Health, Nutrition & 
Population Programme Proposal (HNPPP)

July 2003 - June 2010

(Preliminary document) 

January 2005

Implementation Agency

Ministry of Health & Family Welfare and its attached departments such as Directorate General of Health Services, Directorate General of Family Planning, National Institute of Population Research & Training, Directorate of Nursing, Directorate of Drug Administration, National Nutrition Programme (NNP), Construction, Management & Maintenance Unit and Public Works Department will implement the Programme.

Estimated cost of the program

Financing Pattern

Taka in million

GOB (Dev.)

41544

PA

112765

Sub Total (Dev. Budget)

154309

GOB (Rev.)

161377

Total

315686

Background 

Macroeconomic and poverty trends

With a population of 135.2 million and estimated per capita GDP at $421 in FY 2003/04 (Bangladesh Economic Review 2004), Bangladesh remains one of the poorest countries in the world and still faces severe deficiencies in the quality of its health, population and nutrition services. While Bangladesh has made progress in reducing poverty over the last 20 years, 49.8 percent of people were poor in FY 2000 (HIES 2000), equivalent to an estimated 56 million people. Under-nutrition remains prevalent and large numbers of people lack basic services. If progress were to continue at the rate achieved in the 1990s, then the Millennium Development Goals (MDGs) would only be partially met by 2015, at best: extreme poverty would be reduced as targeted, but 16 million would still live on less than $1/day, and 40 million would be below the upper poverty line. Universal primary education would be achieved by 2015, but with concern about its quality. Targets for child mortality and maternal mortality reduction would be met. However, environmental sustainability targets would not be reached. The gender equality goal has nearly been reached in primary education but women would still fare worse than would men in higher secondary education, literacy and labour force participation. It is now Government intention to recruit female teachers in preference to men, so that they make up 60 percent of the teaching workforce.

Stable macroeconomic conditions with low rates of inflation have created the basis for consistent economic growth rates in Bangladesh over the last decade. The incidence of income-poverty declined by a percentage point a year although inequality increased somewhat.  Progress has also been made in improving Bangladesh’s Human Development Index. Between 1990 and 2002, the index increased by 23 percent, with marked improvements in life expectancy, adult literacy, gross primary school enrolment ratio, and declines in infant mortality rates. These improvements have placed Bangladesh among the medium-ranking HDI countries (Human Development Report 2004). These results have been achieved by a stable macroeconomic environment leading to sustained economic growth and by the efforts of government and non-government organisations to expand the coverage of essential services to the disadvantaged sections of society.

HNP sector financing and expenditure structure

In 2001/02, total (public and private) spending on HNP services in Bangladesh (THE),[1] accounted for 3.2 percent of GDP equivalent to US$12 per capita per annum. This represents a modest increase compared with 1996/97 estimates[2] and is about what one would expect for a country of Bangladesh’s income per capita (BNHA-2).

However, the public sector financed only one third (34.5 percent) of THE in 2000/01, unchanged from 1996/97, while two thirds of spending on healthcare was financed privately, most of it out-of-pocket spending by households (63.8 percent). GOB financing actually declined from 24 percent of THE in 1996/97 to 18.5 percent in 2001/02.  At the same time, donor financing increased from 10.5 percent in 1996/97 to 13.3 percent in 2001/02 (BNHA-2).

Expenditures on public-sector provision of HNP services declined from 32.6 percent of THE in 1996/97 to only 26.2 percent in 2001/02, while the share of the MoH&FW as such declined in parallel from 27.6 percent to only 23.3 percent. The share of MoH&FW expenditures, as a percentage of the GoB’s combined revenue and development budget expenditures remains low and has shown a declining trend since 1996/97.  Total MoH&FW spending (revenue and development) in FY 1999/00 was 19,690 million Taka, equivalent to only 5.3 percent of total GoB spending and to only 1.1 percent of GDP (World Bank and ADB 2003).

Health outcome status & trends

Despite recently stagnant or declining public spending on healthcare, there has been a remarkable improvement in health indicators in Bangladesh over the last 30 years.  In the mid-1970s, the infant mortality rate (IMR) was 153/1000 live births.  By 1999-2003, it had declined to 65/1000. Under-fives mortality (U5MR) had declined similarly to 88/1000. Population growth rates have also declined. Immunisation coverage has remained fairly high and the country will attain polio-free status very soon. However, the aggregate data disguise considerable variations.  Socio-economic indicators of health status in Bangladesh indicate significant areas of inequality that must be addressed if health-related MDG targets are to be met.  For example, mortality among children in the poorest households is almost twice as high as for children from the wealthiest ones.  Leading causes of death among children are still diarrhoea and ARI, followed by perinatal causes.  Further reductions in IMR and, by implication, a contribution to the reduction in U5MR, will now largely come from reductions in neonatal mortality rates, adding importance to the emphasis given in this Plan to improving antenatal and obstetric and neonatal care. Injury, severe malnutrition and neonatal tetanus each contribute 7-8 percent of the total child mortality. This represents the deaths of 350,000 children each year.

Maternal mortality (Maternal Mortality Ratio, MMR) had declined by an estimated 36 percent between 1986 and 2000, but remains relatively high at 320/100,000 (BMMS 2001). This represents the annual loss of 12,000 women from maternity-related causes. 

Future health risks

New challenges to good health are emerging, in particular HIV/AIDS, tuberculosis, malaria, arsenicosis, accidents and injuries and non-communicable diseases.  These impose catastrophic treatment costs and heavy income losses on the poor, which may precipitate irreversible poverty and are difficult to insure privately.

As the epidemiological transition accelerates, non-communicable diseases will account for a larger and larger share of the total disease burden.  It is estimated that by 2010, non-communicable diseases will increase their share of mortality to 59 percent, as compared to 40 percent in 1990 (Streatfield et al. 2001).

The demographic transition will also bring new sources of vulnerability. The number of elderly women in Bangladesh increased from 0.83 million in 1951 to 4.06 million in 2001 (Statistical Profile of Women in Bangladesh 2002).  Widowhood and poverty are prevalent among this group.  Many of these women will be widows or generally lacking economic security.

Nutrition status & trends

Bangladesh continues to suffer high levels of malnutrition in the form of both protein-energy malnutrition and micronutrient deficiencies. Forty-eight percent of children under five (age 6 to 59 months) are underweight, 43 percent are stunted in height and 13 percent are wasted (Bangladesh Demographic and Health Survey 2004).  These rates are unacceptably high, even if considered in the context of Bangladesh’s still low per capita income. Child malnutrition, especially at the youngest ages, impedes child development, is associated with increased rates and increased severity of infectious diseases and contributes to over one half of child deaths. Among rural adult non-pregnant mothers, 45 percent have a Body Mass Index (BMI) of less than 18.5, which is indicative of ‘critical’ food insecurity (HKI 2001; BDHS 1999-2000).  Poor maternal nutrition affects, in turn, the high incidence of low birth weight in Bangladesh, estimated as 40 percent, which affects newborn health and survival.

Dietary intakes of both children and adults are severely deficient in multiple micronutrients, particularly vitamin A, iron, iodine and zinc.  Bangladesh has made significant progress in reducing vitamin-A deficiency among pre-school children over the past 15 years. However, the consumption of vitamin A rich foods is still low, suggesting that the underlying causes of Vitamin A deficiency require further attention and support. Iron deficiency anaemia, which is also highly prevalent, affects one-third of adolescent girls and non-pregnant women and is even higher in pregnant women (51 percent; HKI/IPHN 2002).  Fully half of children age 6 to 59 months are anaemic.

The immediate causes of malnutrition in women and children are inadequate dietary intake and high infectious disease burden, due to household food insecurity and inappropriate household practices in feeding, personal hygiene and caring for adolescent girls, pregnant women, mothers and their young children, exacerbated by a lack of knowledge and awareness about a healthy way of life.

Population status & trends

After declining rapidly in the 1980s, the Total Fertility Rate (TFR) seems to have remained unchanged for most of the 1990s at 3.3 children (BDHS 1999/2000), although different surveys gave different results.  This went together with steady gains in contraceptive prevalence among currently married reproductive age women, which had reached 54 percent in1999/2000, mainly by using temporary methods.  By early 2004, contraceptive prevalence had further increased to 58 percent, while TFR for the period 2001-2003 had declined to 3.0. Replacement level fertility had been a GOB target for 2005, but the fertility plateau of the last decade has meant delay to 2010 at the earliest.

It is now thought that the paradox of rising family planning use but flat fertility had been partly a result of the ‘tempo’ effect of falling fertility, triggered by rising age at childbearing during the 1980s.  This resulted from the widespread adoption of family planning to delay or space second and higher order births.  As fertility was falling, first order births, which were not affected by the tempo effect, were becoming a greater proportion of all births (previously one in seven, now one in three).  Thus the tempo effect was dampened then disappeared during the 1990s.

Further efforts are needed to shift family planning use patterns towards more effective, longer lasting and lower-cost clinical and permanent methods covering low performing and disadvantaged areas with added emphasis.  But the major impact on fertility will be achieved by raising the age of marriage, which will push up age at first birth, and again trigger a tempo effect, to bring fertility down.  Bangladesh has great scope to reduce early marriage, where at present 50 percent of teenage girls (15-19) are married, compared to only 33 percent in India, 25 percent in Pakistan, and far fewer in other comparable countries.

Goal, Purpose and Priority Objectives of HNPSP

Within the overall development policy framework of the Government of Bangladesh, the goal of the health, nutrition and population (HNP) sector is 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 with the ultimate aim of their economic emancipation and physical, social, mental and spiritual well being.

The main purpose of HNP sector programme (2003-2010) will be to increase availability and utilisation of user-centred, effective, efficient, equitable, affordable and accessible quality services be it the Essential Services Package, improved hospital services, nutritional services or other selected services.

Within the context of the I-PRSP the HNP sector will emphasise on reducing severe malnutrition, high mortality, and fertility, promoting healthy life styles, and reducing environmental, economic, social and behavioural risk factors and causes to human health with a sharp focus on improving the health of the poor and other vulnerable.  Priority objectives, by which the success of HNPSP should be measured, will be (i) reducing MMR, (ii) reducing TFR, (iii) reducing malnutrition, (iv) reducing infant and under-five mortality, and (v) reducing the burden of HIV/AIDS, TB, malaria and other common communicable diseases.

HNP Services : Organisation of public-sector HNP services delivery at different levels

The GoB has overall constitutional responsibility for HNP services and through the MoH&FW (and some other ministries, for example Defence and Railways) is an important provider of health services in Bangladesh.

The MoH&FW health system is structured as a hierarchical pyramid with five layers: three at the primary, one at the secondary and one at the tertiary level.  At the base are ward-level DGHS Health Assistants and DFP Family Welfare Assistants, serving a population of about 6,000 to 7,000 people, performing home visits and working from a Community Clinic (where operational), tasked with family planning, maternal and child health, including immunisations, communicable disease control, symptomatic curative care for common complaints, and upward referrals.  The next level is the Union Health and Family Welfare Centre (HFWC), staffed by three paramedicals, Sub-Assistant Community Medical Officer, Family Welfare Visitor, and Pharmacist, providing family planning, maternal and child health services and some curative care.

On the family planning side, 250 posts of union-level Medical Officer (Family Welfare) have been created to provide care for MCH referral cases and to supervise and perform clinical contraceptive services.  On the health side, a Medical Officer is posted to each of 1275-upgraded HFWCs under the Health Directorate (formerly called Union Sub-centres).

Text Box: The Health and Family Planning Management Structure in Bangladesh The Secretariat. The Honourable Minister is the Chief Executive of the Ministry of Health and Family Welfare. The Secretary, who heads the Secretariat, is also the Principal Accounting Officer of the Ministry. The Secretariat is staffed by civil servants from within the Civil Service system. Directorates: The Directorate General of Health Services: Supervises all health implementation activities The Directorate General of Family Planning: Supervises, besides family planning, a significant part of maternal and child health services. The Directorate of Drug Administration: Supervises national drug regulation and manufacture The Directorate of Nursing Services: This directorate oversees nurses as a profession The Directorates are (almost entirely) staffed by professionals and technicians. The Directorates are based in Dhaka and are housed separately from the Secretariat and from each other. Six Regions (Divisions): with Divisional Directors from both Health and Family Planning Directorates but without direct line-management role in service provision. Responsible for some support and HRD functions. 64 Districts: Consist of separate management structures for Health and FP. District health management (Civil Surgeon) reports to the Health Directorate and is responsible for general health services and the district referral hospital. Family planning management (Deputy Director FP) reports to FP Directorate and is responsible for FP and related MCH and reproductive health services. 397 Rural Upazilas: Upazila Health Complexes (with 31/50 hospital beds) serve as the first-level referral level facility and provide outpatient general health and MCH services plus inpatient care, with six beds reserved for family planning and MCH. While usually under the same roof, Upazila Health and Family Planning staff work under separate lines of command. Unions and Wards: Union-level Health and Family Welfare Centres (HFWCs) are established based on administrative sub-divisions, regardless of population sizes, while Community Clinics are intended to serve a population of about 6,000. Services provided at this level are mainly EPI, MCH & FP and limited curative care. Some HFWCs are staffed and equipped for normal deliveries and obstetric first aid and offer adolescent health services.
At the next level is the Upazila Health Complex, which is the first-level referral centre for the population in the upazila and the administrative centre for upazila health and family planning services. Staffing norms foresee, on the health side, nine doctors, two Medical Assistants, a pharmacist, radiographer and an EPI technician and staff nurses, joined on the family planning side by an Upazila Family Planning Officer, Medical Officer (MO-MCH), Assistant Family Planning Officer, Senior Family Welfare Visitor and two Family Welfare Visitors and other support staff.  The UHC is responsible for inpatient and outpatient care, family planning and MCH services, including clinical contraception, and for disease control.  On the health side, the fourth layer is the district hospital, which is a 50 to 250-bed facility.  Heads of health and family planning services at upazila as well as district level both have technical as well as administrative responsibilities and combine responsibilities for clinical care with community and public health responsibilities. In 55 of 64 districts, Maternal and Child Welfare Centres (MCWCs) of the Family Planning Directorate are staffed and equipped to provide Comprehensive Emergency Obstetric Care and other clinical reproductive health services. Another 9 MCWCs are almost ready to provide EmOC and other services. The fifth tier of the public-sector health system is comprised of the medical college and other specialised hospitals, providing tertiary-level referral care.

Nutrition services

The Bangladesh Integrated Nutrition Project (BINP) was the first comprehensive nutrition intervention in Bangladesh aimed at achieving measurable reductions of malnutrition in young children and reduced incidence of low birth weight.  The original timeframe and scope was for implementation in 40 rural upazilas from July 1995 to June 2000.  Subsequently, the project was revised to cover a total of 60 upazilas and extended up to June 2002.  From July 2002, the 61[3] BINP project upazilas were continued under the National Nutrition Project (NNP), which was initially operated as a separate development project, funded under a separate World Bank credit, but has been integrated into HNPSP from 1 July 2004.  The National Nutrition Project was expanded to run in 105 upazilas and also to take up another 120 upazilas over a course of three years.  By 2010, nutritional intervention through NNP needs to be expanded in all upazilas of the country.

NNP community nutrition interventions are designed to reduce the prevalence of moderate and severe underweight in young children, increase pregnancy weight gains, reduce the incidence of low birthweight and reduce the prevalence of iron-deficiency anaemia among adolescent girls and pregnant women. Related interventions include growth monitoring and promotion of young children from birth until two years of age, weight gain monitoring of pregnant women, targeted food supplementation of growth faltering and severely malnourished children and undernourished pregnant women and breastfeeding mothers, and conduct of adolescent girl nutrition services.  Iron-folate is provided during pregnancy and vitamin-A post-partum.  Community nutrition activities are organised around community-donated Community Nutrition Centres, established for a population of 1,250 to 1,500, and run by part-time female contract workers, called Community Nutrition Promoters (CNPs). CNPs are supervised by Community Nutrition Organisers.  In addition, Village, Union and Upazila Nutrition Management Committees are established for community mobilisation and intersectoral co-ordination.  In view of the intensive, but not necessarily permanent effort required for community nutrition interventions, their implementation is managed through contracting with NGOs.

Under financing from NNP, the Institute of Public Health Nutrition (IPHN), under the Directorate of Health Services, has been providing micronutrient supplementation with Vitamin-A throughout the country. Other national-level NNP activities consist of communication support (implemented by UNICEF), breastfeeding promotion and support, (implemented by the Bangladesh Breastfeeding Foundation) and iodine fortification of salt.  NNP, like BINP, includes in addition household food security interventions to be implemented through the Ministries of Agriculture and Fisheries and Livestock and through the Vulnerable Group Development (VGD) Program of the Ministry of Women and Children’s Affairs.

Improvement of nutritional status of the population is a priority activity of the Government, which is actively considering setting up a separate Directorate for nutrition.

NGO HNP services

Non-governmental organisations (NGOs) are a significant and growing source of HNP services in both rural and urban Bangladesh. Their services have mainly been in the areas of family planning and MCH.  More recently, NGOs have extended their range of services and are now the major providers of urban primary care. NGOs have been commissioned by the MoH&FW to provide the community nutrition services under BINP and NNP.  Besides, NGOs are also providing services for HIV/AIDS prevention and for the national tuberculosis and leprosy control programmes. BNHA-2 data suggest that total volume of expenditures on HNP services by NGO facilities and other non-profit institutions increased more than threefold in real terms over the five years since 1996/97, accounting for over nine percent of total sectoral expenditures (THE) in 2001/02.  According to BNHA-2, less than two percent of national expenditures for NGO facilities were incurred for in-patient services.  This reflects the NGO service focus on primary health care, family planning and MCH. As such, female patients use 1.6 times more NGO resources than do males.

NGOs are important sources of innovation in the sector, including differential pricing, targeting of services to the poor and very poor, cost analyses for efficiency improvements, and strategic planning for long-term sustainability. While user satisfaction with NGO services, as measured by multiple indicators, is generally high, actual utilisation and hence, population-level coverage, is variable and can be quite low, depending, e.g., on the vicinity of government facilities. NGO policies of charging for services and for medicines, though essential from a cost-recovery and sustainability perspective, have, moreover, been shown to deter utilisation by the poor and very poor, especially among women without access to cash of their own. 

Private-sector for-profit healthcare providers

This is a rapidly growing sector, which already provides most health services (according to BNHA-2, some 55 percent by value).  It includes

The commercial sector also plays an important role in the supply of health related products, including social marketing of subsidised contraceptive supplies, ORS and, to a small extent, bed nets.  About 40 percent of non-clinical contraceptives are distributed through pharmacies and drug sellers.

Some kinds of practice, such as ayurveda, appear to be on the decline, but others, such as semi-qualified Rural Medical Practitioners (RMPs) flourish, particularly in rural areas.  While reliable figures on the numbers of these different types of informal practitioners are lacking, the Bangladesh Health Labour Market Study has estimated the total number of private practitioners in Bangladesh to be around 0.45 million, or 3.6 per 1000 population.  Of these, traditional and unqualified providers outnumber formally qualified ones by twelve to one (Peters and Kayne 2003).

The current regulatory framework for private-sector health care provision is fragmented and outdated, poorly implemented and poorly enforced and is viewed as inadequate for ensuring minimum standards of service quality.  Establishment of a suitable regulatory framework, with adequate mechanisms for implementation and enforcement is therefore of high priority.  This should include re-directing regulation to the assurance of the quality of services and to ensure fair competition.

The pharmaceutical sector

Drug regulations in Bangladesh are supervised and implemented by the Directorate of Drug Administration (DDA) under the MoH&FW. This Directorate also regulates all activities related to import and procurement of raw and packing materials and to production, import, export, sale and pricing of finished drugs, including those of ayurvedic, unani and homeopathic systems.  DDA regulatory activities include the preparation of a Bangladesh National Formulary, which was brought out in July 2004 in its second, revised edition.

In 1982, Bangladesh had a pioneering role among developing countries in formulating and implementing a National Drug Policy (National Drug Control Ordinance 1982), soon to be updated and revised as the National Drug Policy 2004.  The National Drug Policy has lent support to the development of an efficient and internationally competitive drug manufacturing industry in Bangladesh, which now meets 90 percent of domestic drug needs at reasonable prices. Drug sales are effected through 1,353 drug wholesalers and 33,975 retail trading outlets. Quality control is effected by the Drug Administration through market collection of drug samples and through testing at two drug-testing laboratories. Nevertheless, problems still remain with regard to the importation and/or manufacture of substandard, counterfeit, and ineffective drugs. In addition, inappropriate drug information, irrational prescribing and inappropriate dispensing practices need to be addressed.

Recent trends in the HNP sector

Changes in patterns of financing & provision

During the five-year period up to 2001/02, THE has kept pace with GDP growth.  However, growth in the volume of HNP services and in the resources provided by the public sector has fallen consistently behind THE and GDP growth rates. According to the 1999-2001 Bangladesh National Health Accounts (BNHA-2), the share of services and resources provided by the public sector declined from 32.6 percent of THE in 1996/7 to 26.2 percent in 2001/02.  Provision by the MoH&FW as such similarly declined from 27.6 percent of THE to 24.3 percent in 2001/02.  At the same time, provision by NGOs and other private-sector not-for-profit organisations has more than tripled from 2.9 to 9.2 percent.  The share of private-sector for-profit provision of health care and commodities also declined from 62 percent of THE in 1996/97, to 55 percent in 2001/02.  This included in both years a share of 46 percent of THE for drug purchases.  It is noteworthy that the value of purchases from drug retail outlets (Taka 39,625 million in 2001/02), much of it poorly regulated and unsupported by provider and consumer education on ‘rational use of drugs,’ was nearly twice the value of HNP services provided by the MoH&FW.

MoH&FW spending under HPSP has emphasised spending on the Essential Services Package delivered at the upazila level and below. During HPSP, ESP delivery (including overhead) accounted for an estimated 70 percent of MoH&FW expenditures from both revenue and development budgets (Streatfield et al. 2003). However, this includes inpatient care in Upazila Health Complexes and excludes primary care delivered at District and Medical College Hospitals so that the share of public spending on promotional, preventive and primary care is not known precisely. In 2000/01, ESP expenditures (revenue and development combined), 41 percent went to reproductive health, including family planning, 40 percent to child health, 14 percent to limited curative care, and only 4 and 1 percent, respectively, to communicable disease control and behaviour change communication (HEU and FMU 2002).

NGOs are playing an increasing role in health service provision (BNHA-2), almost all at the primary level.  Their role is particularly important in urban areas where population growth has not been matched by a growth in services provided by the central government and local bodies. Both the Government and bilateral aid agencies have entered into commissioning arrangements with non-government providers to offer ESP services at heavily subsidised prices intended to be affordable by the poor.  This has financed a rapid expansion in NGO primary health care provision.  Although initially this expansion was financed by international aid, in the period covered by BNHA-2, donor funding of NGO health service delivery declined from 78 percent in 1999/2000 to 67 percent in 2001/02 because of a steep increase in GOB funding.

Private expenditure on healthcare accounts for 64 percent of total health expenditures. The purchase of pharmaceuticals remains the major item of household out-of-pocket health expenditure, reflecting high levels of self-medication. Over-the-counter purchases of drugs account for 70 percent of household expenditure on healthcare, or 46 percent of total HNP sector expenditure, making this by far the single largest expenditure item within the sector. This high expenditure share remained stable over the BNHA-2 period.

The for-profit modern clinical health care sector is mostly found in urban areas and particularly the larger cities. Recently, for-profit clinical health care services have been extended to some flourishing upazilas as well. BNHA-2 identified 682 clinics and hospitals registered with the MoH&FW, indicating an annual growth rate in facility numbers of 15 percent.  Total bed capacity of this sector is about 27 percent of the national total. Between 1999/2000 and 2001/02 the industry has had an estimated income of about Taka 2,100 million per year.

Healthcare consumers use private practitioners predominantly for first-line curative care, including among the poor.  According to BDHS data from the late 1990s, private providers saw 92 percent of all the children brought to a health facility with diarrhoea, and 89 percent of children with ARI (Gwatkin et al 2000 based on 1996/97 BDHS).  While the poor consult trained private providers, they are more likely to use unqualified and semi-qualified providers such as Rural Medical Practitioners.  In 2003, 43 percent of service users visited unqualified practitioners for curative care, while another 13 percent obtained treatment from drug shops (SDS 2003).

BNHA-2 estimated there were about 838 diagnostic centres registered with MoH&FW in 1999/2000, with increasing investments in state-of-the-art diagnostic tests and services.  Private diagnostic centres now account for the largest share of this sector, but the rationality and quality of their services are frequently questioned. Regulatory mechanisms are required to ensure the quality of diagnostic services.

With the exception of tea plantations, export garment manufacturers and some large manufacturing enterprises, very few employers offer health care or health insurance to their employers.  Private health insurance is also extremely limited but is growing rapidly from being worth Taka 5.8 million in 1996/97 to Taka 19 million in 2001/02.  However, as yet, it accounts for only a tiny proportion of household expenditure on health care.

Urban primary health care services

The urban population of Bangladesh comprises the population living in six city corporations and 223 municipalities. Urban areas are growing rapidly. In 2001, 23 percent of the total population of Bangladesh was urban; by 2010, the urban population is expected to account for 33 percent of the total population. Urban household incomes, even among the very poor, are higher on average than among the very poor from rural Bangladesh (HIES 2000).  However, differences in household incomes are more striking in urban than in rural Bangladesh. Moreover, the concentration of urban household incomes in richer households is increasing (HIES 2000).  The urban poor are particularly affected by environmental hazards, such as crowding, inadequate sanitation and solid waste disposal, exposure to industrial wastes, accidents and violence.  As a result, rates of child mortality among urban slum dwellers have been consistently higher than among the rural population as a whole.

Compared to the rural population, urban households spend considerably more on consultations with qualified medical providers and at private clinics and hospitals and for diagnostic services (BNHA-2).  The currently inadequate regulatory framework for private for-profit provision of health care therefore, especially affects urban dwellers of all income groups.

The mandate for providing primary health care in urban areas is vested in MoLGRDC. As a result, primary health care services provided directly by the DGHS are confined to those supplied by Medical College Hospital Outpatient Departments, District Hospitals, government outpatient dispensaries and maternal and child health services provided by the Family Planning Directorate. Urban primary health care, apart from for-profit private providers, is for the main part, provided by NGOs contracted by the ADB-financed Urban Primary Health Care Project implemented by four City Corporations and by NGO consortia contracted by USAID and DfID. While generally rated high in terms of user satisfaction, the utilisation of NGO-provided urban primary health care remains well below existing capacities (Mitra and Associates and Measure 2003; Mitra and Associates in collaboration with Johns Hopkins University 2003).  The improved effectiveness of NGO-provided urban ESP services depends on improved targeting of subsided services to the very poor, the integration of maternal and child nutrition into urban primary health care, community ownership and intersectoral collaboration for improved environmental health, water and sanitation. Main policy challenges for urban health are the establishment of a strong co-ordination mechanism between MoH&FW and MoLGRDC, an enhanced stewardship role of the MoH&FW with regard to regulation of urban-for-profit health services, strengthened public-private partnerships, and GoB commitment to sustainable financing for subsidised health care for the urban poor.

The HNP sector performance

Reaching the poor

Poor people only benefit from publicly financed ESP services to the extent that they are prepared to use public-sector facilities. In this respect, facilities-based data on health care utilisation give a different picture from household survey findings on treatments obtained.  Studies on facilities utilisation show that the poorest quintile now accounts for 38 percent of total utilisation of public-sector ESP services at the upazila-level and below, while the poorest two quintiles account for 55 percent (HEU  2003). On the other hand, most (60 percent) treatments sought by all households are obtained from unqualified service providers, with very poor households more likely to turn to unqualified providers than less poor ones (65 percent, compared with 59 percent).  Only 17 percent of visits by members of very poor households were to government facilities (SDS 2003).  It thus remains the case that only a minority of the poor chooses to use subsidised government services and most have to pay to do so (either through user fees, informal charges or both).  The great majority consults private, mostly unqualified providers.

There are many reasons, both on the supply and demand sides, why the poor do not use public services more.  Poor service quality and unofficial charging are well known disincentives. The lack of medicines and bad staff attitudes, which are chief problems identified by government health and family planning services, are likely to affect the poor particularly. Under-paid clinicians have weak incentives to give priority attention to people who cannot pay.  Poor people find that without patronage relationships they cannot get good treatment or influence providers.  Women fare worst of all because they have less access to patrons.

Gender equity

There remain significant gender inequalities in health status, effective access and utilisation in Bangladesh.  These have multiple causes.  For instance, maternal malnutrition, which is a serious problem, is not only a consequence of income poverty but also of the poor social value placed on maternal health.  It is connected with women’s lack of bargaining power in the household, low expenditure on the health of women and girls and discriminatory practices in care and feeding of adolescent girls and reproductive-age women.  Most of the common health and nutritional problems of poor women and girls can be set within this wider context of dis-empowerment in which gender, health and poverty are linked. 

Women still face considerable constraints in accessing health care and many of these stem from within the household.  Restrictions on travel, especially unaccompanied, which the distance to facilities exacerbates, and the lack of money for treatment are the two most frequently cited problems. Women’s lack of personal income can be another contributing, while husbands may be reluctant to spend money on their wives’ medical needs.  Over 40 percent of currently married women remain dependent on other peoples’ decisions for their own health care (BDHS 1999-2000). This has serious implications for reducing maternal mortality.

For public-sector facilities, male utilisation rates for both in-patient and outpatient MoH&FW services far exceed those of females, except in the reproductive age group (15 to 49 years of age), where the female advantage is largely accounted for by their use of reproductive health services, particularly family planning (HEU  2003).  A similar pattern was found for national health expenditures overall (BNHA-2).  In both instances, males 65 years and over utilised MoH&FW services twice as often as did women in the same age group. Excluding reproductive health care, benefits from use of MoH&FW services accruing to males measured in financial terms were likewise higher than those accruing to females (HEU  2003).

Consumer satisfaction and technical quality of services

Monitoring of user satisfaction by Service Delivery Surveys (SDSs) conducted in the course of HPSP indicates marked differences with respect to user satisfaction with preventative and curative care provided by Government. Government services account for a very high proportion of preventative care obtained from any source. On the part of households, use of preventative services accounts for over half of all care sought from government services, with user satisfaction high (95 percent) and at par with satisfaction with preventative care obtained from private-sector providers, including NGOs (SDS 2003).  On the other hand, most care sought by households (85 percent) was for treatment purposes, and only a small proportion (13 percent) of treatments had been obtained from government sources.  Only more than half of users of government services for treatment purposes were overall satisfied with services received, while satisfaction with treatments from private-sector providers was much higher.  Satisfaction with treatments obtained from government sources were directly related to ‘actionable’ quality-of-care-related factors such as behaviour of the service providers, provision of full explanations of health problems and their remedies, the availability of prescribed medicines and waiting times (SDS 2003).

Provision of clinical contraceptives by the Directorate General of Family Planning is guided by defined standards, with adherence monitored by Quality Assurance Teams. Within the Health Services Directorate, useful work has likewise been done to formulate clinical protocols for hospital-level services, although implementation is not being monitored. However, survey findings indicate that important deficiencies exist in the technical quality of care delivered even by formally trained practitioners in both the public and private sector.  Quality deficiencies are likely to be even higher in the case of alternative private practitioners, the largest but least monitored group of providers in the country (World Bank 2003). 

Supply-side targeting & benefit incidence

During HPSP, prioritisation of resource allocations to the ESP was the principal policy instrument for targeting resources to the poor.  While the selection of services to be financed publicly can be an important component of pro-poor health policy, the role of the ESP in Bangladesh and, in particular, a reliance on the share of total expenditure represented by ESP services, needs at least to be complemented by other measures of success.  At present, large shares of ESP budgets are converted centrally into supplies and services in support of a bundle of preventive and limited curative activities. This makes it difficult to find to what extent and where these supplies and support services are expanding and accelerating service delivery on the ground.

Benefit incidence analysis estimates the extent to which public expenditures on health benefit poorer groups. Recent data on costs per visit in conjunction with utilisation according to economic quintiles suggest that a higher share of public expenditure on health and family welfare services accrue to the poorer strata of the population.  This holds true both at the upazila level and below, where the share of the poorest two quintiles is 55 percent, and district hospitals, where their share is 46 percent (HEU  2003).  It is, however, uncertain whether findings hold at the tertiary level (Medical College Hospitals and specialised hospitals), which were not included in the analysis.

On a geographical basis, pronounced variations in per capita public spending are likely to persist because resource allocation is based on facility size and uniform staffing norms, but not on population-based health needs.

Overall, supply-side subsidies have not proven to be a very effective way of directing scarce public resources to the health needs of the poor. The benefits ‘leak away’ to the rich when they demand treatments and when providers turn away poor people or fail to exempt them from informal charges. The underlying problem relates to the weak employment and management incentives under which government clinicians operate, issues that are addressed later in this Plan.

The direct and indirect costs of services, along with household preferences, education and socio-cultural norms act as demand-side barriers to services utilisation by vulnerable groups. For all of these reasons, there is increasing interest in demand-side subsidies for HNP services. A Demand Side Financing (DSF) pilot using health vouchers for poor pregnant women has already been launched in 21 upazilas with technical support from WHO.

improvements in financial management

Public expenditure management developments during the HPSP period have resulted in the creation of a new financial management unit within the MoH&FW Secretariat and the development of a financial management reforms strategy to underpin the wider reforms of the HPSP.  The Financial Management and Audit Unit (FMAU) was established in July 1997 as an extension of the existing Chief Accounts Officer’s office with technical support from DfID, to provide a more complete financial analysis of Ministry activities.

The Development Partner funding innovation during HPSP was a facility for DPs to contribute through a pooled fund (PF) which financed a proportion of the MoH&FW development budget.  This was intended to replace assistance tied to the implementation of individual projects.  As a result, the 128 projects that formerly comprised the MoH&FW development budget were condensed into 25 HPSP Annual Operational Plans, each of them consisting of several cost centres whose resources were managed by a single Line Director (LD). The PF has attracted over 54 percent of all external aid committed to HPSP.  Moreover, most of the rest of DP assistance outside the PF (Direct Project Aid, DPA) was reflected in one or other of the Annual Operational Plans.  The intention was that LDs should be able to plan and manage all the activities within their area of responsibility in a co-ordinated fashion, whether funded by GoB, through the PF, or by DPA.  As a result, MoH&FW has been able to take greater control over the implementation of its development and recurrent budgets.

Financial management has been strengthened within the MoH&FW, both at central and district levels, including improved budget preparation processes, basic financial reporting, expenditure monitoring by components and sub-components, resource tracking, developing IT applications, improvements in management accounting, production and analysis of financial information, improvements in audit and internal control, preparing central accounts, financial statements, disbursement of funds, reimbursement claims, production of Statements of Expenditure (SOEs) and preparation of withdrawal applications as required under the Development Credit Agreement (DCA) with the World Bank and withdrawal applications for other Development Partners. Statements of Expenditure for reimbursement purposes are now produced quarterly with a target of six weeks after the reporting period.  Time delays still occur from time to time and are dependent on the completion of the expenditure data from the CGA and reconciliation of accounts with the LDs.  To shorten this time, the reconciliation system will need to be improved.

The need for a unified and independent internal audit function in the MoH&FW has been identified on many occasions.  During HPSP, the Project Finance Cell of the former Financial Management Unit was mandated to conduct internal audits of all Directorates and offices of the MoH&FW.  This function has now been incorporated into the re-named FMAU.  In addition, the Audit Cell of the DGFP also conducts internal audits on its own development budget activities.  The FMAU has produced an internal audit manual and held training sessions throughout 2003.

Improvements in planning and budgeting

Emphasis is increasing on the concept of medium term planning and budgeting within the GoB.  A medium term expenditure framework (MTEF) provides a mechanism for the sector to begin to build linkages between capital and recurrent budgets, development and revenue budgets, individual annual budgets (a multi-year perspective) and between government and other (internal and external) sources of funding. DfID and DGIS (The Netherlands) have begun a programme of support, which has as its goal the need to improve the efficiency and effectiveness of the allocation of resources and to achieve more equitable and improved public service delivery.  The overarching purpose of their financial management reforms (FMRP) support package is to develop accountable and transparent institutional management and operational arrangements for aggregate fiscal discipline, strategic prioritisation of expenditure and improved performance during budget execution.  The approach to be adopted will progressively promote the role of the MoH&FW as the key agent of change in budget preparation and resource allocation at central level by increasingly devolving decision making within budget envelopes.

The MoF has embarked on a reform strategy that will eventually see spending agencies being given a more medium term (say 3 years) budgetary allocation or resource envelope, with freedom to prepare 3-year rolling budgets.  In return for this, the MoF will require clear output and outcome targets to be established by these agencies, with explanations sought and agencies held accountable where performance has not been as agreed. The tables to be found in Chapter IV of this Plan have been prepared on this basis and the Plan itself might be seen as providing the output and outcome target data required by MoF to substantiate MTEF–based planning.

The requirement for more of a needs-based approach to resource planning and budgeting has been promoted by the FMAU in conjunction with the HEU.  In addition, there are other initiatives being undertaken in the MoH&FW to adapt the traditional budgeting system for the revenue budget to newer approaches for needs-based budgeting.  These include the introduction of local-level planning at the upazila level, which identifies activities for the year along with the budgeted costs of service delivery.  Similar initiatives are being undertaken in the pilot hospitals under the Improved Hospital Management component, where hospital-level plans are being drawn up.  Both the Local-level Planning and the hospital-level plans identify the funds required for service delivery, analysed according to revenue or development budget and associated source of funding.  The continuing challenge to the FMAU is to assist with the co-ordination of these needs-based budgets into the budget process operated by the Directorates.

However, MoH&FW Revenue and Development Budgets are still prepared independently and on different timelines.  The formation of the Financial Management and Budget Committee as a high-level decision making body was a first step towards managing the Ministry’s financial resources in a co-ordinated way. 

When preparing the HNPSP PIP (2002/03-2005/06), MoH&FW undertook a review of financing in the health sector and derived forward projections of its resource envelope up to 2006/7.  This formed an important first step in developing sector resource allocation scenarios. As part of this, a model has been developed for use in future analyses which has many control parameters to enable consideration of various scenarios, including variation in the underlying macro economy, the extent and efficiency of tax collection and the share of government budget negotiated by the MoH&FW. Such modelling can also be used to examine the potential of `non-MoF’ sources of financing for the health sector such as social and community insurance, the revenue potential from local government tax reform and user charges.  

Modernising HNP Services in Bangladesh

This chapter is divided into three parts. The first defines seven broad investment strategies that need to be implemented in the longer term if the HNP sector’s modernisation is to progress. They are intended to guide developments, the allocation of resources and the concentration of effort to 2015. Their implementation will take sustained time and effort. 

The second part identifies ten priority policy responses based on these longer-term strategies that can be implemented almost immediately and which are likely improve the performance of the HNP sector as a whole by 2010. Some have already been anticipated in the HNPSP PIP 2003/04-05/06. They form the basis of the Government’s negotiation with the World Bank and other Development Partners for support.

The third part identifies five sets of HNP services of particular importance. Three are services that need to be expanded quickly if the MDG and i-PRSP targets are to be achieved. They have already been incorporated in the HNPSP PIP 2003/04-05/06. Two address current and emerging disease burdens identified in the Conceptual Framework Paper that require additional resources. Taken together, these are activities around which all of the providers in the sector can gather, each contributing according to their comparative advantage. Accelerating the expansion of these services relies on improved efficiencies as well on increased resources. Success will depend to a substantial extent on the implementation of the policy responses outlined in the second part of this chapter.