12 02 13 15 in the Govt. Treasury Average Number of Patients Served Per Day: The average number of patients served the day before the survey is given in table . Table: 8.1.2. Average Number of Patients Served the day before the survey by Health Facility Type Health Facility Number of Male Number of Female Number of Total number of Patients Patients Child Patients Patients Zilla Hospital 145 180 169 495 MCWC -­‐-­‐-­‐ 57 38 95 UHC 70 114 71 255 UHFWC 14 37 17 68 136 Table: 8.1.3 Average Numbers of Patients Served From 7 MCWCs by years -­‐Wise (2003-­‐
2011): Year Female Delivery Child Outdoor Outdoor Patient Normal Caesarian Admitted 2003 3975 2628 935 161 2371 2004 9541 7012 2227 253 1692 2005 9430 1736 810 122 2089 2006 7559 2715 986 181 3488 2007 14017 2539 798 202 4206 2008 12039 749 554 161 5577 2009 6555 6238 1908 217 2553 2010 9083 3521 927 342 3681 2011 3832 6195 1268 396 912 Table: 8.1.4 Average Numbers of Patients Served From 14 UHCs by Year-­‐Wise (2003-­‐2011): Year Outdoor Patients Indoor Patients Delivery Male Female Child Male Female Child Norma Caesarian l 2003 11726 13305 8946 3429 3279 385 221 66 2004 23661 15823 9846 7613 4618 321 241 79 2005 23442 13009 8099 8705 3918 309 278 79 2006 25964 15779 9360 8183 1788 347 288 81 2007 30771 20643 14050 2488 2090 441 321 84 2008 42647 37195 28095 11418 4064 776 476 123 2008 38229 34818 26461 11153 4029 616 449 127 2010 27143 37187 24650 4758 5794 787 617 150 2011 4963 7094 6197 1171 1311 88 118 30 137 Table: 8.1.5 Status of Sanctioned/ Filled in Post and Presence of Health/FP Service Providers on the Day of Survey at the Zilla hospital. Manpower Sanctioned Filled in Post Presence of Total Post SPs on Male Female Survey Day 1. Doctors 31 20 11 28 2. SACMO 0 0 0 0 3. Nurse/Senio 45 2 43 33 r Nurse 4. Pharmacist 4 2 2 4 5. Lab 2 1 0 1 Technician 6. Dental 1 1 0 1 Technician 7. Radiographe 2 1 0 1 r 8. Health 0 0 0 0 Assistant 9. FWA 1 0 1 1 10. FWV 3 0 3 3 11. Sweeper 15 6 9 15 12. Others 16 11 5 15 Table: 8.1.6 Status of Sanctioned/ Filled in Post and Presence of Health/FP Service Providers on the Day of Survey at the MCWC. Manpower Sanctioned Filled in Post Presence of Total Post SPs on Male Female Survey Day 1. Doctors 2 1 1 1 2. SACMO 0 0 0 0 3. Nurse/Senio 2 2 2 r Nurse 4. Pharmacist 0 0 0 0 5. Lab 0 0 0 0 Technician 6. Dental 0 0 0 0 Technician 7. Radiographe 0 0 0 0 r 8. Health 0 0 0 0 Assistant 9. FWA 0 1 2 2 10. FWV 2 0 2 2 11. Sweeper 3 0 1 1 12. Others 4 2 1 3 13. 138 Table: 8.1.7. Status of Sanctioned/ Filled in Post and Presence of Health/FP Service Providers on the Day of Survey at the UHC. Manpower Sanctioned Post Filled in Post Presence of SPs on Male Female Survey Day 1. Doctors 21 9 4 9 2. SACMO 5 3 1 1 3. Nurse/Senior Nurse 17 1 12 12 4. Pharmacist 2 2 0 1 5. Lab Technician 2 2 0 2 6. Dental Technician 1 1 0 1 7. Radiographer 1 1 0 1 8. Health Assistant 42 19 9 19 9. FWA 25 0 19 9 10. FWV 3 0 3 1 11. Sweeper 5 2 2 2 12. Others 18 10 4 10 Table: 8.1.8 Status of Sanctioned/ Filled in Post and Presence of Health/FP Service Providers on the Day of Survey at the UHFWC (n=28) Manpower Sanctioned Post Filled in Post Presence of SPs on Male Female Survey Day 1. Doctors 1 1 0 1 2. SACMO 1 1 0 1 3. Nurse/Senior Nurse 0 0 0 0 4. Pharmacist 1 1 0 1 5. Lab Technician 0 0 0 0 6. Dental Technician 0 0 0 0 7. Radiographer 0 0 0 0 8. Health Assistant 1 1 0 0 9. FWA 3 0 2 2 10. FWV 1 0 1 1 11. Sweeper 1 0 1 1 12. Others 1 1 0 1 8.2 Findings From Face To Face Interview With Service Recipients. Socioeconomic and Demographic Characteristics: A total of 490 exit clients and beneficiaries of the catchment areas of District Hospitals, MCWCs, UHCs and UH&FWCs were selected through random sampling. They were interviewed with semi-­‐structured questionnaire to assess the utilization of health and family planning services provided by the health facilities. Of the total clients of 490 interviewed, 126(35.7%) were male and the remaining 364(74.3%) were female. The mean age of male patients was 36.7 and the mean age of female patients was 30.8 years. As high as 92.0% of the patients were married, 6.9 per cent was unmarried and 1.1 per cent were widower/divorced/separated. Regarding education of the respondents we find that as high as 40% had no schooling, 24.5% had education at grade 1-­‐5 and 27.1 % had education at grade 6-­‐10. Only 8.4% of the patients had education at H.S.C. level(grade 12) and higher level. The dominant occupation of the 139 respondents was housewife(64.1%), and 8.8% had business as occupation, followed by service(6.7%), agriculture(5.7%) and laborer(4.7%). The average monthly household income was Tk 4650/-­‐ and mean landholding size was found to be 20 decimals. Both the indicators suggest that the patients visiting the health facilities are from poor households. The mean number of children ever born was found to be 2.6 per woman and the mean number of living child under 5 was 0.95. The mean age of the youngest living child was 42 months. Service Providers, Time Spent and their Behaviour. As high as 435(88.8%) of the patients reported that they were provided service by the MBBS doctors. And 35(7.1%) received services from SACMO and 16(3.3%) received services from FWVs. The mean waiting time of the patients was 30.7 minutes and the mean time taken by the service provider to issue medicine was 8.5 minutes. While examining patients privacy was maintained in 48.6% of the cases. On the question of service provider’s behavior to the patients 51.0% of the patients found their behavior satisfactory, 38.8% found their behavior fairly satisfactory, 7.1% found their behavior not satisfactory and 3.0% observed their behavior to be very unsatisfactory. Client Examination Prior To Treatment: The exit clients and beneficiaries of the catchment areas were asked whether they were examined by the service provider before giving prescription. The examination included pulse rate, blood pressure, use of Stethoscope and anemia. As many as 260(53.1%) of the patients replied that they had their pulse rate examined by the provider, 100(20.4%) replied that their blood pressure was examined, in 226(46.1%) Stethoscope was used, and 111(22.7%) patients were examined for anemia. Opinions/Views On Improvement of Health Services. The patients gave us good number of suggestions for the improvement of health facilities. There were multiple responses to this question. Highest responses to this question was for the supply of adequate medicine, followed by 289(59.0% for the regular attendance of the doctor, 221(43.1%) was for the placement of MBBS doctor, 137(28%) was for the availability of equipment. A good number of responses were for the improvement of toilet facilities. The other suggestions was for Ambulance Service (12.2%), Emergency ward, Eye care service (12.2%), dental care service(8.8%) and for facilities keeping open for longer time(10%). Immunization Status of Under 5 Children and Treatment Seeking Behavior: Among the under 5 children 74.1% was fully immunized and 22.7% was partially immunized. About the sickness of children it was found that as high as 66.9% of them had some kind of sickness in the 3 months preceding the survey. The kind of sickness from which they suffered were common cold and fever (47.6%), loose motion/diarrhea(28.3%), pneumonia(14.6%). Among the sick children as many as 164(77.4%) was taken to the health center. Family Planning Services. Among the eligible couples surveyed 55.5% was currently using any family planning method. Regarding the health/FP worker’s home visitations, 35.7% indicated that they were visited by FP worker, 10.6% replied that they were visited by health worker and 32.2% replied that their houses were not visited by any health/FP worker in the last three months before the survey. Maternal Health. 22% of the respondents reported occurrence of birth during one year preceding the survey. Their deliveries was assisted by Dai(24.5%), Trained TBA/TBA(19.6%), SBA(43.1%), Relatives/neighbor(12.7%) and health center(6.1%). Among those who had delivery in the preceding year of the survey 26.9% had complications before delivery, 21.3% had complications during delivery and 19.4% had complications after delivery. 140 Opportunity/Use Status of Services from Health Centres. The mean distance of the health centers from the patients house was found to be 1.6 Km. Among the patients interviewed, 87.1 % have indicated that they have visited the health centers in the last six months. About the services for which they visited the health center, 70.3% replied that they have visited the health center for health service, 11.5% have visited the health center for family planning and 18.2% visited the health center for both health and family planning services. On a detailed inquiry on the kind of purposes for visiting health centers, it came out that treatment for common disease (46.6%) was the dominant response for visiting health centres, followed by children’s sickness(37.2%) , Emergency health care(22.5%), Complications during delivery(14.5%) and side effects of FP methods(13.3%). Notion About Health and FP Programme. A great majority(80.2%) of the patients indicated that the services provided from the government health facilities has improved while compared to earlier days, 7.6% suggested that there has been no improvement and 9.2 % indicated that situations are as before. 8.3 Findings From FGD Meetings With 7 Homogeneous Groups 7 FGD meetings were conducted under the chairmanship/coordination of Upazilla Nirbhai Officer at his/her respective Upazila office. Each one of the seven FGD meetings consisted of one homogenous group-­‐ such as Female members, Male members, Private Physicians, Teachers, Community Youth Leaders, Chairman/members and Farmers. The major objective of FGD meetings was to elicit the notion about HNPSP improved services from UHC and UHFWC especially towards the women, children and the poor after the introduction of HNPSP activities and strengths and weaknesses of the programme and people's notion about needed steps to improve HNPSP services in future as well Table: 8.3.1 Responses of 14 number of Teachers at Gurudaspur Union from FGD Meetings Issues Focused through FGD Responses as stated by 14 number of High School Teachers Meetings at Gurudaspur Upazila 1. Notion about ü HNPSP programme has been highly commendable and implementation of HNPSP practicable and common people have been much (2003-­‐2011) benefited through this programme 2. Improved status HNPSP ü Quality of health services through UHC has much activities when compared to improved than what it was before 2003 before 2003 3. How far HNPSP obtained ü More attempts should be taken to reach the health pro-­‐poor service especially services to the door steps of the poor people especially women and children and the the women and children. poor ü All essential drugs should be supplied to the patients through governmental efforts and steps should be taken that the patients do get the medicines. 4. Needed steps to improve ü Posting of qualified doctors and supply of essential Community Clinics services drugs be ensured as well 5. Needed steps in improve ü Doctors should visit the students at least once in a health services in future. month to ensure health service/cares and health awareness programme with them and they should be sincere and self-­‐motivated about this. 141 Table: 8.3.2 Responses of 12 number of Youth Leaders at Kulaura from FGD Meetings Issues Focused through FGD Responses as stated by 12 number of Youth Leaders at Meetings Kulaura Upazila: 1. Notion about ü HNPSP programme not properly rendered since 2003 implementation of HNPSP and accountability has not yet been ensured and if (2003-­‐2011) ensured then only health services would be fetched by every house in the village. 2. Improved status HNPSP ü UHC-­‐ health workers don't duly render their activities when compared to responsibilities as such health services to the patients before 2003 are almost the same as before the start of the programme in 2003 3. How far HNPSP obtained ü The health workers should be equipped with all pro-­‐poor service especially needed facilities and supervision of their activities women and children and the should ensured to make health services more poor accessible to women and children 4. Needed steps to improve ü All the CCs should be made functional-­‐ adequate no. of Community Clinics services doctors and health workers to be posted ü More dedicated and self-­‐motivated doctors and health workers to encourage to work in the CCs ü Domiciliary and counseling to the women ensured by the health workers. And the health service providers should be made strictly accountable for their performances. 5. Needed steps in improve ü Needed manpower to be posted in health centers health services in future. ü Essential machines and equipments should be installed ü Supervisory supports to field workers to be ensured ü Bureaucratic poses and procedures should be curtailed ü Each field workers should be entrusted with targets to reach ü Health services should be extended and developed in all the Unions. . 142 Table: 8.3.3 Responses of 14 number of Male Patients at Tongi UHC from FGD Meetings Issues Focused through FGD Responses as stated by 12 number of Male patients at Tongi Meetings Upazila: 1. Notion about ü HNPSP programme very important and with implementation of HNPSP dynamism and transparency the programme should be (2003-­‐2011) reached to every house of the rural Bangladesh. 2. Improved status HNPSP ü HBPSP services to the people are not yet apparent activities when compared to before 2003 3. How far HNPSP obtained ü The previous government, when in power-­‐ reduced the pro-­‐poor service especially HNPSP activities at the CC which much affected the women and children and the access of the people to health services. poor 4. Needed steps to improve ü CC services should be expedited through needed Community Clinics services manpower and different activities 5. Needed steps in improve ü CC should be manned with MBBS doctor, free medical health services in future. treatment, supply of essential medicines and making proper environment and people aware of health services. ü Teachers of educational institutions should be involved in this awareness programme. Table 8.3.4 : Responses of 12 Female Patients at Dagonbhuyian from FGD Meetings Issues Focused through FGD Responses as stated by 12 Female Patients at Dagonbhuyian UNO office
Meetings 1. Notion about ü People have been benefited through HNPSP implementation of HNPSP programme largely.. (2003-­‐2011) 2. Improved status HNPSP ü Health services have improved than what it was before activities when compared to 2003-­‐ except for administrative activities are not yet before 2003 properly implemented. 3. How far HNPSP obtained ü Besides medical treatments, the supply of essential pro-­‐poor service especially drugs to the patients especially to the women, children women and children and the and the poor. poor 4. Needed steps to improve ü The post for MBBS doctor should be created and Community Clinics services posted at CC 5. Needed steps in improve ü The confidence of the people towards HNPSP services health services in future. are likely to increase if the MOs and other doctors regularly visited the people besides the routine and normal works of the health workers. Table 8.3.5 : Responses of 12 chairman/members at Lalmohon UHC from FGD Meetings 143 Issues Focused through FGD Meetings 1. Notion about implementation of HNPSP (2003-­‐2011) 2. Improved status HNPSP activities when compared to before 2003 3. How far HNPSP obtained pro-­‐poor service especially women and children and the poor 4. Needed steps to improve Community Clinics services 5. Needed steps in improve health services in future. Responses as stated by 12 number of chairman/members of Lalmohon Upazila: ü People are benefited about health and nutrition awareness-­‐ these services could be improve if more supervisory supports are conducted every month ü ü Health services have improved profusely due to recruitment of doctors and nurses in the UHC ü . ü Doctors and nurses at some places take money for drugs and medicine. If both the doctors and nurses work honestly and sincerity then this would be encouraging to the poor people to their services. ü ü The services from the CC would much improve if provided with MBBS doctor and well trained nurses and supply of essential drugs. ü Health services would be quality and improved if satellite clinics are arranged in the village every week. Table 8.3.6 : Responses of 12 Private medical practitioners at Monirumpur UHC from FGD Meetings Issues Focused through FGD Meetings Responses as stated by 12 Private medical practitioners at at Monirumpur UHC. 1. Notion about implementation of ü Implementation of HNPSP activities are going HNPSP (2003-­‐2011) smoothly. 2. Improved status HNPSP ü Scope of treatment to the patients has increased activities when compared to which is better than what was before 2003 before 2003 3. How far HNPSP obtained pro-­‐
ü Services to the women, children and poor people poor service especially women have much improved. and children and the poor 4. Needed steps to improve ü MBBS Doctor should be present in the CC at 3 days Community Clinics services in a week and rest 3 days should be attended by SACMO to ensure health services to the patients. 5. Needed steps in improve health 6. Regular supply of essential drugs should be services in future. ensured. Opening and closing of health center should be ensured at the right time. 144 Table 8.3.7 : Responses of 12 number of farmers at Mithapukur from FGD meetings Issues Focused through FGD Responses as stated by 12 number of farmers at Mithapukur Meetings Union: 1. Notion about ü The number of doctors, nurses and equipments has implementation of HNPSP increased and environment has improved. (2003-­‐2011) 2. Improved status HNPSP ü Scope of treatment has increased than what was before activities when compared to 2003 but standard of services are yet to be achieved. before 2003 3. How far HNPSP obtained ü Incidence of diarrhea has reduced and death of pro-­‐poor service especially children from diarrhea diseases and death of mothers women and children and the from delivery has fallen. poor ü Poor people awareness has increased to access health services from the hospital] 4. Needed steps to improve ü Patients will access the health services if the presence Community Clinics services of doctors and availability of essential drugs in the CC are ensured. ü Regular home visits by health workers should be ensured to increase the awareness of the poor people about health services 5. Needed steps in improve ü Modern equipments should be installed in the health health services in future. center as the poor patients can not afford treatment cost for some of the major injuries at far off Rangpur Sadar Hospital 145 8 .4 Findings From The Consultative Meetings With The Service Providers. Review of Stakeholders Consultation Report Stakeholders Consultation for Annual Programme Review (APR) 2007. Begum and Ali (2007) while making stakeholders’ Consultation for APR 2007 made the following observations: Key Issues & Areas of Improvements •
More doctors, nurses, technicians and field workers are needed. •
Timely and full-­‐time presence of the doctors who are deployed in the health facilities is important to ensure better service to the patients. •
Doctors should also be stationed in the health Centers. •
It is also important to provide doctors with required specialization (particularly Gynecologist and Surgery Specialist) in the public health facilities in order to provide required specialized services to the users. •
In-­‐service training for the medical staff, technicians and field staff are required. •
More training for the village doctors and traditional birth attendance are also necessary. •
It is suggested to provide with some basic pathological facilities in each of the Upazila Health Complexes. It is also important to ensure that the pathological facilities provided in the health centers are well equipped with necessary machinery and space, required technical staff and operation costs. •
It is necessary to have a functional operation theatre in each of the Upazila Health Complexes for caesarian and other minor operations. •
It is strongly recommended to provide the medicines and family planning supplies based on local demand and size of the population of the catchments area and also on a timely manner. •
Dissemination of information among the users and the local community regarding the services that each of the public health centers should provide is necessary to maintain better communication between the users and the providers which is key to ensure better services to the people. •
Monitoring of the health facilities by the higher authority is the key to ensure better services to the patients. Establishing effective monitoring system and holding the providers accountable is therefore important to ensure better services. •
Appropriate regulatory mechanism needs to be developed to regulate private practice of the doctors of public health facilities. •
It is also strongly recommended to regulate the production and promotion of drug in order to ensure the supply of safe drug in a reasonable price. •
Visits of medical representatives to the health centers, particularly during prime visiting hours of the doctors should also be strictly prohibited. •
There should also be an appropriate regulatory mechanism to monitor the function of private pathological centers. •
Officials of the implementing agencies and health providers should be made aware about the objectives and components of HNPSP. •
Some motivational program should be taken to aware the health providers so that they are aware about their noble responsibility and do behave accordingly to their clients, particularly the poor clients. •
In order to ensure better services in the public health facilities, users and the local community also have some responsibility. It should encourage poor patients to come to the health centers for designated services. Awareness raising and motivational program can therefore be taken in this respect. •
Strengthening local government and involving them in the health management may ensure effective local participation and better service delivery. 146 •
•
•
•
•
Also, in running the health centers at the local levels, some initiatives may be taken to provide some autonomy, regarding both financial management and service related, so that the providers can take decisions based on local demand and run the health centers more efficiently. Medically trained persons should be made involved at the policy making and implementation levels. It is also necessary to reform some of the existing rules and regulation to make them compatible with the needs of the time. It is also now high time to think about health insurance for the people, particular the poor people. For better function of the health centers, state machinery should ensure environment free from any political and/or other interferences. Stakeholders Consultation for Annual Programme Review (APR) 2008. Begum and Ali (2008) while making stakeholders’ Consultation for APR 2008 made the following observations: Challenges and Areas of Improvement • Despite much endeavour and recent improvement, as observed still 40 percent of the country’s pregnant women are currently (2007) outside the purview of ANC and 80 percent do not use this care by a level minimum level prescribed for this care, hence, full coverage of the women by acceptable level of ANC within stipulated time may prove difficult. • Despite some improvement in the safe delivery indicators such as, in the place of birth and assistance during child delivery, still about 85% of child birth takes place at home and more than 80 percent of the deliveries are assisted by the untrained and non-­‐
medically trained persons contributing to the risk of mothers. So, the challenge ahead is how soon these indicators could be brought to desired level to have desired impacts on the maternal health. • The postnatal care has remained yet largely an unknown concept, keeping utilization of this care still very unimpressive. Around 80 percent of the mother do not bother to use this care and the 20 percent who use it mostly do so within 24 hours of delivery getting dictated by the postnatal situation. Hence, making PNC popular on its own right may also prove a challenge. • One of the disturbing issue of family planning programme is couple’s discontinuation of contraceptive method within short period of use viz., within one year, affecting the effectiveness of the programme. The situation has not had improved much during the recent years and present method discontinuation rate is as high as 44 percent. To increase programme efficiency minimization of this problem is essential and needs to be done as quickly as possible. • In case of FP methods the injectables seems to gaining much popularity and possess the potential of acting as alternative for oral pill, the dominant FP method. This method being a long acting one and more efficient than pill deserves support and promotion to enhance the efficacy of the FP programme. •
The suggestions for improving the FP services at local level may therefore be summarized as follows: • Manpower requirements of all kinds need to be addressed and adequate numbers of manpower at all levels need to be recruited immediately to deliver services properly. • There is still great demand for home delivery of FP services free of cost, particularly among poor and young women who are often restricted not to move out of the house, 147 hence, number of FWAs is to be increased to match the requirement and in doing so the remote areas to be emphasized more. •
Monitoring and supervision of field level activities needs to be taken seriously as they do not do their job properly and sincerely. •
Create awareness about the importance of maternal health and make them understand that the pregnancy and childbirth are not easy events in women’s life; hence, they need special attention and care during this period. •
To straighten the delivery of maternal health care services and enhance their use, all supply constraints require removal; hence, existing manpower shortage has to be addresses with due emphasis, and endeavour has to be made to keep in place all required providers; such as, lady gynae specialist, adequate number of nurse, aya and other support staff, etc., for smooth delivery of services. •
Along with manpower problem, the shortcomings in the service provision also require remedial measures; this not only deprives women from the required services but encourage women to avoid also such care in anticipation that such care is not good. •
To make maternal services including ANC, delivery care, and PNC easily accessible and accessible at lesser cost, the Union has to be the focal point of delivery of these services. •
In maternal health care programme, special emphasis has to be made on miscarriage and maternal morbidity due to reproduction related problems and female diseases. Substantial number of women suffers from these problems with far reaching implications for their life but hardly there are any treatment facilities for these personal problems of women. •
Also there has to be separate gynae ward for the mothers and separate check-­‐up room, rest room and toilet facility for the pregnant women at the health center to ensure privacy and proper care. 148 Stakeholders Consultation for Annual Programme Review (APR) 2009. RTM International(2009) based on the findings of of the stakeholder consultation, made the following recommendations: Based on the findings To increase skilled manpower: The vacant posts of providers including doctors, nurses, anesthetists, health technologists, FWAs, HAs, MAs, FWVs and nurse-­‐midwifes are to be filled in on an urgent basis. Bedsides, additional posts are to be created wherever necessary. Skilled service providers for safe delivery should be made available in all areas. Training of FWVs/Community Paramedics and MAs should be conducted through public and private sector training facilities on a priority basis. Public-­‐private partnership can significantly contribute in meeting the large demand of skilled human resources. To improve supply and logistics: The supply of drugs and logistics should be increased and made more regular to avoid frequent stock outs. The supply may improve if the task of procurement of some essential drugs is assigned and delegated to the upazila authority. However, FP commodities are currently procured centrally, but frequent stock outs are experienced due to lengthy and complicated procurement process. To increase use of delivery care: Better delivery care alone can prevent maternal mortality. The measures needed to increase delivery care are: -­‐ increase placement of skilled service providers for safe delivery, and pair of caesarian service providers (gynecologist and anesthetist), -­‐ improve facilities for delivery care at UHFWCs and at community clinics. Special attention is needed to ensure placement of skilled service providers (FWV and MAs/SACMOs) in all SDPs, -­‐ review and if necessary, modify the existing voucher schemes and scale up for the national program, -­‐ intensify motivational campaign among the people about the need for proper delivery care, -­‐ increase coordination between health and FP departments, and -­‐ provide increased attention to clinical FP methods (sterilization, implants, IUDs, PPFP and injectables). To make the community clinic functional: The community clinics will not be properly functional unless the MA/SACMO and FWV sit there at regular intervals to provide child and RH care. This, in turn, requires that sufficient manpower has to exist at the Upazilla Health Complex (UHC) and UHFWCs first, if the community clinics are to be functional. Involvement of primary stakeholders and community leaders in the public sector activities and introduction of community health insurance scheme including DSF at all levels will increase use of care and improve quality of services. To consider urban health as an important component of the program: In urban areas, special attention should be given to slum areas. Both large and small urban areas should be brought under the national health sector program network. Existing services in a few large urban areas through local government institutions and NGO partnership are inadequate. The capacity of the Ministry of Local Government and local government institutions to run comprehensive health care services is also inadequate. The whole approach needs to be reviewed and reconsidered. To design especial programs for hard to reach areas: Special program strategies should be developed for the hard to reach and low performing areas. In some areas within and around the large cities and towns, as well as in apparently accessible areas, many people are deprived of health cares. Local situations should be taken into consideration in designing program strategies and approaches. Innovative approaches should be initiated through, NGOs, private sector and public-­‐private partnership initiatives, which may include: 149 Mobile vans and/or boats may be used for conducting BCC and providing essential services. Health-­‐FP workers should be recruited from the adjacent areas and posted in the HTR areas. The ratio of worker to population should be high, about twice as high as in the normal areas. In addition to UHCs and FWCs, in large upazilas mini-­‐UHCs are to be established. Adoption of these measures requires that the HTR areas should be allocated more fund than the other areas. The government should use the need-­‐based allocation formula. To support NGO and private sector institutions: The role of NGOs, charitable hospitals and private sector institutions are important for a sustainable national program. Support to these organizations and institutions should be strengthened for creating enabling environment for mobilizing local and international resources for active participation in health acre activities including services, training and research. Private medical colleges and paramedical institutions should be provided with adequate support for quality assurance and market development through supportive policies, guidelines and technical assistance. To ensure community support and participation: Increase and improvement of performances of the sector greatly depend on effective involvement of the community and the primary stakeholders in planning, management, service delivery and evaluation. Mere existence of union and upazila health-­‐FP committees as at present will not contribute much. Some NGOs have already been involving the primary stakeholders quite effectively. This model should be replicated in the entire country. 150 Findings on Consultative Meeting. The consultants along with the field interviewers and IMED officials conducted consultative meetings with Civil surgeons, Deputy Directors (MCHC) and UHFPO/MOs at the field level to have perception about the operation of HNPSP and factors affecting their performances Table: 8.4.0 Opinions/Notions about HNPSP status and performance by Field Level Health and Family Planning officials/managers drawn through / elicited through Consultative Meetings. Issues discussed Opinions/responses elicited through Consultative By Civil Surgeons Medical Officers/THA/RMO By Deputy Directors(MCHC) meetings 1. Coordination/int
ü Unification and integration ü Integration between FP and ü A separate administrative structure egration between between health and family Health is all in paper but in for both health and family planning health and fp planning will be effective for reality there is no coordination need to remain continued. implementation of HNPSP and integrated approach to ü The health officials should render fp activities. work together counseling and refer clients to the ü If integration not feasible at the ü Integration and coordination concerned persons field level it could at least be between Health and Family ü coordination and integration coordinated/ implemented at Zila Planning is not functional due between health and family planning and Divisional levels to lack of mentality and proper should be strengthened ü The integrated approach has motivation and training ü Health Assistants to be made more improved to some extent at the amongst field level workers. accountable and active to assist in fp present. ü Coordination between health activities. ü Present status of integration is and family planning should be ü Nutrition program should be getting more improved than past worked out from highest tier to brought within the jurisdiction of ü FP is a part of health services-­‐ the lowest tier of family planning programme could not earn the expected administration of both health confidence of the people for last and family planning sectors if ü Integrated management of both 40 years as it was not the integration has to be health and family planning from zila implemented by health achieved in true sense. level will much improve the situation professionals of HNPSP activities. 2. Manpower needs and skill development of programme personnel ü Vacant post should be immediately filled in and more of manpower be recruited in proportion to bed occupancy of the hospital and increasing public demand. ü Due to shortage and as well as skilled manpower-­‐ proper management and timely services to the patients are hampered. ü Capacity building of both the health and FP workers through refreshers training and in service training should be geared up. ü Number of medical/technical persons has not been recruited in proportion to the number of hospital beds. ü 3rd and 4th class employees remain untrained due to shortage/vacant post of doctors and concerned professionals. ü New posts to be created and vacant posts to be filled up. ü Manpower should be oriented through basic training and be made skilled through advanced training ü Post of family planning workers need to be created in proportion of size of population of the concerned areas. ü ü Optimal use of equipments hampered due to shortage of manpower ü Equipment and machineries need to be updated and old machines need to be repaired or replaced timely. ü Essential diagnostic services can be rendered if regular maintenance of ü There are shortages of equipments and some of them are outdated. ü Supply of drugs is lagging behind the requirement or demand of the patients ü Updating of equipments and skilled doctors/technician should be placed for proper use of equipments and machines. ü Due to acute shortage of manpower-­‐ vacant posts should be filled in and post of family planning assistants should be recast and ü Training should be imparted to upgrade their medical skills ü Capacity building to be ensured through on the job training ü Chronic shortage of manpower at MCWC-­‐ Skill of the health and fp personnel should be upgraded through training. ü Post of Consultant be filled in and on the job training helps health and fp workers make more positive impact 3. opinions on drugs, equipments, diagnostic facilities and their best use ü Volume of drugs to be increased and DD-­‐Kits, equipments and diagnostic facilities to be upgraded. ü Due to shortage of manpower and needed instruments/equipments-­‐
diagnostic checkups and services can not be effectively used at the MCHC. ü Arrangement of Essential ingredients/reagents for blood bank, biochemical tests and hormonal tests 152 machines/equipments and skilled technical personnel are made available. ü Equipments/supply of drugs and diagnostic facilities are in satisfactorily used. ü Optimal use of equipments, drugs and chemicals for diagnostics checkup is limited due to lack of demand for and lack of trained/skilled persons as well will improve health services of center 4. Delegation of administrative and financial powers for better use of available resources ü Local level administration should be entrusted with financial power for expenses for repairs and maintenances of equipments/ ambulances and fuels of generators and purchase of drugs and equipments from local initiatives. ü Local level planning and administrative power to be more enhanced. ü Both financial and administrative power should be increased along with decentralization ü Lack of fund to make ambulance running regularly and fuel for generator. ü Too much dependency on higher administration to get fund ü Local level administration should be strengthened to work with independently with accountability as well. ü Zila and Upazila level officers should be entrusted with the administrative and financial authority to transfer their field level staff-­‐ such as FWA and FWVs ü For optimal use of resources/commodities-­‐ more financial and administrative powers to be permanently transferred to concerned DD. ü Complete Financial authority should be placed, local level repairs of ambulance and other equipments, repair and maintenance works of hospital and residential quarters etc may be entrusted with the deputy civil surgeon 153 5. Procurement and supply management ü Timely purchase of drugs should be strictly followed so that drugs can be used before the expiry date ü Procurement procedures should be made easier and less cumbersome. ü Small amount of equipments and drugs should be procured both locally and as per local demand for those items. ü Procurement of drugs and other essential equipments should be arranged through their own local management ü Proportion of nurses to doctors and patients is not realistic. ü Services to the patients are very hampered due to shortage of skilled and adequate number of nurses. ü Nurses should have both basic and more advanced and exhaustive CC training. ü The vacant posts of nurses should be filled up and there should one nurse per five patients. ü Shortage of nurses as per number of patients. ü Training and Behavioral approaches of nurses are not satisfactory. ü Quality of nursing services should be made of international standard through advanced training. ü To improve the services of CC-­‐ recruitment of CHP should immediately taken ü Monitoring of domiciliary services should be ensured along with services at CC ü All essential manpower to be recruited for increasing CC services to the patients. ü HA and FWA provide services at the clinics but not enough to provide quality service. ü CC should be manned with medical assistants and other support staff to make qualitative services to the patients. ü Field allowances and other ü Necessary fund should be ensured to enhance the power of procurement -­‐ ü Procurement of drugs and equipments and supply management may be placed to Upazila Health and FP Officer under the supervision of Civil Surgeon. 6. Present status of nursing services and suggestions for improvement ü Quality of Nursing services deteriorated due to shortage of nurse and lack of on job training. ü Post and number of nurses should be created as per number of patients and number of beds-­‐. ü Post of Nursing Super and senior staff nurses be increased and on the job training to be provided to them to improve their service and skills. 7. Present status of Community clinics and improvement of its domiciliary services. ü Recruitment of CHCP should be immediately completed and FWA be provided with training and drugs-­‐ ü Recruitment of permanent staff for domiciliary services ü Due to services from CC-­‐ the home visits by FWA has reduced ü CC should be provided with all facilities to improve its services to 154 ü CC services to be improved through recruitment of needed number of manpower and training (IST), supply of essential drugs, and improvement of referral system ü All the essential items of primary health care should be rendered from the CC and people should be motivated to access health services from CC rather than from door to door approach. awards to field workers for their performances will make them well motivated to serve patients at domiciliary levels. the patients ü Monthly Field allowances of the health assistants and family welfare assistants should be increased from tk. 50 to tk. 1000 and for proper rendering of their services-­‐ they should be provided with motorbyke. 8. Management committee and local level participation for increased use of facility ü Management Committee should include responsible and dedicated local level representatives ü Active participation by local politicians, social workers and rich people should be ensured ü Management Committee should be more active through more meetings and get together with local people and patients. ü The recreation expenses for arrangement of MC discussions should be increased and provision for honorium for the field workers be increased. ü The MC should be in touch with people through meeting with them on every 2-­‐3 days ü Management Committee should composed with well motivated, educated and socially respected people to improve the health services to the people ü MC should work keeping in coordination with the Health personnel of Health department. ü Both the service providers and service recipients need to have ü BCC/IEC activities to be strengthened to make both ü Health services can be improved if Management committee and local people work together ü Management committee with local participation should be ensured. ü The present hospital management committee should arrange monthly meeting compulsorily and recreation allowance should be provided for arrangement of meeting ü MC should motivate the people about health problems through monthly meeting/ consultation with local people and be responsible and accountable for their works/actions. 9. BCC/IEC for increasing ü BCC/IEC programme has no alternative-­‐ it has increased the need 155 demand for health and fp services. learning and awareness through BCC/IEC ü BCC/IEC activities would help service recipients to understand their need for proper health and fp services. ü The BCC/IEC activities should be launched both in the local level participation and national level Medias. ü Both the service providers and service recipients should be supportative to each other service providers from doctors to sweepers at the hospitals to be aware and responsible to serve the people. ü BCC/IEC activities will help motivate and educate the people about their health problems and build interpersonal relationship with service providers. ü Funds to be provided at Zilla and Upazila levels to carry out the BCC/IEC activities. ü
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10. Present status of MIS at various health centers and its improvement in future ü MIS services should be improved through recruitment of skilled personnel ü People involved in preparation MIS report should have foreign training at times. ü They should also be accountable for any lapses and falsehood in the presentation of MIS report ü MIS system though fairly good yet it need to be more dynamic and upgraded through more effective training and proper recruitment of skilled people. ü Use of internet, wave camera and updated technology should be ü MIS personnel should have refreshers training. ü MIS people should provide unbiased reports and provide feedback any lapse in the report is found. ü Adequate and more skilled MIS people should be recruited ü Adequate supply of electricity and lack of technology and skilled person are needed for smooth functioning of MIS system ü The columns for EPI should be excluded from the Reporting form to make it simpler to fill ü
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for health and family planning services by people Health services to be rendered not only through curative services but also through preventative approaches which can be infused in the people through effective BCC and IEC activities BCC/IEC programme should be strengthened and coordinated through health and family planning together. Number of meetings and refreshment allowance should be increased 10 fold to enhance the BCC/IEC activities. Honorium may be provided to field workers as resource persons for these activities. Both health and family planning should work in unified approach MIS system should be more updated and improved than the present system. MIS management should transparent and unbiased. More needed manpower and trained persons for effective management of MIS system. For information management and research works 2-­‐3 post for Deputy Civil Surgeons may be created in the office of Civil Surgeon. Monthly feedback of information to DGHS office should be ensured 156 used to make MIS system more effective. 11. Suggestions for more improved rendering of services. ü Recruitment of vacant posts, creation of new positions, proper working condition and job descriptions and regular monitoring of H and FP activities by field personnel. ü Timely and regular procurement of essential drugs, modern diagnostic equipments and machines need to be ensured through Public Private Partnership(PPP) ü For more upgraded and well-­‐
managed services to the patients -­‐
adequate and more skilled personnel should be recruited immediately. ü To expedite the field activities-­‐ the UH & FPO may be provided with transport and essential furniture and improvement of infrastructural facilities of the hospital/center. ü Vacant post as well new posts should be created as per need of hospital bed occupancy. ü Budget for health sector should be submitted to the concerned department within the three months of every year. ü Monitoring and rewards for good in and calculate the data ü Mentality of service providers to be positive and rewards for good performance and punishment for bad performances ü More of doctors and well trained nurses, supply of adequate drugs and electricity . are needed to ensure improved services to the patients ü Number of field workers to be increased and be made motivated through training and rewards for their works ü MIS technology and lab facilities to be updated and modernized. ü ü People should be made more aware of health habits and prevention about common diseases ü Health and Family Planning should be disintegrated into two separate Ministries-­‐ ü More budget/fund for Nutrition and Family Planning activities to be ensured ü Vacant posts should be immediately filled in, upgradation of skill of health and family planning personnel through training and promotion and rewards to be granted on the basis of evaluation of respective work performance. ü More and more of trained Nurses and Doctors to be recruited for rendering of proper and affordable services to the patients ü Through integrated management the DDO-­‐Ship of UHFPO, RMO, UFPO and MOMCH may be entrusted to enhance their financial and administrative powers-­‐. ü 3 Emergency MO and 3 IMO posts should be created in place of one EMO and one IMO existing in 50 bedded hospital. 157 performance should be ensured. 158 Findings From Consultative Meeting with Key Stakeholders. Consultative meetings were conducted by a Team of Consultants headed by MM Reza (
Health Secretary ) for End-­‐line Evaluation of HNPSP study with the key stakeholde
MOHFW, Planning Commission, IMED and the World Bank concerned Ministries // p
planners (Secretary-­‐ MOHFW, Member, SEI Division-­‐ PC, Division Chief, IMED, Chief(Population Wing-­‐ PC), top programme managers of HNPSP (DG and Line Direc
and The World Bank. The major objective of these meetings was to have an impressionistic view or notion a
the major strengths and weaknesses of HNPSP programme and the suggestions as state
policy planners and managers of the Programme in terms of implementation and
improved performance of HNPSP in future. The list of persons with whom the meetings were conducted is enclosed in the (annex-­‐ )
Major Strengths of HNPSP programme: Ø Unlike the earlier projectized approach-­‐ the sector-­‐wide programme approa
HNPSP showed that the wastage of resources was lesser than that of pre-­‐HN
period and resources have been better managed and optimally used and so
duplication of activities reduced. Ø Primary Health Care services evidenced to be successful-­‐ through effective u
ESD and launching of EPI programme and Child Health Care which seemed managed by the concerted/integrated efforts of both health and family plan
workers. The nutrition programme by Pusti Apa also proved success u
Integrated FP and Nutrition programme in 172 Upazillas. Ø Stocks in and out position of medicine/drugs proved better managed du
computerizations of data under this programme Ø Poor man's accessibility to health services enhanced as outdoor patients cou
served through Essential Service Delivery at the Union level health centers and
Thus the poor people access to govt health care facilities increased despite
absence of quality services at govt hospitals Ø Sectoral approach increased health awareness amongst poor people as h
services are rendered to the people in wider aspects and in more through conce
efforts by Health and FP workers at the grassroots level. In reality-­‐ the sec
approach helped combat/reduce the prevalence of bird flu, swine-­‐flu and nipa with more efficiency and promptness as observed during the outbreak of t
diseases. Ø The statistics on CM, MMR, TFR, EPI, TB, case detection of CD indicates an ov
improvement in health service but yet to be up to the world standard. Ø Use of ESD has improved despite some problem in human resources managem
health staff shortage, placement and retention of doctors in hospitals in re
Upazila and Unions. Ø It is expected by 2015-­‐ 3 of the major Millennium Development Goals are likely attained due to -­‐ poor accessibility to health services though still barred by cultural factors. The gap between rich and poor men's access to health facilitie
reduced to some extent and almost in all areas. . OP on Fiduciary Arrangement_ updated_3 Aug 11 Major weaknesses of the HNPSP programme: Ø Due to time and resource constraints, shortage of relevant manpower -­‐ OPs were often hurriedly prepared, formulated and submitted by the MOHFW to Planning Commission for approval. And so also Planning Commission hardly made any time to make a meticulous scrutiny of OPs or understanding the contents to see any inconsistency, lapses or omissions etc. IMED also appeared seemingly overloaded with routine works to go through the HNPSP documents/reports. They seemed more interested to provide monitoring reports on physical infrastructures, financial expenditure and procurement for the programme. Ø The Line Directors involved with their respective OPs usually get posted or deputed with the assignment of implementing the OPs or improving the OPs just before 6 months to one or two year of their time for retirement. As such they have no time for getting oriented with OPs/programme nor has the impetus to invest their time productively and with more innovativeness. Consequently ownership and accountability for the programme by LDs is dampened. Moreover, Implementation and monitoring of the OPs can not be tracked out due to frequent of transfer of LDs. Ø Decentralization of administrative and financial authority is yet to be equally vested with all OPs-­‐ LDs and their subordinating officials below. Ø Contracting out the maintenance works, waste management etc of health facilities at field level and BCC/IEC services at the upazila and unions/CCs through PPP and GO-­‐
NGO efforts are yet to be implemented. Ø Effective implementation of some of the OPs need highly skilled and experienced professionals with accounts and financial management background but there is no provision for recruiting managerial persons with relevant expertise in accounts & finance or in human resources managment. Ø OPs at management and implementation levels-­‐ in health and FP facilities showed that the number of appropriate and trained paramedics and nurses are not in proportion to medical graduates. Recruitment of these professionals/technical persons are lagging behind due to inter-­‐ministerial delays, indifferences, procedural cumbersomeness, apathy and conflict of interests amongst the professional groups. Ø 38 OPs have been so far developed for HNPSP but there is little scope to make any changes in OP although some of them need change and modification. Since Donors are more interested to invest in sector programme rather than in individual OP. Ø No proper orientation or any concerted efforts were taken prior to the unification and integration between the health sector and family planning sector personnel. Nor was any piloting or consultative approaches conducted to see how the unification and integration between fp and health sectors could be revamped and reconciled when the integration failed due to egoism and vested interests of the both sectors personnel Ø ESD services at most of the health facilities are not optimally used due to acute shortage of medical professionals-­‐ MBBS doctors, qualified nurses, health assistants and skilled obstetrics personnel Ø The supplementary food (nutrition programme) for malnutrited and poor children dropped or curtailed due to inadequate & timely fund release, indifference, and lack of proper management and to some extent due to malpractices by the concerned programme personnel. Ø Lack of adequate and regular contingency fund led to frequent stock out of medicines. Regular updating of stock-­‐out of medicines and related medical OP on Fiduciary Arrangement_ updated_3 Aug 11 160 Ø
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accessories are also hampered due to lack of maintenance funds and logistics supports for proper functioning of computers. Proper utilization of equipments/ diagnostics tools became limited and mishandled both due to both shortage of skilled staff and medical technicians to handle machines like radiography and ultrasonography etc. Lack of adequate fund to run generators and its proper maintenances hampered the functioning of OT and other equipments usually run by electricity during load-­‐
shedding for emergency. So, this consequently drags the performances of hospitals and clinics. Both the gynecological and obstetric cares/services are not installed side by side in the Upazila Health Complex-­‐so home-­‐based delivery by TBAs still remains prevalent and popular in the rural areas despite a lot of health risks for both the mother and child. Some of the components of health if are formulated as acts-­‐ may be lead to inflexibility and stagnancy and consequently damage the creativeness and innovativeness or dynamism of the programme in future. There are some anomalies in policy and strategies-­‐ what is in the policy but not stated in the strategies. Urban health referral system-­‐ problems and solutions are known but no decision to carry over as such leads to chronicity of the problems. Tertiary and secondary cares could not be fully utilized except for Primary Health Care services Suggestions/Recommendations to improve the over all performance of HNPSP: Ø For preparation of Design and formulation and implementation of OPs should be initiated through the concerted efforts of all concerned Ministries and Agencies/Cells and Sectors. They should often sit together to steer the needed steps to modify the ongoing OPs in terms of funds allocation, recruitment of human resources, procurement of equipments or any other related shortfalls or any set backings. Ø Inter ministerial efforts and well coordinated and holistic approaches should be ensured within all the key persons involved in HNPSP design, formulation and implementation through forum and continuous meetings and feedbacks and sustained interactions Ø All the concerned officials who are thoroughly experienced, more self-­‐motivated and with proven efficiency/expertise should be promoted to work as Line Directors for the concerned OPs. If situation demands-­‐ they may be contracted to work even after their retirement. Ø Decentralization of administrative and financial authority should be entrusted with the local level officials ( CS, Directors and Deputy Director) to transfer or promote their field level staff on the basis of their respective field performances and they should also be authorized to purchase or procure furniture, drugs and other day to day hospital accessories and maintenance and repair works of hospital as well. Ø For additional beds in the Hospitals the need for furniture, drugs, equipments and recruitment of medical professionals should be implemented through development fund of the Government -­‐ since allocation of fund from revenue head is time-­‐
consuming and cumbersome as well. OP on Fiduciary Arrangement_ updated_3 Aug 11 161 Ø As often practiced/followed in developed countries for hospital management services-­‐ recruitment of non-­‐medical persons-­‐ highly motivated and smart graduates experienced in human resources, accounts and financial management should be initiated by the Government. Ø The MO HFW should be entrusted with the discretionary power to employ or recruit mid-­‐level Health and Family Planning personnel/workers with minimal level of concurrence from Ministry of Law, Ministry of Finance, Ministry of Public Administration and Public Service Commission. Ø Some mechanism may be devised to make a coordinated efforts amongst the Public Division, PSC, Law Ministry, Finance Ministry and concerned MOHFW to speed up or smoothen the recruitment procedures on adhoc basis. Ø There should be some consensus amongst all concerned Ministries to make a commitment to do their respective exercises in the formulation, approval and implementation of the programme through forum and committee meetings and consultations within themselves. Ø To develop the in-­‐house expertise within the Planning Cell of MOHFW/ or under the jurisdiction of each of OPs-­‐ necessary funds should be released/allocated for conducting monitoring and evaluation of their respective areas on regular basis. And for unbiased evaluation and also due to work-­‐load-­‐ provision for budgetary release should be made to outsource the monitoring and evaluation of OP performances to experienced research firms of the country in collaboration with any donor agencies if needed. Ø Budgetary allocation of funds for implementation of various OPs should not be strictly fixed rather it should be made flexible due to the price escalation and changes in the value of foreign currency to procure equipments and needed health accessories for Hospitals/health centers and also to keep up with the international standard of per capita health cost. Ø Some budgetary arrangement should be made to render both gynecological and obstetric cares/services (caesarian delivery with OT facilities) are to be provided in the same UHC so that risky delivery by TBAs may be averted by the pregnant mothers. Ø Improved health awareness programme should be targeted towards not only the curative aspects of treatment but also help people avoid common diseases (communicable and non-­‐communicable diseases) through preventive measures and basic health education. Ø Non communicable diseases and conventional & non conventional urban health programme demand may be more emphasized in next programme. Ø Coordination and Referral to upper health facility, ICC unit to secondary and tertiary health facilities, emergence and reemergence of new and old diseases and hospital autonomy to be included in the next programme. Ø Doctors to have specialized training to handle machines and other computer based application (medical management information systems). Ø The quality of nursing services should be upgraded up to international standard through advanced diploma courses for which the nursing colleges at Dhaka, Chittagong, Rajshahi and Bogra along with 2 other nursing colleges at private sector and nursing institutions of the country should be manned with faculty members, qualified teachers/trainers. And also to increase the number of nursing professionals-­‐ all the medical colleges and hospitals of the country should provide nursing courses within their respective campuses. OP on Fiduciary Arrangement_ updated_3 Aug 11 162 Ø Nurses in our country work under low profile status-­‐ upgradation of their rank, status and salary supports-­‐ should be ensured despite some professional jealousy from doctors may crop up at the initial stage. Ø Docs/Paramedics/FP workers, who are dedicated, self-­‐motivated and opted to serve the poor and disadvantaged people in the remotest health facilities at Union levels should be rewarded in the form of quicker promotion and financial incentives. Ø Health and Family Services through CCs may be made reasonably more functional if regular supply of ESD and be manned with registered medical professional at least with SACMO. Ø Both in-­‐service and refreshers courses should be made functional and be rationally imparted to all concerned Health and Family Planning personnel on nutrition, reproductive health, common CD and NCDs, MCH servcies Ø Food safety issues are neglected-­‐ there are only 8-­‐10 food inspectors for 1.5 crores of people in Dhaka city-­‐ So food safety act may have to be in the health policy issue. Ø Recruitment of medical professionals are a lengthy, cumbersome one and too many queries, papers submission in Public Division, Public Service Commission, Law Ministry and within the own Ministry are to be carried out. So some drastic measures have to be thought out to expedite the process of recruitment. OP on Fiduciary Arrangement_ updated_3 Aug 11 163 Annex-­‐ A Sample Size and Data Collection Instruments Sampling Design: A multi-­‐stage stratified random sampling method was required to select the sample spots and respondents. Initially the seven administrative divisions were considered as seven different strata. Each of the district was considered a cluster. One district was chosen randomly from each of the divisions. From each of the selected district, two Upazilas were randomly selected. From each of the selected Upazila, two unions were randomly selected. From each of the selected unions, two UH & FWCs were selected randomly. The exit clients and beneficiaries in the catchment areas were also selected by systematic random sampling. The number of respondents at different spots/locations is given in the table below: Table : Distribution of Sample Spots/Locations and Respondents. Division/District/Upazila/ Spots/Location Number of Respondents Union To be visited Consultative Meetings At National Level 18 7 districts/14Upazila/28 7 District hospitals/7 MCWCs/ (7+7+14) =28 Unions 14 UHCs Service Providers Opinion 7 Divisions/7 District/14 7 District Hospitals/7 MCWC, (7+7+14+28)=56x5 =280 Upazilas/28 Unions 14 UHCs, 28 UH&FWCs Client Survey through exit interview 7 Divisions/7 Districst/14 7 Zila Hospitals, 7 MCWCs, 14 (7+7+14+28) =56 Upazilas/28 Unions UHCs,and 28 UH&FWCs Observation Checklist and Document Review 7 Divisions/7 Districst/14 14 UHCs, 28 UH&FWCs (14+28)= 42x5=210 Upazilas/28 Unions Beneficiaries of the programme catchment area 7 Upazilas At the office of the UNO 7 FGD meetings with 7 homogeneous groups i) Male patients (ii) Female patients (iii) Private medical Practitioners (iv) Teachers(v) Community Youth Leaders (vi)Cairman/Members of Union Council and (vii) Farmers. Data Collection Instruments: Four Different Data Collection Instruments were utilized in order to obtain the desired information. They are • FORM A: Observation Checklist and Document Review To Assess Facilities and Maintenance at Service Delivery Points(District Hospitals, MCWCs, UHC, and UH&FWCs). OP on Fiduciary Arrangement_ updated_3 Aug 11 164 •
FORM B: Questionnaire for Socio-­‐economic and Demographic Characteristics of Exit Clients at (District Hospitals, MCWCs, UHC, and UH&FWCs) and Beneficiaries in Catchment areas of UHCs, and UH&FWCs. •
FORM C: Guidelines for Consultative Meetings with Stakeholders( National, Regional and local levels; Programme Managers and Implementing Agencies.) •
FORM D: Guidelines for conducting FGD on seven different groups i) Male patients (ii) Female patients (iii) Private medical Practitioners (iv) Teachers(v) Community Youth Leaders (vi)Cairman/Members of Union Council and (vii) Farmers. Sample Units selected and Interviewed/Consulted/FGD Unit Number Number selected Interviewed/ Consulted/ FGD Facility District Hospital MCWC Upazila: UHC Union: UH&FWCs Sub-­‐total Service Providers District Hospitals MCWC UHC UH&FWC Sub-­‐total Sub-­‐total Client Survey Exit Catchment Sub-­‐total FGD 07 07 14 28 56 07 07 14 28 56 56 280 210 490 07 07 07 14 28 56 07 07 14 28 56 56 280 210 490 07 Per cent interviewed 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 Field Work. The field work was conducted during July 23 -­‐-­‐August 06, 2011. OP on Fiduciary Arrangement_ updated_3 Aug 11 165 List of Sampled Districts/Upazila/Unions for Data Collection Division /Districts 1. Dhaka /Gazipur Upazilas 1. Gazipur Sadar 2. Tongi 2. Chittagong/Feni 3. Feni Sadar 4. Dagonbhuyian 3. Rajshahi/ Natore 5. Gurudashpur 6. Singra 4. Khulna / Jessore 7. Sarsha 8. Monirampur 5. Sylhet/Maulavibazar 9. Barleka 10. Kulaura 6. Barishal/Bhola 11. Dowlotkhan 12. Lalmohan 7. Rangpur/Mithapukur 13. Mithapukur 14. Pirganj Unions 1. Doyail 2. Pogaldigha 3. Gacha 4. Bahadurabad 5. Sardi 6. Baligoan 7. 6 No. Dagonbhuyian 8. Ramnagor 9. Hawli 10. Riyaghat 11. Chowgram 12. Andulbaria 13. Benapol 14. Laxhmonpur 15. Nehalpur 16. Khanpur 17. South Shahbazpur 18. Talimpur 19. Pritimpasha 20. Brahamonbazar 21.Chorpata 22. Syedpur 23. Bodarpur 24. Kalma 25. Pairabonda 26. Durgapur 27. Bara Darga 28. Shanerhat OP on Fiduciary Arrangement_ updated_3 Aug 11 166 Annex-­‐ B EVALUATION TEAM, STEERING COMMITTEE, TECHNICAL COMMITTEE AND FOUR WORKING COMMITTEES. 1. Evaluation Team: The following team members will be responsible for carrying out the evaluation with assistance from the officials of IMED. List of Members for carrying out the end line evaluation of HNPSP Name and Designation Worked as 1) Mr. Md. Habib Ullah Majumder, Secretary, Principal Investigator/Co-­‐
ordinator 2) Syed Md. Haider Ali, DG (Evaluation) Co-­‐ Principal Investigator 3) Mr. Md. Abdul Quayum, Director Research Associate (Evaluation), IMED 4) Mst. Quamrun Nessa, Deputy Director Research Associate (Evaluation), IMED-­‐ 5) Mst. Sufia Zakariah, Deputy Director Research Associate (Evaluation), IMED-­‐ 6) Mr. Md. Moshiur Rahman, Programmer Research Associate (Evaluation), IMED-­‐ 7) Mr. Md. Mosharaf Hossain, Assistant Director Research Associate (Evaluation 8) Mst. Nargis Jahan , Assistant Director Research Associate 9) Deputy Chief, Family Welfare, MOHFW Research Associate 10) Senior Assistant Chief (FW-­‐2), MOHFW Research Associate 11) Senior Assistant Chief (Planning), MOHFW Research Associate 12) MM Reza (Rtd. Health Secretary), Demographer (Team Member) 13) Dr. Shah Keramat, Professor (Rtd), DU Health Specialist 14) Dr. Khan A Matin, Professor, ISRT, DU Statistician 15) Mst. Khaleda Akhter, Joint Chief (Rtd), H & P Program Specialist 16) Enamul Hoque Chowdhury, AD (Rtd), IMED Data Management Specialist OP on Fiduciary Arrangement_ updated_3 Aug 11 167 Members of the Steering Committee: I.
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Secretary , IMED DG, Directorate General of Health Services DG, Directorate General of Family Planning Director General , Social & Education Sector, IMED Joint Chief, Ministry of Health & Family Welfare Joint Chief, Health Wing , Planning Commission Executive Director , National Nutrition Project Director General (Evaluation) , IMED Chairman/Convener Member Member Member Member Member Member Member-­‐Secretary Members of Technical Committee: I.
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Director General (Evaluation) IMED Deputy Chief , Health Wing, Planning Commission Deputy Chief, Health, Planning Wing (MOHFW) Director, MCH Services & Line Director Director, MIS Directorate of Family Planning Director, Institute of Public Health & Nutrition. Director ESD Director (Research), NIPORT, MOHFW Director, ( MIS) Directorate of Health Services Director-­‐2, Evaluation Sector, IMED Demographer (Team Leader) Health Specialist (Consultant). Statistician (Consultant) Health and Population program related Expert (Consultant) Ms. Sufia Zakariah, Deputy Director, Evaluation Sector, IMED Convener Member Member Member Member Member Member Member Member Member Member Member Member Member Member-­‐Secretary Members of the Working Committee: There will be 4 (four) working committees one for each of the 4 major areas of this study as mentioned below: Working Committee -­‐ 1 : ü
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Director-­‐1/Research Associate -­‐ Member Deputy Chief -­‐(Family Welfare)-­‐ MOHFW Deputy Director-­‐1/Research Associate Assistant Director-­‐1/Research Associate Dr. Saidur Rahman, DPM, Hospital Service, DGHS DPM, Field Service, DGFP All the Four Consultants of the Evaluation Team This committee will develop survey research questionnaires for district hospital/ UHFWCs/ Community Clinics/Community people attending the clinics and work for subsequent analysis of data as will be collected from survey. OP on Fiduciary Arrangement_ updated_3 Aug 11 168 Working Committee -­‐ 2 : ü
D.G (Evaluation)/Co-­‐Principal Investigator-­‐ Convener ü
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Director-­‐2/Research Associate – Member Deputy Chief –(Health)-­‐ MOHFW Evaluation Specialist, NIPORT Deputy Director-­‐2/Research Associate Programmer/Research Associate All the Four Consultants of the Evaluation Team This Committee will develop research instruments to be used for collecting data from the offices of the Line Directors and this committee will be responsible for coordinating and organizing meetings with the line directors, and thereby analyzing data/information as received from them. Working Committee -­‐ 3 : ü
D.G (Evaluation)/Co-­‐Principal Investigator-­‐ Convener ü
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Director-­‐1/Research Associate-­‐ Member DGHS or any representatives from DPM, EPI Senior Assistant Chief (FW-­‐2), MOHFW Deputy Director-­‐2/Research Associate Programmer/Research Associate Assistant Director (Rtd)/ Data Management Specialist All the Four Consultants of the Evaluation Team This Committee will be responsible for administering FGDs at the Field level and recording FGD data/information for subsequent analysis by them. ing Committee -­‐ 4 : ü
D.G (Evaluation)/Co-­‐Principal Investigator-­‐ Convener ü
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Director-­‐2/Research Associate-­‐ Member Senior Assistant Chief (FW-­‐2), MOHFW Dr. Refat Rahena, Medical Officer Deputy Director-­‐2/Research Associate Assistant Director-­‐2/Research Associate Assistant Director (Rtd)/ Data Management Specialist All the Four Consultants of the Evaluation Team Representative of Institute of Epidemiological Disease Control and Research Institute This Committee will work for management and control of the overall field operations program and ensure timely completion of field surveys. OP on Fiduciary Arrangement_ updated_3 Aug 11 169 Annex C Team of Consultants and Distribution of tasks among them -­‐ (refer Sec.1.6) 1. Composition of the team of Consultants Ø M. M. REZA (Team Leader)-­‐ Former Secretary, MOHFW. Ø Prof. Shah Md. Keramat Ali (Rtd.), Institute of Nutrition and Food Science, University of Dhaka. Ø Khaleda Akhter, Joint Chief (Rtd.), SEI Division, Planning Commission Ø Prof. Khan A. Matin, Institute of Statistical Research and Training, University of Dhaka. Ø Enamul Haque Chowdhury-­‐ (Rtd.), Assistant Director, IMED. 2. Distribution of Tasks : (a) OPs evaluated by the Consultants I. OPs evaluated by M. M Reza (Team Leader): = Human Resource Management -­‐ MOHFW = Human Resource Management-­‐ DGHS = Human Resource Management-­‐ DGFP = Capacity Development aspect of different OPs II. OPs evaluated by Prof. Shah Md. Keramat Ali : = NNP = Essential Services Delivery = Improved Hospital Services Management III. OPs evaluated by Khaleda Akhter : = Improved Financial Management-­‐ MOHFW = Improved Financial Management-­‐ DGHS = Improved Financial Management-­‐ DGFP = Procurement, DGHS = Procurement, DGFP IV. OPs evaluated by Prof. Khan A Matin : = Clinical Contraception Service Delivery Programme = Family Planning Field Services Programme = Maternal, Child and Reproductive Health Services Delivery Programme. VI. Other tasks: Enamul Haque Chowdhury assisted with field surveys and data processing under the supervision of Prof. Khan A. Matin. He also conducted technical aspects of preparation of the Report. OP on Fiduciary Arrangement_ updated_3 Aug 11 170 Annex-­‐ D Indicators with Benchmark, Targets and Achievements of HNPSP Priority Objectives as in Table-­‐ I RPIP, 2008 Priority Objectives Benchmark Reducing Maternal Mortality Per 100,000 Live birth Reducing Total Fertility Rate Per Woman Population Growth Rate 322 BMMS 2001 3.00 BDHS 2004 1.42% Reducing Malnutrition Projected Target Mid-­‐2011 240 2.2 1.20% 50.9% underweight children (6-­‐59 months) Child Nutrition Survey, 2000 12.9% CNS, 2000 of severely underweight children Reducing Infant and Under-­‐five Mortality: Infant deaths per 1000 live births 65 BDHS 2004 36% <2% Death of Children under 5 per 1000 live births 52 88.0 BDHS 2004 37 Reducing the burden HIV/AIDS, TB, Malaria and other disease: Case detection -­‐ TB 38% 70% NTP 2003 Cure Rates -­‐ TB HIV Prevalence among pregnant women aged 15 to 24 years 83.7% NTP 2003 <1% among high-­‐risks groups except IDUs in central Dhaka with 4% (5th Sero-­‐Surveillance 2004. NASP Prevention and Control of major Non-­‐communicable diseases: Prevalence of Smokeless 20.9% Tobacco use in adults WHO 2004 Prevalence of Smoking in adults 19.7% WHO 2004 Increase in screening for Early NOT AVAILABLE Detection of Cancer(Cervix, Breast & Oral Cancer) through self Examination Detection of Hypertension with NOT AVAILABLE Awareness raising Note : *1 45.0 MICS 2009 , 39.0 SVRS 2009 *2 67.0 MICS //2009, 50.0 SVRS 2009 OP on Fiduciary Arrangement_ updated_3 Aug 11 85% <1% in general population Achievement 194 BMMS 2010 2.7 BDHS 2007 1.36% BBS 2009 41.0 BDHS, 2007 Not Available 52 BDHS 2007 *1 65.0 BDHS 2007 * 2 72% NTP,2007 70.5 NTP 2010 92% NTP,2007 & 2010 <1% among most at risk opulation(MARP), except IDUs in central Dhaka with 7%( 8th Sero-­‐ Surveillance 2007 NASP 15% NOT AVAILABLE 15% 22% WHO 2009 NOT AVAILABLE 30% of the eligible women 20% NOT AVAILABLE 171 Annex-­‐ E_1 List of Key Stakeholders Consulted Sl # 1. 2. 3. 4. 5. Name Designation Ms. Niru Shamsun Nahar Mst. Khodeja Begum Mr. Helaluddin Ms. Nargis Akhter Ms. Shaila Sharmin Zaman Mr. Abdullah-­‐al-­‐Mamon Dr. Shabullah Mr. Zafrullah Khan Ms. Niru Shamsun Nahar Mr. Wahid Khan Joint Chief Division Chief Deputy Chief Senior Assistant Chief Senior Assistant Chief Senior Assistant Chief Member, SEI Division Secretary(Health-­‐Rtd) Joint Chief, SEI, Planning Commission Consultant Ministry/Avenu
e Planning Commission IMED MOHFW, Secretariat Building Planning Commission PPC, Azimpur Population Bhaban 6. Dr. M. A. Sabur Ex-­‐ Team Leader, PSO IMED, Ministry of PLanning 7. Ms. Sadika Akhter Research Investigator, IMED, Ministry ICDDRB of PLanning 8. Dr. Bushra Binte Alam Chief Programme World Bank Ms. Iffat Mahamud Manager, HNPSP Office 9. Mr. Humayun Kabir Secretary, MPHFW MOHFW, Mr. Helaluddin Deputy Chief Secretariat The above listed Consultative Meetings were conducted by a five-­‐member team of Consultants headed by MM Reza, the Team Leader for HNPSP Study are as following: Mr. MM Reza-­‐ Health Secretary (Rtd) Dr. Md. Shah Keramat Ali-­‐ Professor (Rtd) , Food and Nutrition, Dhaka University Dr. Khan A Matin, Professor, ISRT, Dhaka University Ms. Khaleda Akhter, Joint Chief ( Rtd), Planning Commission Mr. Enamul Hoque Chowdhury, Assistant Director (Rtd), IMED. OP on Fiduciary Arrangement_ updated_3 Aug 11 Meeting Held on : 28 May 2011 11 June 2011 14 June 2011 10 June 2011 12 June 2011 18 June 2011 22 June 2011 27 June 2011 12-­‐ July 2011 172 Annex-­‐ E_2 List of Service Providers consulted at the field levels. Sl # Name Designation Organization/Department/Place Date of Meeting 1. Dr. Md.Golam Civil Surgeon Zila Hospital Moulovi Bazar 30-­‐7-­‐2011 Rajjak Chowdhury 2. Dr. Farid Ahmed Civil Surgeon Zila Hospital Bhola 29-­‐7-­‐2011 3. Dr. Moyazzem Civil Surgeon Zila Hospital Rangpur 26-­‐7-­‐2011 Hossain 4. Dr. Abdul Hannan Civil Surgeon Zila Hospital Jessore 27-­‐7-­‐2011 5. Dr. Md. Abdul Goni Civil Surgeon Zila Hospital Natore 27-­‐7-­‐2011 6. Dr. Syed Md. Civil Surgeon Zila Hospital Gazipur 25-­‐7-­‐2011 Habiullah 7. Dr. Anawarul Islam Civil Surgeon Zila Hospital Feni 28-­‐7-­‐2011 8. Dr. Md. Lutful Kabir Deputy MCWC, Moullove Bazar 30-­‐7-­‐2011 Khan Director-­‐ FP 9. Dr. Hemonto Kumar DD (FP) MCWC, Bhola 29-­‐7-­‐2011 Das 10 Dr. Abdus Samad DD (FP) MCWC, Rangpur 26-­‐7-­‐2011 11. Dr. Dilip Kuma DD (FP) MCWC, Jessore 27-­‐7-­‐2011 12. Dr. SM Jakir DD (FP) MCWC, Natore 27-­‐7-­‐2011 Hossain 13. Dr. Shusil Chandra DD (FP) MCWC, Gazipur 25-­‐7-­‐2011 14 Dr. Mojibur FHO MCWC, Feni 28-­‐7-­‐2011 Rahman 15. Dr. Amitab Dey UFPO UHC, Sadar Upazila, Moulovibazar 16. Dr. Modhusudon UFPO UHC, Kulaura 30-­‐7-­‐2011 Pal Chowdhury 17. Dr. Saif Ali UFPO Dagonbhuyian, Feni 27-­‐7-­‐2011 18. Dr. Sanjo Kumar RMO Monirampur 27-­‐7-­‐2011 19. Dr. Arun Kumar MO Jessore Sadar Upazila 27-­‐7-­‐2011 20. Dr. Md. Esmile RMO Tongi, Gazipur 25-­‐7-­‐2011 Hossain 21. Dr. Liakot Ali Khan RMO Gazipur 28-­‐7-­‐2011 22. Dr. Shushil Kumar UFPO Sreepur, Gazipur 27-­‐7-­‐2011 23. Begum Nuray TFPO Tongi, Gazipur 27-­‐7-­‐2011 Jannat 24. Dr. Md. Shamsul UFPO Pirgonj, Rangpur 25-­‐7-­‐2011 Islam 25. Dr. Lahonya UFPO Lalmohan, Barisal 28-­‐7-­‐2011 Borajgo 26. Dr. Parveen Begum MO, Clinic Bhola 27. Dr. Afroza Begum MO (MCH) Lalmohan 30-­‐7-­‐2011 28. Dr. Shersha Alam UFPO Doalotkhan, Bhola 27-­‐7-­‐2011 OP on Fiduciary Arrangement_ updated_3 Aug 11 173 Annex-­‐ F Comparative statement of budget of original approved PIP of HNPSP (2003-­‐2006), approved first revised PIP of 2003-­‐
2010 and the proposed 2nd revised PIP of 2003-­‐2011 (In lakh taka) OP Sl. Name of Operational Plan Approved allocation for 1st Revised Allocation for 2nd Revised Proposal for 2003-­‐
No. 2003-­‐2006 2003-­‐2010 2011 GOB PA Total GOB PA Total GOB PA Total 1 Essential Service Delivery, DGHS 8180 55600 63780 32710 237170 269870 52217 236420 288637 2 Communicable Disease Control, DGHS 470 6900 7370 5390 17100 22490 17798 52326 70124 3 Micobacterial Disease Control (TB & Leprosy) , DGHS 1060 8750 9810 3190 32870 36060 3340 46152 49492 4 Health Education & Promotion, DGHS 600 1450 2040 4040 5020 9060 4553 5996 10549 Improved
Hospital
5 Services
Management,
DGHS
15430 35330 50760 36380 93670 130040 45888 86842 132730 6 Alternative Medical Care, DGHS 2460 700 3160 7920 1230 9140 5315 750 6064 7 Nursing Education and Services, DNS 600 1190 1780 1570 5450 7010 3294 6220 9513 8 Public Health Interventions & Non communicable disease control, DGHS 420 2590 3010 1970 16850 18830 3776 15184 18960 9 National AIDS/STD Programme and Safe Blood Transfusion, DGHS 730 19860 20590 3230 49780 53010 1552 59621 61173 10 Pre-­‐service Education, DGHS 810 900 1710 3260 1500 4760 13825 8165 21990 11 In Service Training, DGHS 3230 9360 12600 7690 36540 44230 8792 21221 30014 12 Procurement, Logistics and Supplies Management, DGHS 6780 570 7360 16870 540 17410 31234 1071 32305 13 Research and Development, DGHS 100 1690 1800 230 4340 4560 133 2434 2567 14 Management Information System, DGHS 680 1580 2260 1790 4180 5980 1851 4809 6660 15 Quality Assurance, DGHS 30 240 270 90 530 620 99 524 623 16 Strengthening of Drug Administration and Management, DDA 1020 1340 2360 1150 1540 2690 619 422 1041 17 National Nutrition Programme, MOHFW 4970 34240 39210 11320 123400 134730 14326 137717 152043 18 Clinical Contraception Services Delivery, DGFP 9620 5690 15310 22580 26330 48910 33360 28854 62214 19 Family Planning Field Services Delivery, 13500 98050 111550 21850 165950 187800 39060 165532 204592 20 Maternal, Child and Reproductive Health Services Delivery, DGFP 4200 12150 16350 9250 44590 53850 15323 59021 74344 21 Information, Education, and Communication (FP), DGFP 1000 2040 3040 3420 7760 11180 4191 7089 11280 22 MIS – Services and Personnel (FP), DGFP 400 560 960 1170 900 2070 1314 1465 2779 23 Training, Research and Development (FP), NIPORT 740 1420 2160 460 10270 10730 1480 9165 10645 24 Procurement, Storage and Supply Management, DGFP 5580 150 5730 9750 560 10310 10349 545 10895 25 Sector-­‐wide Program Management-­‐MOHFW 60 720 780 100 2370 2470 167 3225 3392 26 Sector-­‐wide Program 20 750 760 50 1710 1760 101 1273 1374 OP on Fiduciary Arrangement_ updated_3 Aug 11 174 OP Sl. Name of Operational Plan Approved allocation for 1st Revised Allocation for 2nd Revised Proposal for 2003-­‐
No. 2003-­‐2006 2003-­‐2010 2011 GOB PA Total GOB PA Total GOB PA Total Management-­‐DGHS 27 Sector-­‐wide Program Management-­‐DGFP 40 290 340 130 290 420 122 246 367 28 Human Resource Management-­‐MOHFW 60 610 670 100 1430 1530 184 1036 1220 29 Human Resource Management-­‐DGHS 40 110 150 120 340 460 232 356 588 30 Human Resource Management-­‐DGFP 20 40 60 200 3000 3200 249 2298 2548 31 Physical Facilities Development, MOHFW 56420 8450 64870 330150 78800 408950 295529 74385 369913 32 Health Economics Unit, MOHFW 210 760 960 510 3100 3610 505 2030 2535 33 Improved Financial Management-­‐MOHFW 130 860 990 360 2030 2390 411 2171 2582 34 Improved Financial Management-­‐DGHS 90 170 260 120 130 250 105 157 262 35 Improved Financial Management-­‐DGFP 90 50 140 250 70 310 193 148 341 36 Policy Reforms, MOHFW 100 4460 4560 110 89330 89440 293 32263 32556 37 Micro Nutrient Supplementation, DGHS 120 380 500 2340 7420 9760 2551 7047 9598 38 National Eye Care 0 0 0 1180 1270 2440 867 1041 1908 Grand Total 140000 320000 460000 542970 1079350 1622320 615198 1085221 1700419 OP on Fiduciary Arrangement_ updated_3 Aug 11 175 Annex -­‐ G Approved Costs and Estimated Expenditures of HNPSP by 38 Ops (In Crore Tk.) Estimated cost PIP(2003-­‐11) Estimated Expenditure (2003-­‐11) Sl. Name of the Operational % fund % of No Plan (OP) utilized GOB PA Total GOB PA Total Total 1 19 Essential service delivery Communicable Disease Control TB & Leprosy Control Health education & promotion Improved Hospital Services Management Alternative Medical care Non-­‐communicable Disease Control & Other Public Health National AIDS/STD & Safe Blood Transfusion In-­‐service Training Pre-­‐service education Mangt for Procurement, Logistics Research &Dev. (Health) MIS-­‐Health, Services & Personal Quality Assurance Sector-­‐wide Program Management (Health) Human Resource Management (Health) Improved Financial Management (Health) Micro-­‐nutrient Supplementation National Eye Care Sl. No Name of the Operational Plan (OP) 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 20 21 Nursing Education & Services Strengthening of Drug Administration management 478.91 2373.54 2822.45 17.22 368.09 2038.88 2406.97 84.38 164.02 33.81 477.37 540.60 641.39 574.41 3.87 3.47 76.16 18.40 230.69 468.20 306.85 486.60 47.84 84.71 45.53 59.96 105.49 0.64 43.82 53.34 97.16 92.1 449.08 53.14 787.22 7.50 1236.30 60.64 7.46 0.37 224.06 49.80 655.51 7.06 879.57 56.86 71.14 93.77 37.35 152.17 189.52 1.14 11.92 106.69 118.61 62.58 14.56 85.56 132.02 552.67 195.04 81.96 567.23 280.60 213.98 3.42 1.69 1.29 12.40 68.80 109.08 418.61 149.15 182.93 431.01 131.46 49.06 75.99 77.67 136.47 312.34 1.43 8.71 24.24 321.05 25.67 1.94 0.15 457.82 1.07 3.47 17.18 460.29 18.25 143.37 71.09 18.72 1.11 60.75 6.63 79.47 7.74 0.48 0.05 16.72 0.97 50.06 5.25 66.78 2.67 84.03 80.36 3.81 14.78 18.59 0.11 0.57 8.01 9.58 51.53 2.32 4.12 6.44 0.04 1.81 3.39 1.53 80.75 1.38 1.64 3.02 0.02 0.83 1.45 2.28 75.5 16.47 77.80 94.27 8.22 7.53 15.75 Estimated Expenditure (2003-­‐11) 89.85 77.28 27.56 77.36 104.92 9.46 10.92 20.38 Estimated cost PIP(2003-­‐11) GOB PA Total 0.63 0.12 % of Total GOB PA 32.98 62.15 95.13 0.57 26.68 46.45 6.19 4.22 10.41 0.06 10.81 13.23 328.60 278.55 607.15 3.66 479.94 22 Clinical Contraception Services Delivery 23 Family Planning Field Services Delivery 341.99 1650.03 1992.02 12.02 MCRH Services Delivery 153.23 537.71 690.94 Information, Education & Communication (FP) 40.53 71.01 MIS-­‐Services & Personnel 13.14 29.37 % fund utilized 76.87 24.04 230.93 584.15 96.21 268.48 1 4 3 1.20 1699.68 85.32 4.17 104.59 382. 89 487.48 70.55 111.54 0.67 30.15 15.00 28.14 0.17 9.44 103.50 5.45 108.95 0.66 56.55 Sector-­‐wide Mgmt-­‐FP 1.22 2.45 3.67 0.02 1.91 29 Human Resource Mgmt-­‐
FP 2.50 22.98 25.48 0.15 30 Improved Financial Management –FP 1.93 1.48 3.41 0.02 24 25 26 27 28 Procurement, Storage & Supplies Management 212.63 Total 62. 83 92.98 83.36 4.04 13.48 47.9 2.2 9 58.84 54.01 3.78 5.69 155.04 2.34 17.79 10.40 1.90 1.03 2.93 79 85.92 31 32 33 34 35 36 37 38 Training, Research & Dev. (NIPORT) N N P Physical Facilities Development (c.r & m) Sector-­‐wide Mgmt-­‐
MOHFW Human Resource Management -­‐MOHW Improved Financial Managmt -­‐MOHFW Health Economics Unit Policy reforms 14.80 106.65 121.45 0.73 6.76 81.66 88.42 72.8 143.43 1107.08 1250.51 7.55 86.24 799.12 885.36 3227.62 520.55 3748.17 22.62 2960.57 333.06 3293.63 87.87 1.67 29.47 31.14 0.19 0.83 10.45 11.28 36.22 1.84 8.29 10.13 0.06 1.55 2.99 2.07 44.82 4.08 4.83 2.93 21.17 20.30 365.63 25.25 25.13 368.56 0.15 0.15 2.22 3.00 4.11 1.20 10.20 18.24 187.01 13.20 22.35 188.21 52.28 88.94 51.07 Source: HPNSDP (2011-­‐2016), April, 2011, Planning Wing, MOHFW
70.8 Annex -­‐ H FORM -­‐ A END LINE EVALUATION OF HEALTH, NUTRITION AND POPULATION SECTOR PROGRAMME (HNPSP) AeRvi‡fkb †PKwj÷ Ges WKz‡g›U wiwfD
h¡Ù¹h¡ue f¢lh£rZ J j§mÉ¡ue ¢hi¡N
j§mÉ¡ue ®pƒl
AeRvi‡fkb †PKwj÷ Ges WKz‡g›U wiwfD Gi gva¨‡g miKvix wewfbœ ¯^v¯’¨ ‡mev †K†›`ªi (‡Rjv
nvmcvZvj, gv I wkï Kj¨vY †K›`ª , Dc‡Rjv ¯^v¯’¨ †K›`ª , Ges BDwbqb ¯^v¯’¨ I cwievi Kj¨vb †K‡›`ªi
my‡hvM mywea¸‡jv hvPvB Kiv |
SERIAL No.
1
K(1)
L
L (1)
L (2)
L (3)
L (4)
L (5)
L (6)
L (7)
L (8)
L (9)
L
(10)
L
(11)
L
(12)
L
(13)
L
(14)
L
cwiwPwZ :
¯^v¯’¨ ‡mev †K†›`ªi Ges wVKvbv :
bvg :
BDwbqb : / e-K
Dc‡Rjv/_vbv:
†Rjv :
wefvM :
¯^v¯’¨ ‡mev ‡K‡›`ªi aib : (‡Rjv nvmcvZvj = 1, Gg wm Wwe-D wm=2, BD GBP wm = 3, BD GBP A¨Û
Gd Wwe-D wm =4)
¯^v¯’¨ ‡mev †K‡›`ªi myweavmg~n Ges i¶Yv‡e¶Y:
mvwe©K cwi®‹vi cwi”QbœZv
( Lye cwi®‹vi = 1, cwi®‹vi = 2,
Acwi®‹vi = 3)
wi‡mckb KvD›Uvi G mvwf©m cÖfvBWvi‡`i Dcw¯nwZ
( Av‡Q = 1 bvB = 2)
‡mevMÖvnK‡`i Rb¨ wU‡KU KvD›Uvi
( Av‡Q = 1 bvB = 2)
ewn©wefvM- Wv³vi‡`i Dcw¯nwZ
( Av‡Q = 1 bvB = 2)
dvg©vwmmU†`i Dcw¯nwZ
( Av‡Q = 1 bvB = 2)
wK¬bvi
( Av‡Q = 1 bvB = 2)
IqvW© eq
( Av‡Q = 1 bvB = 2)
†eW AwKD‡cbwm †iU (kZKiv nvi)
ewn©wefv‡Mi ‡ivMx‡`i Rb¨ cix¶v/ civg‡k©i Rb¨ Avjv`v i“g
( Av‡Q = 1 bvB = 2)
civg‡k©i e¨vcv‡i †MvcbxqZv
( Av‡Q = 1 bvB = 2)
†ivMxi cix¶v Avm‡bi cv‡k c`©v
cvwb mieivn
ewnivMZ †ivMx‡`i Uq‡jU myweav
gwnjv‡`i Rb¨ Avjv`v Uq‡jU myweav
†Wwjfvwi / AvB BD wW cÖwZ¯’vc‡bi Rb¨ Avjv`v i“g
(cwi®‹vi=1
( Av‡Q = 1
Acwi®‹vi=2 )
bvB = 2)
( Av‡Q = 1
( Av‡Q = 1
bvB = 2)
bvB = 2)
( Av‡Q = 1
bvB = 2)
(15)
M
¯^v¯’¨ ‡mev †K†›`ªi hš¿vw`:
hš¿vw`i bvg
cÖvc¨Zv
nu¨ = 1, bv =
2
Kvh©Ki
nu¨v =1, bv = 2,
cÖ‡hvR¨ bq=3
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
cÖvß eq¯‹‡`i IRb gvcvi hš¿
wkï‡`i IRb gvcvi hš¿
GWvë ‡÷‡_vm‡Kvc
i³Pvc gvcvi hš¿
AvB BD wW Bbmvk©b wKU
i³ mÂvjb ‡mU
gvB‡µv‡¯‹vc
A‡¯¿vcPvi hš¿cvwZi ‡mU
I GÛ wR wKU&m
wUD†eKUgx wKUm
f¨v‡mKUgx wKUm„
A‡Uv‡K¬f
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jvBU Bb IwU (Acv‡ik‡bi N‡ii Rb¨
we‡kl evwZ)
15. Gqvi KwÛkb Bb IwU
N)
N (1)
N (2)
N (3)
N (4)
N (5)
N (6)
N (7)
N (8)
N (9)
N(10)
N (11)
N (12)
¯^v¯’¨ ‡mev †K†›`ªi Rbej Ges Dcw¯’wZ :
Rbej
gÄyiK…Z c†`i
msL¨v :
Wv³vi
m¨vK‡gv
bvm©
dvg©vwmmU
j¨ve †UKwbwkqvbm& :
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†iwWIMÖvdvi
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Gd Wwe-D G
Gd Wwe-D wf
Svo–`vi
Ab¨vb¨ c†`i msL¨v :
c~ibK…Z c‡`i msL¨v :
cyi“l
gwnjv
cwi`k©‡bi
w`‡b
Dcw¯’wZi
msL¨v
O
O (1)
O (2)
O (3)
O (4)
P-1
P-2
¯^v¯’¨ ‡mev †K†›`ªi Ily‡ai gRy`:
30wU AZ¨vek¨Kxq gRy`K…Z Ily‡ai g‡a¨ (BDwbqb ch©v‡qi WªvM wKU) KqwU eZ©gv‡b Av‡Q
?
cÖK…Z msL¨v.......
30 wU gRy`K…Z cÖ‡qvRbxq Ily‡ai (g¨v‡jwiqv Ges wUwe Ilya Qvov) g‡a¨ eZ©gv‡b KqwU Av‡Q
? cÖK…Z msL¨v .........
Dc‡Rjv chv‡©q- 100 wU gRy`K…Z cÖ‡qvRbxq Ilya :
( Av‡Q = 1 bvB = 2)
bv _vK‡j, KZw`b a‡i †bB ......... w`b
ch©‡e¶‡Yi c~e© w`‡b ¯^v¯’¨ ‡mev †K†›`ª ‡mevcÖvß †ivMx‡`i msL¨v †`‡L)
‡gvU AvDU‡Wvi:
cyi“l AvDU‡Wvi :
gwnjv AvDU‡Wvi :
AvDU‡Wvi :
(WKz‡g›U
Q (1)
GgAvBGm dig Gi e¨envi :
AvBGg wm AvB cÖwZ‡e`b cvVvb nq wKbv
RR (1)
R (2)
R(3)
R (4)
R (5)
R (6)
Avw_©K welqvw` :
(ch©‡e¶‡Yi gva¨‡g)
ewn©wefv‡Mi †ivMx‡`i wK †mev wd †bqv nq ?
( nu¨v = 1 bv = 2)
†mev wd †bIqvi Rb¨ wK †Kvb MvBW jvBb Av‡Q ?
( nu¨v = 1 bv = 2)
Mixe †ivMx‡`i †mev wd ‡bIqv n‡Z Ae¨vnwZ †`Iqv nq wK bv ? ( nu¨v = 1 bv = 2)
A_©vfv‡e G¨v¤^y‡jÝ e¨envi Ki‡Z Amyweav nq wK bv ?
( nu¨v = 1 bv = 2)
A_©vfv‡e †Rbv‡iUi e¨envi mxwgZ nq wK bv ?
( nu¨v = 1 bv = 2)
‡mev wd miKvix †KvlvMv‡i Rgv nq?
( nu¨v = 1 bv = 2)
S)
‡mevcÖvß †ivMx‡`i evrmwiK Mo msL¨v (2003-2011) - Gg wm Wwe-D wm
:
eQi
gwnjv
‡Wwjfvwi
wkï
ewn©wefv
M
AvDU fwZ©
¯^vfv wmRvwi
‡Wvi
Av‡Q
weK
qvb
2003
2004
2005
2006
2007
2008
2009
2010
2011
‡gvU AvDU‡Wvi:
cyi“l AvDU‡Wvi :
gwnjv AvDU‡Wvi :
AvDU‡Wvi :
T(1)
U((1)
U((2)
U((3)
U((4)
V
V-1
( nu¨v = 1
wkï
bv = 2)
UHC MZ ermi (2010) GB †K‡›`ª KZwU †Wwjfvix n‡q‡Q:
KZRb gv‡qi g„Zy¨ n‡q‡Q-------KZRb RxweZ Rb¥ wjß f~wgKv n‡q‡Q .................... ?
KZRb wkïi R‡b¥i g„Zz¨ n‡q‡Q ...............
‡mev †K‡›`ªi aib :
ch©‡e¶‡Yi c~e© w`‡b ¯^v¯’¨ ‡mev †K†›`ª ‡mevcÖvß †ivMx‡`i msL¨v (WKz‡g›U †`‡L)
wkï
W-1
X (1)
X (2)
X (3)
Y
Y (1)
Y (2)
Y (3)
Y (4)
Z
Z-1
Z-2
‡gvU AvDU‡Wvi:
cyi“l AvDU‡Wvi :
gwnjv AvDU‡Wvi :
wkï AvDU‡Wvi :
†K‡›`ªi AemwUwUªK (cÖm~wZ) †mev : (cÖ‡hvR¨ ‡¶‡Î)
AemwUwUªK dv÷ GBW
( Av‡Q = 1 bvB = 2)
‡ewmK B, Gg, I, wm ( Riyix AemwUwUªK †mev )
( Av‡Q = 1 bvB = 2)
Kw¤úª‡nbwmf B, Gg, I, wm
( Av‡Q = 1 bvB = 2)
Rb¥ wb‡ivaK mvgMÖxi ÷K
Bb‡RK‡Uejm&
( Av‡Q = 1 bvB = 2)
B¤ú-¨v›U ( Av‡Q = 1 bvB = 2) AvB, BD
wW ( Av‡Q = 1 bvB = 2)
KbUvª‡mcwUf wcj
( Av‡Q = 1 bvB = 2)
KbWg
( Av‡Q = 1 bvB = 2)
MZ 1 eQ‡i KbUªv‡mcwUf mieiv‡n †Kvb NvUwZ wQj wK ? (nu¨v = 1, bv = 2)
(WKz‡g›U wiwfD Gi gva¨‡g)
Y (3) DËi hw` Ónu¨vÓ nq Zvn‡j †Kvb mvgMÖxi NvUwZ n‡qwQj ?
Bb‡RK‡Uejm& ( nu¨v = 1 bv = 2), B¤ú-¨v›Um ( nu¨v = 1 bv = 2), KbUvª‡mcwUf wcj (
nu¨v = 1 bv = 2),
AvB, BD wW ( Av‡Q = 1 bvB = 2) , KbWg (nu¨v = 1, bv = 2)
(WKz‡g›U wiwfD Gi gva¨‡g)
‡mevcÖvß †ivMx‡`i evrmwiK Mo msL¨v (2003-2011)
‡mev †K‡›`ªi aiY :
eQi
cyi“l
_
AvDU‡Wvi
gwnjv
wkï
Bb‡Wvi
gwnj wkï
v
cyi“l
‡Wwjfvwi
¯^vfvw wmRvwiqv
eK
b
2003
2004
2005
2006
2007
2008
2009
2010
2011
Rwi‡ci Av‡Mi w`‡b ‡mevcÖvß †ivMx‡`i msL¨v
†K‡›`ªi aib :
`(1)
†gvU :
cyi“l:
gwnjv :
a
a (1)
a (2)
‡K›`ª †Lvjv _vKvi mgqKvj :
‡K›`ª †Lvjvi miKvix mgq : mKvj 8.00 ...........
‡K›`ª eÜ nIqvi miKvix mgq : weKvj 2.30 ...........
‡mev
wkï:
†Lvjvi cÖK…Z mgq Kvj
eÜ nIqvi cÖK…Z mgq Kvj
ch©‡e¶Y Ges WKz‡g›U wiwfD Kvixi bvg
¯^v¶i :
ch©‡e¶Y Ges WKz‡g›U wiwfD Gi ZvwiL:
FORM-­‐ B END LINE EVALUATION OF HEALTH, NUTRITION AND POPULATION SECTOR PROGRAMME (HNPSP) Gw·U †mevcÖvß †ivMx‡`i Ges ¯^v¯’¨ †mev ‡K‡›`ªi wbKU¯’ GjvKvq emevmKvix ¯^v¯’¨ †mev
MÖnYKvix‡`i Rb¨ cÖkœgvjv
h¡Ù¹h¡ue f¢lh£rZ J j§mÉ¡ue ¢hi¡N
j§mÉ¡ue ®pƒl
SERIAL No.
K (1)
K (2)
L
L (1)
L (2)
L (3)
L (4)
L (5)
L (6)
L (7)
L (8)
L (9)
L (10)
L (11)
L (12)
L (13)
L (14)
L (15)
L (16)
L (17)
L (18)
L (19)
cwiwPwZ:
†K‡›`ªi bvg Ges wVKvbv :
bvg :
BDwbqb : / e-K / †ivW bs t
Dc‡Rjv t
†Rjv t
wefvM :
‡K‡›`ªi aib : (‡Rjv nvmcvZj -1 , Gg wm Wwe-D wm=2, BD GBP wm=3, BD GBP Gd
Wwe-D wm= 4)
DËi`vZv / `vÎxi bvg Ges wVKvbv t
ˆewkó¨ t
eqm : ..........
wj½ : cyi“l = 1
gwnjv = 2
‰eevwnK Ae¯’v : (weevwnZ=1, AweevwnZ=2,
ZvjvKcÖvß/we‡”Q`=3 ,
weaev/wecZœxK- 4)
wk¶vMZ †hvM¨Zv : ---------- , (Awkw¶Z/ †Kvb ¯‹z‡j covïbv K‡iwb=0)
‡ckv : (K…wl = 1, M„n¯’vjx = 2, e¨emv=3, PvKzwi=4, w`b gRyi= 5, wiKmv/ f¨vb=6,
WªvBwfs-7, †gKvwbK =8, QvÎ=9, Ab¨vb¨=10
gvwmK Avq (UvKv) :
Rwgi cwigvb (Pvlvev`+ emZwfUv) : ........ (kZvs‡k)
†gvU RxweZ f~wgô wkïi msL¨v :
5 eQ‡ii bx‡P RxweZ wkïi msL¨v : ..........
me©‡kl RxweZ wkïi eqm (gvm) : ..........
†K Avcbv‡K wPwKrmv †mev cÖ`vb K‡i‡Q ? ..............
†mev cÖ`vbKvix‡`i †_‡K †mev cvIqvi Rb¨ A‡c¶vi mgq (wgwbU) : ..........
‡mev cÖ`vbKvix Avcbv‡K KZ¶Y mgq w`‡q‡Q (wgwbU): ..........
‡mev cÖ`vbKvixiv wK Avcbv‡K c`v©i Avov‡j cix¶v K‡i‡Q ?
c`©v e¨envi K‡i‡Q =1,
mKj †mevMÖnYKvix‡`i mvg‡b =2
‡mev cÖ`vbKvix wK Avcbvi bvox cix¶v K‡i‡Q ?
nu¨v = 1 bv = 2
†mev cÖ`vbKvix wK Avcbvi i³ cix¶v K‡i‡Q ? (cÖ‡hvR¨ ‡¶‡Î) nu¨v = 1 bv = 2
†mev cÖ`vbKvix wK ‡÷‡_vm‡Kvc w`‡q Avcbv‡K cix¶v K‡i‡Q ?
nu¨v = 1 bv = 2
†mev cÖ`vbKvix wK Avcbvi i³¯eíZv cix¶v K‡i‡Q ?
nu¨v = 1 bv = 2
Avcbvi †mev cÖ`vbKvixi AvPiY : (m‡šZvlRbK =1,
†gvUvgywU m‡šZvlRbK =2,
m‡šZvlRbK bq =3, AZ¨šZ Lvivc e¨envi =4)
¯^v¯’¨‡mevi gvb Dbœq‡bi Rb¨ Avcbvi mycvwik (GKvwaK DËi) t
ch©vß Ilya=1, Wv³vi‡`i wbqwgZ cwi`k©b =2, GgweweGm Wv³vi c`vqb =3,
hš¿vw`i cÖvc¨Zv=4, Uq‡jU myweav=5, G¨v¤^y‡jÝ =6, Ggvi‡RwÝ IqvW©=7,
‡Pv‡Li wPwKrmv =8, `šZ wPwKrmv = 9, ¯^v¯’¨‡mev †K›`ª Db¥y³ ivLv =10 , Ab¨vb¨ (`qv
K‡i wbw`©ó Ki“b ) = 11
5 eQ‡ii bx‡P wkï‡`i wUKv MÖn‡Yi Ae¯’v t
M
M (1)
M (2)
M (3)
M (4)
N
N (1)
N (2)
O
O (1)
O (2)
O (3)
O (4)
O (5)
P
P (1)
P (2)
P (3)
P (4)
P (5)
Q
Q (1)
Q (2)
5 eQ‡ii bx‡P wkï‡`i wUKv MÖn‡Yi Ae¯’v : (m¤ú~Y©fv‡e wUKvcÖvß-1, AvswkKfv‡e
wUKv cÖvß-2, wUKvcÖvß bq-3,
5 eQ‡ii bx‡P †Kvb wkï bvB= 9
MZ 90 w`‡bi g‡a¨ 5 eQ‡ii bx‡P wkï Amy¯’ wQj wK bv ?
nu¨v = 1 bv = 2
(5 eQ‡ii bx‡P †Kvb wkï bvB= 9)
M/ 2 Gi DËi hw` Ó nu¨vÓ nq, Zvn‡j †iv‡Mi cÖKvi/aib : cvZjv cvqLvbv= 1,
mvaviY mw`© Kvwk Ges R¡i = 2, wbDgywbqv = 3 , Ab¨vb¨ †iv‡Mi bvg= 4
ev”Pv‡`i wPwKrmvi Rb¨ ‡Kvb ¯^v¯’¨‡K‡›`ª wM‡qwQ‡jb wK ?
nu¨v = 1 bv =
2
cwievi cwiKíbvi †mev (Avcwb/ Avcbvi ¯^vgx ) t
eZ©gv‡b cwievi cwiKíbv c×wZ e¨envi Ki‡Qb wK ?
nu¨v = 1 bv = 2
Rwi‡ci 3 gvm Av‡M †Kvb ai‡Yi ¯^v¯’¨/ cwievi cwiKíbv Kg©x evwo‡Z G‡mwQj ?
¯^v¯’¨ Kgx©=1, cwievi cwiKíbv Kgx© = 2, †KD Av‡mwb=3, Rvwbbv =4
gvZ… ¯^v¯’¨ (MZ 1 eQ‡i †h me gwnjv†`i cÖme n‡q‡Q) t
Rwi‡ci 1 eQ†ii g‡a¨ †Kvb wkï Rb¥ MÖnY K‡i‡Q wK ?
nu¨v = 1 bv = 2
O (1) hw` nu¨v nq - †Wwjfvwi‡Z †K mvnvh¨ K‡i‡Q ? `vB = 1, cÖwkw¶Z `vB/ wU we G
= 2,
cÖwZ‡ekx / AvZ¥xq = 3, Gm we G (w¯‹^ì ev_© A¨v‡Ub‡W›U) = 4, ¯^v¯’¨ †K›`ª= 5
†Wwjfvixi c~‡e© †Kvb RwUjZv n‡q‡Q wK ?
nu¨v = 1 bv = 2
†Wwjfvixi mgq †Kvb RwUjZv n‡q‡Q wK ?
nu¨v = 1 bv = 2
‡Wwjfvixi c‡i †Kvb RwUjZv n‡q‡Q wK ?
nu¨v = 1 bv = 2
¯^v¯’¨ ‡K‡›`ª †mev cvIqvi my‡hvM
me‡P‡q Kv‡Qi ¯^v¯’¨‡K›`ª n‡Z Avcbvi evoxi `~iZ¡ (wK‡jvwgUvi) : ........
(1 wK‡jvwgUv‡ii Kg n‡j = 0)
RwicKvj n‡Z 6 gv†mi g‡a¨ †Kvb †mev †K‡›`ª wM‡qwQ‡jb wK ?
nu¨v = 1 bv = 2
wK ai‡Yi †mev cvIqvi Rb¨ ¯^v¯’¨ †K‡›`ª wM‡qwQ‡jb ? ¯^v¯’¨MZ KviY =1,
cwievi cwiKíbv †mev cvIqvi Rb¨ = 2, ¯^v¯’¨mn cwievi cwiKíbv †mev cvIqvi Rb¨ = 3,
†mev MÖnxZv‡`i ¯^v¯’¨ †K‡›`ª hvIqvi KviYmg~n (GKvwaK DËi) : mvaviY ‡ivM = 1,
wkïi Amy¯’Zv=2,
cÖmeRwbZ mgm¨v= 3, cwievi cwiKíbv c×wZi cvk¦© cÖwZwµqv- 4,
Riyix ¯^v¯’¨‡mev= 5, †hŠb evwnZ †ivM (Gm wU wW)= 6,
wK ai‡Yi †mev †K‡›`ª wM‡qwQ‡jb ? BD GBP wm =1, BD GBP Gd Wwe-D wm=2, wm
wm =3, gvV Kgx© =4, m¨vUvjvBU wK¬wbK=5,
dvg©vwm=6, Gb wR I = 7, MÖvg¨
Wv³vi= 8
¯^v¯’¨ I cwievi cwiKíbv Kvh©µ‡gi Dbœqb
Avcbvi g‡Z miKvix ¯^v¯’¨ †K‡›`ªi myweav c~‡e©i Zzjbvq DbœZ n‡q‡Q wK ? nu¨v = 1 bv
= 2,
Av‡Mi gZ = 3, Av‡Mi †P‡q Lvivc n‡q‡Q=4
fwel¨‡Z G ¯^v¯’¨‡K‡›`ª n‡Z †mev MÖn‡Yi e¨vcv‡i †Kvb B”Qv Av‡Q ?
nu¨v = 1 bv = 2
mv¶vrKvi MÖnYKvixi bvg
¯^v¶i :
mv¶vrKvi MÖn‡Yi ZvwiL:
Z`viK Kvixi bvg :
¯^v¶i :
ZvwiL:
FORM-­‐ C END LINE EVALUATION OF HEALTH, NUTRITION AND POPULATION SECTOR PROGRAMME (HNPSP-­‐ 2003-­‐2011) Gd wR wW Gi gva¨‡g Av‡jvPbv Kivi Rb¨ wb‡©`kvejx/
(MvBW-jvBb) :
h¡Ù¹h¡ue f¢lh£rZ J j§mÉ¡ue ¢hi¡N
j§mÉ¡ue ®pƒl
Dc‡Rjv wbe©vnx Kg©KZ©v (BD Gb I) KZ©„K mgw¤^Z Gd wR wW Gi gva¨‡g ‡÷K‡nvìvi (
gwnjv †ivMx, cyi“l †ivMx, wk¶K, †emiKvix wPwKrmv‡mex, KwgDwbwU chv©q †bZv/†bÎx,
BDwbqb cwil` †Pqvig¨vb/ m`m¨ Ges K…wlRxex) ms‡M Av‡jvPbv Kivi Rb¨ wb‡©`kvejx (MvBWjvBb) :
wmwiqvj bs
:cwiwPwZ :
Dc‡Rjvi bvg
†Rjv :
wefvM :
BD Gb I Gi bvg :
Av‡jvPbv Abyôv‡bi ZvwiL :
MvBW jvBb :
1.
2003-2011 e¨vcx ¯^v¯’¨, cywó I RbmsL¨v Kvh©µ‡gi (GBP, Gb, wc, Gm, wc)
ev¯Zevqb m¤ú‡K© Avcbv‡`i gZvgZ wK
2.
GB Kvh©µ‡gi mdj Ges `ye©j w`Km~gn :
eZ©gv‡b Dc‡Rjv ¯^v¯’¨ †K‡›`ªi gva¨‡g cÖ`Ë †mevi cwigvb I gvb - 2003
mv‡ji c~‡e© cÖ`Ë †mevi Zzjbvq wK DbœZ n‡q‡Q
3.
bvix, wkï I `wi‡`ªi gv‡S †mev wbwðZKiY:
GB †cÖvMÖ‡gi Ab¨Zg cÖavb D‡Ïk¨ ‡mevMÖnxZv we‡klK‡i gwnjv, wkï Ges
Mixe Rb‡Mvôx‡`i‡K ¯^v¯’¨ †mev`vb e„w×i D‡Ïk¨ KZUzKz AwR©Z n‡q‡Q
4.
KwgDwbwU wK¬wbKm& : wKfv‡e Gi †mev Av‡iv Kvh©Ki Kiv hvq
5.
fwel¨‡Z ¯^v¯’¨‡mev cÖvwß e„w×i Rb¨ cÖ‡qvRbxq c`‡¶cmg~n
Dc‡Rjv wbe©vnx Kg©KZ©vi ¯^v¶i :
ZvwiL:
`jxq Av‡jvPbv (FGD) mgš^qKvixi bvg
¯^v¶i :
FGD Abyôv‡bi ZvwiL:
Z`viK Kvixi bvg :
¯^v¶i :
ZvwiL:
FORM-­‐D END LINE EVALUATION OF HEALTH, NUTRITION AND POPULATION SECTOR PROGRAMME (HNPSP-­‐ 2003-­‐2011) civgk©g~jK Av‡jvPbvi Rb¨ wb‡©`kvejx /MvBW-jvBb
h¡Ù¹h¡ue f¢lh£rZ J j§mÉ¡ue ¢hi¡N
j§mÉ¡ue ®pƒl
‡÷K‡nvìvi‡`i ( wefvM, †Rjv, Dc‡Rjv GKs KwgDwbwU chv©q- GBP Gb wc Gm wc Kvh©µg Gi
ev¯ZevqbKvix e¨e¯’vcK:- cwiPvjK, Dc-cwiPvjK, wmwfj mv‡©Rb, Dc‡Rjv ¯^v¯’¨ Kg©KZ©v/
†gwW‡Kj Awdmvi Ges gvVK©gx) ms‡M civgk©g~jK Av‡jvPbvi Rb¨ wb‡©`kvejx /MvBW-jvBb :
wmwiqvj bs
:-
GBP Gb wc Gm wc Gi Kg©m~Pxi ev¯Zevqb Ae¯’v Ges cÖvmw½K
KviYm~gn :
ü RvZxq chv©q: Kvh©µg ev¯ZevqbKvix, e¨e¯’vcK Ges †mevcÖ`vbKvix
( gnv-cwiPvjK Ges jvBb-wW‡iKUim& / †cÖvMÖvg g¨v‡bRvi)
ü gvV chv©q : cwiPvjK, Dc-cwiPvjK, wmwfj mv‡©Rb, Dc-cwiPvjK-Gd
wc, BD GBP GdwcI, GgI GgwmGBP, BDGdwcI, c¨viv‡gwWKm&,
¯^v¯’¨ mnKvix Ges Gd Wwe-D G)
ü GB mv¶vrKvi¸‡jv AskMÖnYg~jK c×wZ‡Z cwiPvwjZ n‡e | GBP Gb
wc Gm wc Gi g~j †KŠkj I ev¯Zevqb m¤ú‡K© DËi`vZvi gZvgZ hvPvB
Kiv GB mv¶vrKv†ii cÖavb j¶¨ |
cwiwPwZ :
DËi`vZvi bvg
(RvZxq / gvV ch©vq) :
wefvM/cÖwZôvb/†mevcÖ`vb †K›`ª :
BDwbqb/ e-K
‡Rjv:
c`ex :
Dc‡Rjv/wc Gm
wefvM :
1.
MvBW jvBb :
KZ w`b Ges †Kvb c`gh©v`v wb‡q GBP Gb wc Gm wc Kvl©µ‡gi ms‡M m¤ú„³ wQ‡jb?
2.
mgq Kvj ( eQ‡i) :
c`gh©v`v Ges ¯’vb :
¯^v¯’¨ Ges cwievi cwiKíbvi mgš^‡qi wel‡q D™¢~Z eZ©gvb cwiw¯’wZ m¤ú‡K© Avcbvi
gZvgZ:
3.
Avcbvi Kg© GjvKvq cÖ‡qvRbxq Rbej Ges `¶Zv Dbœqb m¤ú‡©K gZvgZ:
4.
Avcbvi ¯^v¯’¨ †mevcÖ`vb †K†›`ª hš¿cvwZ, Ilya mvgMÖx, †ivM wbY©‡q WvqvMbw÷K
myweavw` Ges G¸‡jvi m‡ev©”P e¨envi m¤ú‡©K Avcbvi e³e¨
5.
cÖvß m¤ú‡`i m‡e©v”P e¨env‡ii Rb¨ cÖkvmwbK Ges Av©w_K ¶gZv cÖ`vb (Delegation of
financial and administrative power) :
6.
mieivn e¨e¯’v I msMÖn/µq e¨e¯’vcbv :
7.
bvwm©s †mev: eZ©gvb Ae¯’v& Ges mycvwikm~gn:
8.
KwgDwbwU wK¬wbKmn evox evox †h†q †mev cÖ`vb : wK fv‡e †mev DbœZ Kiv hvq :
9.
g¨v‡bR‡g›U KwgwU Ges ¯’vbxq RbM‡bi AskMÖn‡Yi gva¨‡g ¯^v¯’¨ †mev cvIqvi my‡hvM
e„w× Kiv m¤ú‡K© gZvgZ :
10
AvPiY cwieZ©b m¤úwK©Z †hvMv‡hvM (wewmwm / AvB B wm) Kvh©µg Gi gva¨‡g
†mev MÖnxZv‡`i g‡a¨ ‡mev cvIqvi Rb¨ Pvwn`v RvwM‡q †Zvjv :
11.
wewfbœ ¯^v¯’¨ †mev†K‡›`ªi g¨v‡bR‡g›U Bbdi‡gkb wm‡÷g ( Gg AvB Gm) Z_¨ e¨e¯’vcbv : eZ©gvb Ae¯’v I Dbœqb m¤ú‡K© gZvgZ
12.
Av‡iv DbœZ †mev cÖ`v‡bi Rb¨ KiYxq :
mv¶vrKvi MÖnYKvixi bvg
¯^v¶i :
ZvwiL:
mv¶vrKvi MÖn†Yi
Z`viK Kvixi bvg :
¯^v¶i :
ZvwiL:
References: i) Bangladesh Health Workforce Strategy, 2010 MOHFW. ii) Barkat, Abul et al. 2009. Human and Economic Impact of RH Supplies Shortage & Stock-­‐outs in Bangladesh. Report prepared for the Family Planning Association of Bangladesh (FPAB). Human Development Research Center(HDRC). Dhaka. iii) BBS. 2007. Child and Mother Nutrition Survey of Bangladesh 2005. Bangladesh Bureau of Statistics and UNICEF. Dhaka. iv) BBS. 2011a. Preliminary Report On Household Income & Expenditure Survey 2010 v) BBS. 2011b. Population and Housing Census 2011:Preliminary Results. vi) Begum, Sharifa and S.M. Zulfiqar Ali 2008. The Stakeholders’ Consultation Report for The Mid Term Review (MTR) 2008 of Bangladesh Health, Nutrition and Population Sector Program (HNPSP) BIDS. Dhaka vii) Begum, Sharifa and S.M. Zulfiqar Ali. 2007. The Stakeholders Consultation Report: Key Findings and Areas of Improvements for Annual Program Review 2007 for HNPSP. BIDS Dhaka. viii) Chowdhury, Omar H and S. R. Osmani. 2010. Towards Achieving Rights To Health:The Case of Bangladesh. The Bangladesh Development Studies 33(1-­‐2):205-­‐237 ix) DELIVER 2007. Bangladesh:Final Country Report. Arlington, Va: DELIVER for United States Agency for International Development. x) DGFP. 2010. Annual Report 2010. Directorate General of Family Planning. MOHFW. Dhaka. xi) DGHS. 2007. National HIV Serological Surveillance 2006 Bangladesh. 7th Round Technical Report. National Aids/STD Programme(NASP). MOHFW. Dhaka xii) DGHS. 2011. Health Bulletin 2010. Management Information System (MIS), DGHS, MOHFW xiii) Dickens, Todd. 2008. Bangladesh:Government of Bangladesh Contraceptive Bottleneck Study xiv) Evaluation Wing, Implementation Monitoring & Evaluation Division, Ministry of Planning xv) FMRP. 2005. Primary Health and Family Planning In Bangladesh:Assesssing Service Delivery. Final Report 2005. Social Sector Performance Surveys. Financial Management Reform Programme(FMRP). Dhaka xvi) -­‐Full Report. Arlington, Va:USAID/DELIVER PROJECT. Task Order 1. xvii) Health and Population Sector Programme Evaluation. xviii) 'Health transcends poverty-­‐ the Bangladesh Experience'-­‐by Tracey P. Koehlmoos, Ziaul Islam etc. of ICDDRB 2011, a part of 5-­‐countries study conducted by the London School of Hygiene and Tropical Medicine. xix) ICDDR,B , IPHN and NIPORT, 2005. National Nutrition Programme Baseline Survey 2004 Report Special Publication No. 124. ICDDR,B:Centre for Health and Population Research. Dhaka xx) Improving Returns from Capacity-­‐Building Investment, Bangladesh, Oxford Policy Management, 2009. xxi) MOF. 2011. Bangladesh Orthonaitik Samikkha (Bangladesh Economic Survey) 2011(in Bangla). Finance Division. Ministry of Finance. Dhaka xxii) MOHFW 2011a. Strategic Plan for HPNSDP 2011-­‐16. xxiii)
MOHFW. 2008b. HNPSP Mid Term Review (MTR) 2008 Final Report xxiv)
MOHFW. 2009a . HNPSP Annual Programme Review(APR) 2009 xxv) MOHFW. 2011b Public Expenditure and Financial Accountability (PEFA) Assessment. xxvi)
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