Programme description

Title: Health, Nutrition and Population Sector Programme
Commissioned by: German Federal Ministry for Economic Cooperation and Development (BMZ)
Country: Bangladesh
Lead executing agency: Ministry of Health and Family Welfare (MHFW)
Overall term: 2005 to 2011

Context

In 1998 Bangladesh ratified the International Covenant on Economic, Social, and Cultural Rights, including Article 12, which states that 'everyone has the right to the enjoyment of the highest attainable standard of physical and mental health.' The Government of Bangladesh has taken that commitment seriously and is now making clear progress toward achieving the health-related Millennium Development Goals (MDGs) at the aggregate level.

Though the infant and maternal mortality ratios have declined, and life expectancy rose from 54.8 in 1990 to 65.4 years in 2003, much remains to be done. Child malnutrition is pervasive in Bangladesh: nearly half of all children below the age of five are either underweight or have stunted growth. Despite the highly successful reduction of the total fertility rate, from 6.3 in 1975 to 2.7 in 2007, population growth remains an area of concern, as Bangladesh is one of the world's most densely populated countries.

Public spending on health in Bangladesh is among the lowest in the world (3.1% of GDP in 2002). Total annual per capita spending on health for the period 1998–2003 averages USD 12. Just four dollars of that comes from the public sector, up to a third of this being provided by development partners. Private, out-of-pocket outlays for drugs constitute up to 65% of total health expenditure. Public health-care providers are insufficiently equipped and lack medicines; high staff absenteeism and the need to pay unofficial fees are barriers, particularly for the poor, preventing adequate use of public healthcare services.

There is a great disparity between rich and poor in terms of their access to basic healthcare and the quality of services. There are also large geographic disparities. While urban and peri-urban families can choose among a variety of government, non-government, and private healthcare facilities, rural families often only have access to government facilities, although these are often far away and poorly resourced. Thus, the rural poor usually depend on local pharmacists or practitioners for their healthcare needs – both of whom may have little or no formal training.

The Health, Nutrition, and Population Sector Programme (HNPSP) was set up by the Government of Bangladesh to enhance its leadership in the health policy field and to provide its citizens with the best possible healthcare, given the country’s resources. The programme aims to expand people's access to health, nutrition, and family planning services, while also improving the quality of those services and reducing the inequities faced by children, women, and the poor. It will achieve these objectives by:

• allocating more financial resources to the poorest districts in the country
• promoting demand-side financing models, including initiatives to develop social insurance systems
• bringing in a wide range of health-care providers, so that the poor can purchase their healthcare from those providers who serve them best.

The HNPSP is a huge programme, and is also the largest example of a sector-wide approach in the world. The total anticipated cost of the implementation period 2005 to 2010 is USD 4.3 billion, of which USD 1.7 billion is expected to be contributed by the development partners. However, without effective capacities, including strong institutions, systems and local expertise, countries cannot manage their own development processes. This fact is clearly underlined in the 2008 Accra Agenda for Action, which calls for faster implementation of the Paris Declaration on Aid Effectiveness. Capacity development activities provided through technical cooperation are therefore essential.

Objective

The institutional capacity of the ministry to monitor, steer, and implement the HNPSP has improved due to support given to key ministry units.

Approach

The Government of Bangladesh asked GTZ (now GIZ) for assistance in improving the underdeveloped Monitoring and Evaluation (M&E) Unit of the Ministry of Health and Family Welfare (MHFW). GIZ is therefore helping the unit to take over monitoring of the HNPSP, and develop a sustainable and accurate information framework that supports this monitoring. The main activities of the M&E Unit are to review the M&E framework and indicators, making changes where necessary to the list of indicators and the methods used to obtain them. It advises the ministry on additions to existing instruments, and commissions new studies to fill gaps in the monitoring framework; it is developing and maintaining a database of monitoring time series indicators; and it carries out additional M&E training. One of the unit's basic functions is to report on progress made in reaching the HNPSP targets.

To complement this indispensable central monitoring, GIZ has also supported a less conventional, grassroots form of monitoring that gives citizens a direct opportunity to communicate with the policy makers. This is an exhibition of cartoons and paintings on the topic Right to Health, which were collected through a nationwide competition and displayed in conjunction with photos and life stories gathered by the 2007 Reality Check. In organising this exhibition, GIZ cooperated with MHFW and the Swedish International Development Agency (SIDA).

The programme also works with the Health Economics Unit (HEU) of MHFW to promote cost-effective healthcare service delivery and support it in formulating policies on health economics, healthcare financing, poverty alleviation and gender mainstreaming. The HEU is the only unit of the ministry with a mandate to provide policy advice based on sound research findings. The HEU performs a sector monitoring role and is developing this in parallel to the M&E Unit, which is responsible for programme monitoring.

Quality management is another important issue for the ministry. In response, GIZ has brought together experts from the University of Heidelberg in Germany, and BRAC University to jointly develop a course on quality management for students from public and private healthcare organisations.

Finally, GIZ has been working with the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), as well as MHFW and Dhaka City Corporation, to develop mobile and stationary healthcare services for Dhaka’s street dwellers. If the pilot project proves successful, it will be expanded and incorporated into the HNPSP as a way of covering this vulnerable population group, which other government health services do not reached.

Results achieved so far

Following the establishment of the National Data of the Health System for Equitable Health Care, spending on health is now better planned and aligned with the population’s needs. The system provides ministry officials with information about government health expenditure, development partners' contributions and the people's out-of-pocket payments. This information is also being used for the ongoing planning of the next health programme.

The data management information system has been established, which enables health officials to use relevant evidence when making important decisions and addressing key issues. The general performance of the health sector is improving as a result.

The health monitoring framework has been finalised and put in place. This provides information, such as key indicators, that is important for the current planning of the next health programme.

Ophthalmic hospital at Alampur Union Parishad in the Kuhlna District, Bangladesh