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C O N S O L I D A T E D T E C H N I C A L R E P O R T
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Annual Programme Review 2012 Bangladesh Health, Population and Nutrition Sector Development Programme (HPNSDP) Key Findings, Conclusions, and Recommendations October 11, 2012
Acknowledgements: This Consolidated Technical Report of the findings, conclusions and recommendations relative to the first Annual Programme Review of the Health, Population and Nutrition Sector Development Programme has been prepared by the team leader of the Independent Review Team conducting the APR. The contents, including expressed views, of this report are those of the IRT and do not necessarily reflect the views of either the Ministry of Health and Family Welfare, the steward of the Bangladesh health sector or, those of the Health Consortium of Development Partners, who support the MOHFW in the management of this sector-‐wide programme.
On behalf of the IRT, we would like thank the Senior Secretary to whom this report is submitted and under whose auspices this APR took place. In addition, we would like to thank the Joint Chief Planning, Madame Niru Nahar along with her competent team, Dr. Bushra Alam at the World Bank, and Ms. Alana Albee representative of the Development Partners for their support in the conduct of this review. Special thanks, in particular, to Ms. Shaila Sharmin Zaman at the Planning Wing and Ms. Iffat Mahmud at the Bank for their patience and dedicated work in the support of IRT.
Authors: This report was prepared by Leslie Fox, team leader of the Independent Review Team.
Recommended Citation: Fox, Leslie. Annual Programme Review 2012: Volume I, Bangladesh Health, Population and Nutrition Sector Development Programme (HPNSDP). October 2012. Institute for Collaborative Development.
A C R O N YM S
ADP Annual Development Program
AIDS Acquired Immunodeficiency Syndrome
AMC Alternative Medical Care
ANC Antenatal Care
APIR Annual Program Implementation Report
APR Annual Program Review
ARH Adolescent Reproductive Health
ARI Acute Respiratory Infection
BCC Behavior Change Communication
BDHS Bangladesh Demographic and Health Survey
BHE Bureau of Health Education
BHFS Bangladesh Health Facility Survey
BMMS Bangladesh Maternal Mortality Survey
CBHC Community Based Health Care
CC Community Clinic
CDC Communicable Disease Control
CGA Controller-‐General of Accounts
CHCP Community Health Care Provider
CME Continued Medical Education
CPR Contraceptive Prevalence Rate
CSBA Community Skilled Birth Attendant
CMSD Central Medical Stores Department
DAAR Disbursement for Accelerated Achievement of Results
DDS Drugs and Dietary Supplies
DDO Drawing and Disbursement Officer
DFID Department for International Development
DGDA Department General of Drug Administration
DGHS Director General of Health Services
DGFP Director General of Family Planning
DH District Hospital
DMCH Dhaka Medical College Hospital
DOTS Directly Observed Treatment Short Course
DPA Direct Project Aid
DSF Demand Side Financing
DTL Drug Testing Laboratory
ECNEC Executive Committee of the National Economic Council
ECP Emergency Contraceptive Pill
EDPT Early Diagnosis and Prompt Treatment
EGV Equity, Gender and Voice
EGVNP Equity, Gender and Voice, NGO participation
EmOC Emergency Obstetric Care
EPI Expanded Program of Immunization
EQA External Quality Assessment
ERD External Resource Division
ESD Essential Service Delivery
ESP Essential Service Package
FeHA Female Health Assistant
FMAU Financial Management and Audit Unit
FMR Financial Monitoring Report
FP Family Planning
FPI Family Planning Inspector
FSW Female Sex Worker
FPCST Family Planning Clinical Supervision Team
FWA Family Welfare Assistant
FWV Family Welfare Visitor
FY Fiscal Year
GOB Government of Bangladesh
HA Health Assistant
HCWM Health Care Waste Management
HEF Health Economics and Financing
HEP Health Education and Promotion
HEU Health Economics Unit
HIS&e-‐H Health Information System and E-‐Health
HIV Human Immunodeficiency Virus
HNP Health Nutrition and Population
HNPSP Health Nutrition and Population Sector Program
HPSP Health and Population Sector Program
HRM Human Resource Management
HSM Hospital Services Management
iBAS Integrated Budget and Accounting System
ICDDR,B International Centre for Diarrhoeal Disease Research, Bangladesh
ICT Information and Communication Technology
IDD Iodine Deficiency Disorder
IEC Information Education & Communication
IFM Improved Financial Management
HIS Improving Health Services
IHT Institute of Health Technology
IMCI Integrated Management of Childhood Illnesses
IMED Implementation Monitoring and Evaluation Division
IMR Infant Mortality Rate
IPH Institute of Public Health
IRT Independent Review Team
IST In-‐Service Training
IUD Intra Uterine Device
IYCF Infant & Young Child Feeding
LAPM Long Acting and Permanent Methods
LCG Local Consultative Group
LD Line Director
LLIN Long Lasting Insecticidal Net
LLP Local Level Planning
LMIS Logistical Management Information System
MARP Most at Risk Population
MBT Medical Biotechnology
MCWC Maternal and Child Welfare Centre
MDG Millennium Development Goal
MDR Multi-‐Drug Resistant
M&E Monitoring & Evaluation
MIS Management Information System
MMR Maternal Mortality Ratio
MNCAH Maternal Neonatal, Child and Adolescent Health
MOF Ministry of Finance
MOHFW Ministry of Health and Family Welfare
MSR Medical & Surgical Requisites
MTBF Medium Term Budget Framework
NASP National AIDS/STD Program
NCDC Non Communicable Disease Control
NES Nursing Education Services
NGO Non-‐Governmental Organization
NIPORT National Institute of Population Research and Training
NIPSOM National Institute of Preventive and Social Medicine
NNP National Nutrition Project
NNS National Nutrition Services
OP Operational Plan
PA Project Aid
PAD Project Appraisal Document
PBF Performance Based Financing
PFD Physical Facilities Development
PHC Primary Health Care
PER Public Expenditure Review
PIP Program Implementation Plan
PLMC Procurement and Logistics Monitoring Cell
PLSM Procurement, Logistics and Supplies Management
PME Planning, Monitoring and Evaluation
PMR Planning, Monitoring and Research
PPA Public Procurement Act
PPR Public Procurement Rules
PPP Public Private Partnership
PSSM Procurement, Storage and Supplies Management
PWD Public Works Department
PW Planning Wing
RADP Revised Annual Development Program
RFP Request for Proposals
RPA Reimbursable Project Aid
RFW Results Framework
RRT Rapid Response Team
SBA Skilled Birth Attendant
SDAM Strengthening of Drug Administration and Management
SHS Strengthening Health Systems
SOP Standard Operating Procedure
SRH Sexual and Reproductive Health
SWAp Sector Wide Approach
SWPMM Sector Wide Program Management and Monitoring
TATR Thematic Area Technical Report
TFR Total Fertility Rate
TRD Training, Research and Development
UESD Utilization of Essential Service Delivery
UFPO Upazila Family Planning Officer
UHC Upazila Health Complex
UH&FWC Upazila Health and Family Welfare Clinic
UN United Nations
USAID United States Agency for International Development
WHO World Health Organization
WIMS Warehouse Inventory Management System
T A B L E O F C O N T E N T S
Executive Summary ........................................................................................................ 1 1 Introduction and Overview ....................................................................................... 3
1.1 Programme Background: A Summary Social and Economic Profile .................................... 3 1.2 HPNSDP 2011 – 2016 .......................................................................................................... 3 1.3 Context of the APR 2012 and HPNSDP ................................................................................ 4 1.4 APR 2012 Objectives and Deliverables ................................................................................ 4 1.5 APR 2012 Technical Approach and Methodology ............................................................... 5 1.6 APR 2012 Report Contents and Structure ........................................................................... 5
2 Progress Against Objectives and Main Findings of the Thematic Area Technical Reports ..................................................................................................................... 6 2.1 Introduction and Overview ................................................................................................. 6 2.2 Financial Management, with Planning and Budgeting ........................................................ 6 2.3 Procurement and Supply Chain Management .................................................................... 8 2.4 Monitoring & Evaluation ................................................................................................... 10 2.5 Disease Control (including human resources) ................................................................... 13 2.6 Nutrition (including human resources) ............................................................................. 14 2.7 MNCH and Family Planning (including human resources) ................................................ 16 2.8 Urban Health (including population and nutrition) .......................................................... 18 2.9 IEC & Behavior Change Communications .......................................................................... 21 2.10 Overall Conclusion and Recommendations: Key Technical Issues, Challenges and Opportunities .............................................................................................................................. 23
3 Overall Conclusions and Recommendations: Are Conditions In Place for a Successful Programme ............................................................................................ 26 3.1 Review, Analysis and Updating of the HPNSDP Results Framework ................................. 26 3.2 Progress on Key Areas of the Governance and Accountability Action Plan ...................... 26 3.3 Disbursement for Accelerated Achievement of Results ................................................... 27 3.4 Institutional Constraints in Implementation, including Risk Assessment Update ............ 27 3.5 Financial Framework for the Sector, including DP Funding .............................................. 28 3.6 Team Leader’s Thoughts on Future Annual Programme Reviews .................................... 29 3.7 Overall Conclusions and Recommendations for the APR 2012 ......................................... 30
Annex 1 ........................................................................................................................ 32 Thematic Area Technical Review Reports ................................................................................... 32
Annex 2 ........................................................................................................................ 33 Review and Analysis of the Updated Results Framework ........................................................... 33 Additional Comments to HPNSDP Results Matrix Indicators ...................................................... 35 HPNSDP Results Matrix Analysis ................................................................................................. 37
Annex 3 ........................................................................................................................ 43 Governance and Accountability Action Plan ............................................................................... 43 Update on Governance and Accountability Action Plan (GAAP) ................................................. 44
Annex 4 ........................................................................................................................ 50 DAAR Analysis ............................................................................................................................. 50 DAAR Indicators for Year 1 (July-‐December 2011) ...................................................................... 51 Progress on 2012 DAAR Indicators (as of September 12,2012) .................................................. 52
Annex 5 ........................................................................................................................ 54 Team Leader Terms of Reference ............................................................................................... 54
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E X E C U T I V E S UMMA R Y
Overview and Background The Consolidated Technical Report which follows this executive summary provides the principal findings, conclusions and recommendations of the Independent Review Team (IRT) on the first Annual Programme Review (APR) of the Health, Population and Nutrition Sector Development Programme (HPNSDP) 2011-‐2016. The IRT was composed of 17 members, eight international thematic area experts and their national counterparts, plus the team leader. The IRT conducted the APR from September 15, to October 5, 2012; the team leader remained an additional week to prepare this final consolidated technical report and participate in the Policy Dialogue which formed the basis of APR 2012 Aide Memoire.
While the 32 OPs were the principal unit of analysis used by the IRT in this APR, it was the nine Thematic Areas defined by the 2012 APR TORs, which provided the higher level focus of the individual IRT member’s review. Each Thematic Area team thus prepared and presented its draft report, including principal findings and recommendations, to the concerned HPNSDP Task Group to obtain its feedback and finalize its recommendations. Final thematic papers, with refined recommendations, were used to produce a practical action plan by the concerned Task Group and ultimately to improve OP performance while setting a baseline for the purpose of monitoring next year’s implementation.
This first APR of the third SWAp was focused largely on assessing whether the program was on the right track to accomplish its overall objectives, in terms of whether start-‐up measures (e.g., institutional arrangements, financial framework, monitoring and evaluation systems, etc.) were in place and operational. The focus of the APR 2012 was, therefore, less an assessment to determine whether the program had achieved its overall objectives for year one, although it did do this too, than it was a due diligence review of the programme’s institutional, financial, technical and management infrastructure.
HPNSDP is distinguished from its two predecessors by increased attention placed on several new areas, including nutrition mainstreaming, urban health and gender, equity, voice and accountability. Perhaps one of the most important aspects of this third SWAp is the intense focus on achieving results, both the at the level of the 32 operational plans (OPs) which are the building blocks of the programme, and at the results framework (RFW) or strategic level, which defines the set of high level impact and outcome results to which the OPs are intended to contribute.
Each of the Thematic Area Technical Reviews (TATR) is presented in summary below (Section 2) and in full in Volume II, Annexures. Each of these Reviews provides principal findings both in terms of achievements and challenges, as well as a specific set of actionable recommendations and ways forward. The Action Plan and set of thirty recommendations that emerged from the Policy Dialogue are based on the TATR recommendations. While space does not permit a summary of all nine Thematic Areas, to the extent the reader has time, a review of the full TATR relative to his or her interest is a worthwhile effort.
Overall Conclusions and Recommendations The review of the eight Thematic Areas by the IRT consultants shows that significant progress has been made in implementation of the HPNSDP but, as would be expected, there are a number of programmatic and management issues that have been identified which the IRT believes, if the recommendations are implemented, will lead to the achievement of both Operational Plan outputs as well as contribute to the achievement of Results Framework outcome and impact level results. The IRT concludes, however, that the progress of HPNSDP is roughly where it should be at the end of the first year of the programme, taking into consideration the later than expected start experienced. Given the magnitude of the SWAp, the many stakeholders involved, and the normal implementation hiccups associated with the commencement of most new initiatives, the IRT finds the initial delays understandable.
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Both the APIR and this APR have identified the on-‐going crisis in human resources and weak SWAp monitoring and supervision as two of the principal issues that will have a likely impact on the programme’s successful achievement if not addressed immediately; both issues carry-‐over from previous health sector programmes. In this regard, the IRT concludes that:
‒ The Human Resource Management (HRM) OP is best placed to lead the Ministry’s efforts in addressing this health sector-‐wide constraint. However, it is currently understaffed and urgently requires both additional personnel and those with the right mix of skills and expertise to permit the OP to take the lead in coordinating HPNSDP’s response to the current and continuing HR crisis. Furthermore, when the current workforce study being undertaken by the MOHFW with DFID support is completed, the HRM OP, under the guidance of the Senior Secretary, and in collaboration with the HR Task Group, should convene a sector-‐wide workshop to develop individual Task Force HR action plans and identify short-‐term solutions while the longer-‐term reforms of the GOB across all sectors continues to take hold. Each of the TATR’s has reviewed HR issues in their particular domain and made recommendations concerning temporary measures that should address the workforce constraints in the short-‐term.
‒ In terms of improved monitoring and management of the SWAp, the SWPMM OP through the Planning Wing plays a critical role, particularly in resource planning and tracking and Inter-‐OP coordination. In this regard, the IRT singles out for special attention the PMMU, which needs to urgently engage additional staff so that it can support the Planning Wing’s critical role in independently monitoring the performance of Operational Plan’s, not relying simply on LD reporting. While LD meetings were viewed as very useful, there appeared to be inadequate time to discuss inter-‐OP coordination particularly in areas of overlap or cross-‐cutting issues such as nutrition, urban health, IEC/BCC, or human resource needs.
Several other conclusions, largely related to the SWAp’s institutional arrangements are worth noting:
‒ Several new organizational entities or oversight tools were designed to increase the financial and management oversight of this SWAp including, the Financial Management and Audit Unit (FMAU), the PMMU, the Procurement and Logistics Monitoring Cell (PLMC) and Interim Unaudited Financial Report (IUFR). Each of them has shown initial effectiveness during the programme’s start-‐up and this APR has pointed out where additional support is needed to make them fully functional
‒ The IRT has been particularly impressed with the governance structure of HPNSDP and has seen it in full operations during the APR, from the initial Task Group meetings, to the Local Consultative Group’s interactions through to the Steering Committee and culminating in the Policy Dialogue. The Task Groups are the key to the technical success of the programme and should meet regularly with well-‐articulated TORs and strategies; the IRT encourages them to continue their important work after APR.
While the IRT understands that HPNSDP is a limited SWAp in terms of whole-‐of-‐sector stakeholder participation, each IRT expert, from his or her own perspective, felt that there could be greater coordination with and participation of major health care providers that are not covered under the SWAp, particularly NGO and private sector health providers. This is particularly true since the public sector, through the MOHFW, covers only 30 percent of health service delivery throughout the country, while the remaining 70 percent is covered by a combination of the private sector and NGOs, with future projections placing the ratio of public sector to private/NGO sector coverage at 10 percent and 90 percent respectively. The IRT urges strong consideration, therefore, for creating a new cross-‐sector service provider platform that brings together current HPNSDP stakeholders with representatives of other non-‐member HPNSDP organizations, including from the NGO and private sectors and, where appropriate, into the Task Group structure, to undertake joint planning and information sharing exercises.
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The obvious concern, recognized by all HPNSDP stakeholders, is the underfunding of the SWAp. This however, is meta-‐level concern that probably falls outside of the manageable interests of any of the current parties to address. The IRT would note that the conditions, that is, the institutional arrangements, systems and procedures, are for the most part in place to move the Programme forward to the Mid-‐term Review where adjustments, if necessary, can be made. This assumes that the HPNSDP Steering Committee and the Policy Dialogue accept the more important of the principal recommendations that have been made in this report and the full Thematic Area Technical Review found in Volume II, Annexes.
1 I N T R O D U C T I O N A N D O V E R V I EW
Chapter 1.0 provides a brief summary of the programme background, HPNSDP, 2012, the APR 2012 context, objectives and methodology, as well as the structure of this report.
1 . 1 P R O G R AMM E B A C K G R O U N D : A S UMMA R Y S O C I A L A N D E C O N OM I C P R O F I L E
Over the past 25 years, Bangladesh has shown both an acceleration and balanced progress in the country’s economic and social life, sometimes against a background of difficult partisan strife. Gross domestic product and per capita income have increased significantly over the past decade, but so too has the cost of living. And, as much of the world knows from the 2011 Millennium Development Goals’ Report, Bangladesh’s progress in achieving MDGs 3, 4 and 5 have been nothing short of an international success story. However, despite these achievements, it is also fair to note that nearly one third-‐third (32 percent) of the population still live below the poverty line and about 40 percent is underemployed (BBS 2011).
In the social sector, Bangladesh has made remarkable progress in many areas during the last decade, i.e., increasing literacy and life expectancy at birth; sustaining the child immunization above 90 percent, which resulted in continued decline in infant and child mortality; and achieving sharp decline of maternal mortality ratio (PIP, 2010). Furthermore, since the inception of the first SWAP, Bangladesh has made impressive gains in health over the past decade. According to the DHS, between 1997 and 2011, Bangladesh has seen total fertility rate decline from 3.3 to 2.3, under-‐five mortality decline from 116 to 65, infant mortality decline from 82 to 52, children’s vaccination rate increase from 54.1 percent to 81.9 percent, ANC use increase from 29 to 51.7, and percentage skilled deliveries increase from 8 percent to 32 percent. These are unprecedented gains that few countries have ever made in such a short period of time.
1 . 2 H P N S D P 2 0 1 1 – 2 0 1 6
The Health, Population and Nutrition Sector Development Program (HPNSDP) 2011-‐2016 is the third five-‐year Sector-‐wide Approach (SWAp) supporting the Bangladesh health sector. It follows the Health and Population Sector Programme (HPSP, 1998-‐2003), and the Health, Nutrition and Population Sector Programme (HNPSP) which began in 2003 and was completed in June 2011. HPNSDP was designed with the full participation of its principal stakeholders, that is, the Ministry of Health and Family Welfare (MOHFW) and it principal Development Partners and, after careful attention to the lessons learned from these previous SWAp experiences in Bangladesh. The HPNSDP incorporates the broad themes of improving coverage, access, utilization, governance, equity, quality, and gaining efficiency in services.
HPNSDP has two major components: The first component on improving health services aims at improving priority HNP services to accelerate the achievement of the HNP-‐related MDGs and can be divided into two sub-‐components: (a) the delivery of essential health services which seek to improve reproductive, adolescent, maternal, neonatal, infant and child health and family planning (FP),
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nutrition, communicable and non-‐communicable diseases; and (b) supporting the service delivery system including primary health care particularly for strengthening the Upazila Health System (UHS) and the CCs, as well as hospital services. The second component aims at strengthening health systems particularly governance, stewardship, health sector planning, human resources, health care financing, procurement and supply chain management, quality of health care, and pharmaceuticals.
Finally, it worth noting that HPNSDP has placed increased attention on several new areas including nutrition mainstreaming, urban health and gender, equity, voice and accountability. Perhaps, one of the most important aspects of this third SWAp, which distinguishes it from its predecessors, is the intense focus on achieving results, both the at the level of the 32 operational plans (OPs) which are the building blocks of the programme, and at the results framework (RFW) or strategic level, which defines the set of high level impact and outcome results to which the OPs are intended to contribute. This managing for development results focus has not only permitted the programme to monitor and report on results, but has also established an accountability framework relative to the performance of those responsible for achieving the articulated results.
1 . 3 C O N T E X T O F T H E A P R 2 0 1 2 A N D H P N S D P
The implementation of the HPNSDP was delayed by 6 months due to delayed approval of Operational Plans (OPs). Consequently, the sector faced significant challenges due to delayed fund release and short timeframe in its first year. Despite these challenges, the Annual Program Implementation Report (APIR) points to impressive progress made.
With these challenges in mind, this first APR of the third SWAp was focused largely on assessing whether the program was on the right track to accomplish its overall objectives in terms of whether start-‐up measures (e.g., institutional arrangements, financial framework, monitoring and evaluation systems, etc.) were in place and operational. The focus of the APR 2012 was, therefore, less an assessment to determine whether the program had achieved its overall objectives for year one, although it did do this too, than it was a due diligence review of the programme’s institutional, financial, technical, and management infrastructure.
1 . 4 A P R 2 0 1 2 O B J E C T I V E S A N D D E L I V E R A B L E S
Annual Programme Review serves as a sector management instrument to monitor progress in the implementation of the program and to verify that agreed management and policy issues have been addressed during implementation; in this regard, this first APR of HPNSDP is no different. The Independent Review Team, which conducted this APR, was preceded by conduct of the APIR, which was prepared by the MOHFW Planning Wing; the APIR provides the implementation progress of each of the 32 operational plans during the first year of the HPNSDP. The results of APIR analysis along with the Stakeholder Analysis (see below), therefore, serve as the departure point and baseline data sources for the 2012 APR IRT mission.
Since this is the first year of the sector program, the 2012 APR is the first for HPNSDP. The specific focus of the APR was to:
1 Review implementation of HPNSDP in the light of an up-‐to-‐date results framework using latest data, indicators, and targets as provided in the APIR;
2 Assess initial progress of the program during the first year;
3 Review the financing arrangements and assess how well the GOB and DP support meet the priorities and requirements of the HPN sector;
4 Undertake analysis in eight thematic areas to set the baseline and document the building blocks (operational plans) related to the key health systems; identify issues/challenges concerning effective delivery of services; and recommend ways to improve future implementation.
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The overall APR Terms of Reference (TOR) called for eight Thematic Area Technical Reviews (TATR), which are to be used in fashioning eight corresponding Task Group Action Plans, based on IRT recommendations; a Consolidated Technical Report (this document) which summarizes the eight TATRs, provides analyses of and progress on other mandated reviews (e.g., GAAP, DAAR, up-‐dated RFW) and which is used by the Policy Dialogue to prepare a final overall Action Plan which in turn becomes the basis for the APR 2012 Aide Memoire.
1 . 5 A P R 2 0 1 2 T E C H N I C A L A P P R O A C H A N D M E T H O D O L O G Y
The IRT team used a methodology that was similar to the previous APRs under the two previous sector programmes. The MOHFW Planning Wing and World Bank led the preparations for the APR. An initial inception visit was made by the team leader in August 2012 to develop a work program (see, Team Leader’s Inception Report APR 2012, Annex 7), obtain background documentation, become familiar with the Bangladeshi context, and meet HSPSDP stakeholders.
The APR review was conducted by a 17 member IRT (eight international thematic area experts and their national counterparts plus the TL) from September 15, to October 5, 2012; the team leader remained an additional week to prepare the final consolidated report and participate in the Policy Dialogue which formed the basis of APR 2012 Aide Memoire. In addition to a review of the significant documentation on the HPNSDP and its predecessors, the IRT received a briefing from concerned officers in the MOHFW, particularly the Planning Wing, and the APIR consultants who supported the PW in this year’s implementation review. The IRT met with a broad range of stakeholders, including various levels of MOHFW, Line Directors, DPs, NGOs, and other Ministries through a combination of individual and group interviews (see, individual Thematic Area Technical Reviews for list of interviewees). Field visits by the IRT were made to Pabna, Syhlet, Chittagong, and Dhaka City, with participation by MOHFW and DP members who served as resource persons to the IRT. In each District various Upazilas were visited and interviews were made with the civil surgeon, deputy directors, and other health staff at all levels of the service delivery system (District Hospital, MCWC, UHC, Union Health and Family Welfare Centers and Community Clinics).
While the 32 OPs were the principal unit of analysis used by the IRT in this APR, it was the nine Thematic Areas1, defined by the 2012 APR TORs, which provided the higher level focus of the individual IRT member’s review. Each thematic area team thus prepared and presented their draft reports, including principal findings and recommendations to the concerned HPNSDP Task Group to obtain its feedback and guide its recommendations. Based on this feedback, final thematic papers with refined recommendations were prepared, to produce a practical action plans by the concerned Task Group and intended to improve OP performance while setting a baseline for the purpose of monitoring next year’s implementation.
1 . 6 A P R 2 0 1 2 R E P O R T C O N T E N T S A N D S T R U C T U R E
The report has two chapters following this introduction, which respond to the requirements of the overall 2012 APR Terms of Reference (annex 5): Chapter 2.0, which provides an analysis of the progress of the HPNSDP against planned objectives and main findings; and, Chapter 3.0 which provides an overall conclusions focusing on the effectiveness of start-‐up measures and presents the principal analysis called for in the TORs, including GAAP progress, DAAR indicators, Up-‐dated Results Framework, the financial framework for the sector, and institutional constraints in implementation including updates required on the Risk Assessment.
1 The nine thematic areas are: (i) Gender, Equity, Voice and Accountability, (ii) Monitoring and Evaluation, (iii) Procurement and Supply Chain Management, (iv) Financial management with Planning and Budgeting, (v) MNCH and Family Planning, (vi) Nutrition, (vii) Disease Control, (vii) Urban Health, and (xi) IEC and Behavior Change Communications
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2 P R O G R E S S A G A I N S T O B J E C T I V E S A N D M A I N F I N D I N G S O F T H E T H EM A T I C A R E A T E C H N I C A L R E P O R T S
2 . 1 I N T R O D U C T I O N A N D O V E R V I EW
The IRT reviewed 32 operational plans as part of its assessment of the eight Thematic Areas that composed this year’s Annual Programme Review. Each of the following eight sections provides a summary of the principal findings, challenges and recommendations from the concerned IRT technical reviewer. It should be noted that the ninth Thematic Area, Gender, Equity, Voice and Accountability (GEVA) was not reviewed this year. Rather, the HPNSDP Steering Committee felt that the Stakeholder Consultation would suffice to address GEVA issues while serving the needs of the IRT. Issues related to human Resources were a principal crosscutting issue addressed by and reported on in each of the eight Thematic Area Technical Reviews. In addition to the assessment of progress against objectives for each of these technical reviews, this chapter also includes the key technical issues for each thematic area to be discussed during the policy dialogue. The following eight sections provide the executive summary and recommendations from each Technical Review that is “suitable from the technical reviews that will inform the Aide Memoire for the overall APR.”
2 . 2 F I N A N C I A L M A N A G EM E N T , W I T H P L A N N I N G A N D B U D G E T I N G
Planning, budgeting, and financial management are key ingredients to achieving the overall objectives of the HPNSDP. The health sector is challenged by historic institutional attributes of the Bangladesh public sector, such as the complex civil service structure and centralized planning system. The plurality of financing mechanisms by development partners further complicates effective planning and financial management. Despite these challenges, the sector has made many improvements over the years and has worked creatively to overcome structural complexities with innovations such as local level planning and outsourcing human resources. Overall, the HPNSDP is on the right track, as evidenced by the marked improvement in health indicators and increasing willingness by development partners to use government systems for financing.
Results and Achievements Since the last APR in 2009, the MOHFW has made significant progress. The sector program has attracted increased resources from DPs into the RPA pooled fund, reflecting the high degree of confidence in the country public financial management system by international community. The empowerment of the Financial Management and Audit Wing (FMA Wing) to oversee all financial functions for both the revenue and development budget (under the Joint Secretary of Finance) is a welcome step towards harmonization. The MOHFW is on track to outsource critically needed financial management and audit staff on a temporary basis to support the FMAU and line directors, thereby mitigating a major concern in previous APRs. Internal audit has been strengthened. According to APIR 2012, financial management and audit trainings have occurred at all levels of the system, which has greatly contributed in improving overall financial management, reducing financial irregularities and consequently audit objections. Though much work is still needed, the development of the ADP Monitoring System has proven to be a powerful financial management tool for the MOHFW. Finally, the quality and timeliness of financial management reporting has improved, facilitating on-‐time reimbursement by DPs.
Challenges and constraints Several challenges in resource planning, budgeting, and financial management still confront the health sector. Our key areas of concern are:
1 The HPNSDP is not on track to be financed by the amounts set forth in the PIP. Although overall HPNSDP spending for the FY 2011-‐2012 stood at 87 percent against the allocated the Revised Annual Development Plan (RADP), only about 60 percent of the OP provision for 2011-‐12 was allocated in the RADP of the same year and the actual utilization stood at 53 percent of the OP
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provision. The ADP allocation in 2012-‐2013 indicates further decline in the trend, as only 58.5 percent of the OP provision has been allocated for the year. In 2011-‐2012, overall budget execution was 87 percent, though in some OPs it is below 50 percent. Bottlenecks to budget execution include delays in the release of fund, shortage of trained FM staff, and inadequate delegated financial power of Line Directors (LDs). The recent revision of the fund release procedure by the MOF restricting the authority of the line ministries to release more than one quarter of the fund at a time without the approval of the MOF will further slowdown the process of fund release and consequently the utilization of ADP allocation.
2 Systems for comprehensive resource planning and tracking do not exist. As previous APRs have pointed out, Bangladesh has had a historic disconnect between the development and non-‐development budgets in health, which still exists today. The Planning Wing (PW) is responsible for the preparation of the development budget, with almost no interaction with the FMAU, which prepares the non-‐development budget. This lack of coordination has led to sub-‐optimal resource allocation.
Further to this historic phenomenon, the assessment team was also concerned about the lack of systematic planning and coordination of Direct Project Aid (DPA) and parallel funds. Systems for ensuring that development partners coordinate their efforts through joint work planning and honor their aid commitments were not evident. Systematic expenditure tracking for DPA and parallel funds was also not evident, thus it was not possible to clearly ascertain the sources of all financing supporting the HPNSDP and the priorities financed from those sources within the HPNSDP. Finally, a joint systematic review process, in which all SWAp partners jointly evaluate resource utilization by each partner, was also not evident.
3 Lack of human resources in health finance and financial management is a major impediment. The outsourcing of financial management and audit staff should help relieve these constraints in financial management, however planning for permanent staffing is needed once this stop gap measure ends. The organogram of the Financial Management and Audit Unit (FMAU) appears to have too many support staff and not enough technical staff. The Health Economics Unit (HEU) still faces serious human resource capacity constraints, especially in light of the critical work ahead. Staff reposting and technical knowledge in health economics and finance were described as the most pressing human resource issues.
4 Resource allocation is not based on need. Development budget is prepared on the basis of multiyear plan (OPs). Allocations are often made without making field level needs assessment on annual basis. Cost centers at the field level have virtually no participation in budget preparation. As a result, the budget is often not need-‐based causing under-‐allocation in certain priority areas as well as over-‐allocation of resource in certain activities. Local Level Planning (LLP) attempted to resolve this, and strong progress was made in training and the preparation of LLP plans nationwide. Unfortunately, despite the Project Appraisal Document (PAD) and Programme Implementation Plan (PIP) recommendations, the LLP plans were still not linked to budget allocation, thus very little practical impact of LLP is evident.
Principal Recommendations 1 Ensure adequate resource allocation and efficient utilization to achieve HPNSDP results. A joint
review by GOB and DPs should be undertaken immediately to analyze the growing trend of underfunding OP provisions of PIP. In addition, discussions with the finance division must be held to relax the newly-‐imposed quarterly fund release for RPA. Other actions include more aggressive monitoring by planning wing for budget execution by OPs and improved performance of MOHFW in clearing procurements for World Bank approval. Finally, joint OP planning with districts can help allay Civil Surgeon (CS) and Deputy Director, Family Planning (DDFP) concerns of underfunding while improving OP spending.
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2 Implement comprehensive resource planning and tracking system. A comprehensive picture of all planned and expended finances in the HPNSDP is critically needed to ensure strong planning and sector management. Building from the unified workplan developed in previous years, an online system should be developed that accounts for planned and expended budgets from all sources of financing of the HPNSDP: non-‐development, development, DPA, Reimbursable Project Aid (RPA), and parallel funds that support HPNSDP. An expert team should be constituted to assess current resource planning tools, develop joint annual work plan classifications, and develop a blue print and action plan.
3 Increase human resource capacity in health financing and financial management in the health sector. An immediate review of the current staffing structure of FMAU is needed, with an eye towards revising the organogram to increase professional posts and reduce support staff. Also, a review of human resource needs to accomplish objectives in health economics OP should be undertaken, and a strategy to fill human resource gaps should be developed. This strategy should be jointly developed with DPs (including parallel funders), who can help close the technical manpower gap.
4 Link local level planning with fund allocation. LLP is a powerful mechanism to ensure need-‐based resource allocation. However, without concrete steps to mainstream LLP into the national budgeting process, the initiative will not succeed. Financial mechanisms to operationalize LLP must be put in place. Financial management procedures must be developed for LLP administration. Legal, administrative, and procedural actions to enable the delegation of financial and administrative authority should be completed. The PAD and PIP outline the necessary actions, however, little progress has been made. An expert team should be constituted to develop a phased action plan for operationalizing these steps.
2 . 3 P R O C U R EM E N T A N D S U P P L Y C H A I N M A N A G EM E N T
The basic configuration of the public procurement system followed by the MOHFW has not changed over the past years. In the current (third) health, population and nutrition sector program, there are four main procuring entities at the national level. The Procurement, Storage and Supplies Management (PSSM) of Directorate General Health Services (DGHS) and Procurement, Logistics and Supplies Management (PLSM) of the Directorate General Family Planning (DGFP) are using reimbursable project aid mainly for goods and non-‐consulting services. The HED/MOHFW and the PWD (the specialized health wing of the Ministry of Housing and Public Works) both mainly operate using GOB development and revenue budget.
The IRT, in this technical review, looked at the operational plans of PSSM, PLSM, Physical Facilities Development (PFD) and Strengthening of Drug Administration and (SDAM).
Line directors, the tertiary hospitals and the civil surgeons do limited procurement of goods using mainly GOB development and revenue budget.
The MOHFW through PFD and PLMC provide technical support for the procurement of consulting services.
After a long delay the PLMC has been formally constituted under PFD (August 2012) to ensure coordination and technical support to the procuring entities.
Results and achievements A first strategic planning workshop to strengthen procurement management and monitoring was held in December 2011. An initial draft strategic plan was produced.
Although there is no written “public procurement improvement plan” as such, different elements such as capacity building, the development of e-‐tools, improved communication and coordination
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are together gradually helping to develop a sound strategy, which is starting to produce positive outcomes.
The multi-‐layered training approach (5-‐day training, 3-‐week training, CIPS training, etc.) allows for targeting the beneficiaries. It not only allows for improving the general procurement understanding amongst civil servants but also allows for developing specialized procurement capacity.
In general, the number of civil servants that have been trained in procurement has increased significantly and there seems to be a better understanding of procurement principles and procedures throughout the sector, horizontally and vertically.
The managerial procurement capacity in the major procuring entities has also improved as evidenced by lack of stock out of items, reduction of procurement lead-‐time, and improved communication and data management, especially in the family planning sub-‐sector.
The commitment of the government to procurement efficiency, transparency, and accountability is clear. This includes introducing electronic web based tools in procurement and supply processes improving coordination and management of the procurement plans, as well as for the monitoring of the procurement and supply chain processes. It is expected with fair amount of confidence that if the current pace of development is maintained, it will have a significant effect on the reduction of lead times and system wastage in the coming years.
The introduction of regular routine meetings between the major procuring entities and the Line Directors to discuss and review procurement plans, procurement packages, procurement progress, and distribution plans is another major step that will likely result in increased efficiency and reduced lead time and complaints.
The creation of the PLMC is an important step towards reinforcing both the coordination and the monitoring role of the MOHFW, as well as its regulatory function.
Constraints and challenges The currently available storage space at the national level and, in some cases, at the regional or district level is no longer sufficient to deal with either the current volumes (quantity) or to ensure the quality drug management.
Although investments in medical equipment are large and system wastage is significant, very little has been done to develop and maintain a national level medical equipment database.
The introduction of routine procurement and supply audits (internal or external) has not yet begun nor have all procurement agents produced procurement risk mitigation plans.
All line directorates have a designated procurement correspondent and the procuring entities all have focal points but not all relevant staff has been trained yet.
The existing system can’t always ensure that the staff and equipment necessary for functioning of facilities is available immediately after their construction.
The limited administrative and financial authority at divisional and district level has a negative impact on their ability to render the health system more efficient and cost effective.
Conclusions and recommendations The overall strategy to reinforce the procurement and supply management that was started in the previous sector program has produced results. The MOHFW (Development &Monitoring and Evaluation / ME) has continued and initiated a number of activities (capacity building, e-‐tools) that, if sustained, could produce transparent, efficient, and effective procurement and supply systems by the end of this sector program. More attention can, and should, be given to the downstream supply management. There are, however, still a number of issues that have to be addressed in the short term, including the following:
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1 All the different elements that together constitute the procurement and supply strategy should be institutionally linked through the PLMC, whose own institutional linkages, and working relationships both vertically and horizontally should be further examined and defined. A standards operation procedures manual should be developed for PLMC.
2 A critical mass of procurement specialists has not yet been reached and the MOHFW should continue to invest in training.
3 It is strongly recommended that health sector e-‐procurement be undertaken through electronic government procurement (e-‐GP) and not by using a specific MOHFW procurement site. The MOHFW through the PLMC should continue working with the CPTU with an objective to start using e-‐GP within the current fiscal year.
4 The preparation of the annual procurement plans should start simultaneously with the annual development plan in April before the start of the new fiscal year.
5 An in-‐depth study should be commissioned with subject specialists to look into solving the space shortage of storage, taking into account possible construction, as well as reconfiguration of the existing storage and supply system.
6 Standardization and definition processes should be reinforced (medical equipment, tables of equipment, standard tender documents) and a national level web based medical equipment database should be established as soon as possible and administered either by the PLMC or the Central Medical Stores Department (CMSD).
2 . 4 MON I T O R I N G & E V A L U A T I O N
This summary reports the findings of the thematic area: Monitoring and Evaluation. The objective of the M&E thematic review is to highlight health systems issues and challenges in monitoring HPNSDP outcomes and outputs at both the RFW and OP levels and to make recommendations for strategies, implementation, and financing for the remainder of the program. The base of this analysis is the review of the operational plans of the Sector Wide Program Management & Monitoring (SWPMM), of the Programme Monitoring and Evaluation (PME-‐) FP, Management information Systems (MIS)-‐FP, HIS/eHealth, PM&R, the APIR of the Programme Management and Monitoring Unit (PMMU), and various web-‐based Health Information Systems (HIS).
Main Analysis and Findings: SWPMM and the PMMU
The SWPMM became operational in July 2011 with the general objective of improving the performance of HPN sector through appropriate planning, budgeting, and monitoring for coordination and efficient utilization of resources. SWPMM has four components: 1) Planning and budgeting; 2) Monitoring and Evaluation; 3) Governance and Stewardship and 4) Coordination and Collaboration. In regards to improving monitoring and evaluation, SWPMM has established the Program Management and Monitoring Unit (PMMU). SWPMM drafted a strategic M&E Framework and Action Plan in 2008/2009 which was intended to address overall coordination of M&E between OPs to improve HPNSDP monitoring. It has, however, not been approved and thus leaves no guiding framework for SWPMM M&E tasks.
The PMMU, which became operational at the beginning 2012, is replacing the former MEU (Monitoring and Evaluation Unit under the HNPSP). PMMU’s main objective is to manage and monitor the implementation process of the HPNSDP. The PMMU produced the first APIR in September 2012. This document was used as the main source for the IRT (Independent Review Team) to evaluate progress of HPNSDP 32 OPs and their corresponding indicators (316, around 10 for each OP).
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The 316 indicators have been collected using templates to be filled by 32 Line Directors (yearly) in a self-‐evaluation procedure to assess OPs progress of the HPNSDP. Comparing the status quo and relating them to the target indicators for the mid-‐term evaluation (in 2013), and adjusting the mid-‐term targets to the current FY (2011-‐2012), produced the achievement rate of all 316 indicators.
The IRT has reviewed indicators of all OPs and found them to be of mixed quality with the results found in each of the other seven TATRs as well as those reviewed for this Thematic Area (see Annex 1 and discussion in the following full report). The various IRT Thematic Area teams have noted problems with OP indicators, including the lack of baselines, unclear targets and/or ambitious targets, and sometimes confusing recording of achievements. The great majority of OP indicators are quantitative and largely measure numbers, whether of people trained, items procured and distributed or materials developed. These are considered output or process indicators and are supposed to link upwards to the HPNSDP Results Framework (RFW).
The M&E Team recognizes that this is the first time under any of the SWAps that such a rigorous undertaking has been related to managing for development results. While the 32 OP have made significant progress as noted in the APIR, the M&E Team believes that there is an opportunity to move the process forward by: 1) revising many of the indicators found in all the OPs, including this one; and 2) developing an intermediary set of results and corresponding indicators for OP performance management purposes between the current set of output indicators found in the OPs and the outcome and impact results found in the RFW and based on the log-‐frames found in each OP.
A brief review of the current health information systems was conducted in order to assess if data and reports from various sources are reliable, available and may function as a tool for the M&E tasks. Data on urban health services and NGO/private provider service are currently not complete, and data on project implementation and activities (ADP and OP) are still processed in stand-‐alone systems. Routine reports are not yet tailored to the identified needs. Both HIS & eHealth and MIS/FP directorates initiated web-‐based applications for data-‐entry, transmission, storage, and retrieval. The MOHFW health information system still experiences some duplication of data-‐collection and parallel reporting structures. The Data Warehouse project (DMIS) needs a thorough review to test for functionality and better integration into MOHFW organizational structure. There is also an urgent need to determine whether the technical assistance, which has been provided to the MOHFW in the establishment of the data warehouse, has been effective in this regard and what the intentions are by the technical provider (GiZ) in terms of its future support to the Ministry. Finally, the M&E Team notes that hiring and retaining human resources for both HIS/e-‐Health and MIS-‐FP continues to be a challenge, as the GOB’s low salary scale remains unattractive for high level IT experts.
Conclusions and Recommendations: 1 The IRT recommends that. in addition to the revision of the current set of indicators in each OP
that are used to measure OP progress including those reviewed under this Thematic Area, an additional number of intermediary result level indicators based on OP Log-‐frames be incorporated into OP performance monitoring system. Specifically, each OP should review the Output and Purpose level indicators in the OP log-‐frames that are more results oriented than the input/output/process indicators currently used to track progress of the OPs. In this regard, the IRT recommends that a results-‐based management specialist provide technical support to the OP teams undertaking these important exercises (short-‐term activity, 2012-‐2013).
2 Full development of the M&E Strategy from the existing M&E Framework should be completed and approved as soon as possible. As part of this strategy development it is recommended that an analysis of the implementation effectiveness of the existing roles and responsibilities of the concerned units within MOHFW, i.e., SWPMM, PMMU, Planning, Monitoring and Research (PMR), Planning, Monitoring and Evaluation of Family Planning (PME-‐FP), with Management, Monitoring and Reporting functions should be conducted. This would include, as per the TORs,
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the relationship between the PMMU and the Line Directors in terms of monitoring and oversight of OP progress (short-‐term activity, 2012-‐2013).
3 It is recommended that the PMMU begin the process of taking on the independent role for the PW of monitoring MOHFW results progress at both the OP and RFW levels through periodic progress reports, including OP indicator performance reporting that are discussed at the monthly LD meetings with concerned DG heads, are forwarded to the PMMU for information and consolidation. This will likely require targeted TA from an RBM expert, but should be able to be completed by the MTR (short-‐ to medium term).
4 It is further recommended that the PW undertake a review and analysis of the existing MIS system to incorporate OP reporting and analysis to ensure more regular OP performance monitoring. ADP and expenditure data need to be available in real-‐time and accessible by authorized stakeholders. This activity should be accomplished before the midterm review. (Mid-‐term, MTR).
5 It is recommended that the M&E TG review and determine whether the DMIS initiative is fulfilling the function for which it was designed. This activity should take into consideration WHO’s policy recommendation creating interoperable information systems and a common data-‐warehouse. This should include an analysis of whether the current TA provider is providing the right quantity and quality support required to fully operationalize and sustain the DMIS. In the event that this assessment leads to the continuation of the DMIS, the data-‐ware-‐house system’s technical support should be integrated to the HIS/eHealth (short-‐term activity). As per one of the recommendations that came out of a review of the draft M&E report, the analysis should determine whether HRIS can be integrated into current configuration (short-‐term, 2012-‐2013).
6 It is recommended that the PMMU utilize existing IT infrastructure at the MOHFW, specifically that HIS/E-‐health should develop data banks that generate reports based on PMMU specification in order to support PMMU responsibilities in this area (mid-‐term, MTR).
7 Consistent with the PIP and the SWPMM OP, the IRT concludes that the PMMU is best placed to support the Planning Wing’s responsibility to monitor, analyse, and report on the performance of the 32 OPs and progress of the RFW. It is the IRT’s recommendation, therefore, that the PMMU will require additional staff with expertise in performance management and managing for development results; and, an implementation plan that clearly lays out priorities and the activities, timelines, benchmarks and individual PMMU member responsibilities to ensure this most important PW function is achieved. It is hoped that a concerned DP(s) would support this recommendation (short-‐term activity).
8 Consistent with WHO Health Metrics Network recommendation, the MOHFW should consider bringing in technical support to begin the process of developing a draft on Health Information Policy. The policy needs to address data security, data validity, reporting obligations of non-‐MOHFW government health services, the private-‐ and NGO sector (long-‐term, 2016).
9 To further improve the process of data collection at facility level, consider an assessment of data collection and reporting functions at the Upazila level and above to determine if efficiencies (reduce multiple redundant data collection forms) can be improved (mid-‐term activity).
10 A study is recommended to examine the rationale for creating a Central IT Information Unit, preferably headed by the HIS/eHealth, to be attached directly to the Secretary of Health, in order to establish one entity responsible for data processing, software design, reporting, and interoperability of all MOHFW information systems (long-‐term, 2016).
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2 . 5 D I S E A S E C O N T R O L ( I N C L U D I N G H UM A N R E S O U R C E S )
The HPNSDP contains five OPs directly related to disease control. Three OPs, i.e., communicable disease control, National AIDS/STD Program and Tuberculosis (CDC, NASP, TB&LC) deal with communicable diseases and two OPs, i.e., non-‐communicable Disease Control and National Eye Care (NCDC, NEC) with non-‐communicable diseases. Considerable success has been made in managing communicable diseases through well run vertical programmes which have attracted both pool and parallel DP support and extensive technical assistance. Leprosy has almost been eliminated from the country; TB and malaria have strong control programmes in place although the burden of disease remains high; and the country has responded well to emerging threats such as avian influenza, pandemic H1N1 and nipah virus; the prevalence of Human Immune-‐Virus (HIV) in Most at Risk Population (MARPs) remains under 1 percent.
Success in controlling communicable and vaccine preventable diseases, reductions in maternal and neonatal mortality combined with sustained economic growth (the number living in poverty has reduced from 49 percent in 2000 to 31 percent in 2010), rapid urbanization, reduced fertility, and increased life expectancy are all contributing to a major change in the epidemiology of disease. NCDs now account for 52 percent of deaths, up from 44 percent in 2002; diabetes prevalence is about 7 percent and Bangladesh will be among the top ten countries in the world by the number of people living with diabetes in 2025 – just as it is now for TB.
Although most people seek outpatient care from private providers and the non-‐formal sector, the majority of inpatient care still occurs in public facilities. Significant progress and investment has been made in upgrading facilities but less progress has been made in addressing the more fundamental issue of staff numbers, location and skill mix. In particular, the lack of nurses and midwives remains a critical issue.
Results and Achievements Good progress has been made in malaria control with an impressive reduction in mortality from 0.0034/1000 to 0.0022/1000 and 67 percent coverage of households with LLIN; a TB drug resistance survey has been completed, treatment guidelines written, and Multi-‐Drug Resistant (MDR-‐)TB enrollment started outside Dhaka; PEP for rabies is now available in 64 districts; progress is being made in the treatment of kala-‐azar; and the national response to pandemic H1N1 and avian influenza was rapid, flexible and coordinated; targets for cataract surgery for 2014 have already been achieved. A national strategy for NCDs has been developed and a national strategic plan for HIV/AIDS is also in place. However, implementation in both these programmes is weak.
Recruitment was static from 2008-‐2010 but since then over 2000 nurses and 3000 doctors have been recruited. A direct entry midwifery programme has been established that aims to train 3000 midwives by 2015 – a recommendation from the last APR. Drug supply has improved at hospitals with stock-‐outs no longer a major problem and the use of web-‐based systems has significantly improved the quality and timeliness of reporting from district and sub-‐district levels.
Challenges and Constraints A number of challenges exist. The key areas of concern are:
1 The NASP used only 41 percent of PA funds during the FY2011-‐12. The Global Fund for AIDS, TB and Malaria (GFATM) programme, United States Agency for International Development (USAID) HIV Prevention Programme, and NASP OP are complementary and all are needed to implement the national strategic plan. The provision of Anti-‐retroviral therapies (ARTs) (from November 2012), VCT (from September 2013) and national sero-‐surveillance lie with the NASP. The delay in the release of funds means that implementation in these and other areas has been delayed, creating significant problems on the ground and risks for the future.
2 The number of nurses and midwives being trained and recruited remains too low. Despite clear political support and an ambitious OP the key issues remain unaddressed and the capacity of the
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Director of Nursing Services (DNS) to deliver the OP is limited largely by factors beyond its control. The bottlenecks in the recruitment and promotion of nurses remain; a full director of nursing has not been appointed since 1992; and the number and quality of training facilities and, more importantly, trainers is low.
3 Implementation in the area of NCDs is weak and uncoordinated. The NCD strategy rightly focuses on screening and prevention to be delivered via existing hospitals and clinics. However implementation to date is weak and the ability of already busy and understaffed units to manage this is unclear; only limited use has been made of the many national institutes in this field.
Principal Recommendations 1 Conduct a mid-‐term review of the national strategic plan for HIV/AIDS in early 2013. This
should be planned now using money allocated from the OP or other sources, independently led, and engage stakeholders in the field. The outputs should include necessary revisions to the OP and budget to address the key areas of concern.
2 Remove the bottlenecks in nursing recruitment and promotion and build capacity within the DNS. Multiple sets of rules govern nursing recruitment and promotion and these are both complex and confusing. A new set of rules has been drafted and priority should be given to approving and implementing this. The DNS needs strengthening if it is to deliver the OP. Appointing a full director of nursing for the first time since 1992 would give a clear signal of strong commitment in this area.
3 Move from strategy to implementation in NCDs. The current plan is to use hospitals and clinics to screen for diabetes and hypertension. Far more capacity and interest exists at the community clinics and screening should be based here. The expertise of national institutes such as NICVD and BIRDEM should be used to develop and implement simple, low-‐cost, and locally appropriate treatment guidelines and also to monitor their use. Focus should be given to other NCDs. The biggest area of concern is drowning. This is the leading cause of death in children aged 1-‐5 years and proven interventions exist in Bangladesh
2 . 6 N U T R I T I O N ( I N C L U D I N G H UM A N R E S O U R C E S )
Results and Achievements There has been progress in the reduction of stunting and underweight in children under five. At the current rate of progress (from 41 percent to 36 percent in the period 2007-‐2011), Bangladesh will most likely attain MDG 1 of 33 percent underweight by 2015. It will be much more difficult to reach the stunting target of 38 percent given current progress (from 43 percent to 41 percent in the period 2007-‐2011). Gains in exclusive breastfeeding rates are unlikely to result in substantial reduction in stunting unless appropriate infant and young child feeding practices (diet diversity and frequent feeding) improve substantially. Only 30 percent of the mothers in the highest wealth quintile and 23 percent of the mothers who completed secondary education or higher apply at least three of the recommended Infant & Young Child Feeding (IYCF) practices. Only one in ten mothers in the lowest wealth quintile and/or not having attained any education adequately feeds their children.
An estimated 17 percent of all children under five suffer from acute malnutrition. That is some 2.5 million children, of whom half a million suffer from severe acute malnutrition. In addition, more than one in five babies (22 percent) weigh less than 2,500 gram at birth (Low Birth Rate / LBW). Both impact negatively on under five and neonatal mortality, because low birth weight babies are ten to twenty times more likely to die than babies of normal weight, while the odds of severely malnourished children dying are eight times as high as those of well-‐nourished children.
Levels of anaemia among women and children are very high (ranging from 35 percent to 70 percent). Iron deficiency anaemia is estimated to cause 2.5 percent drop in adult wages and 8 percent loss in gross domestic production.
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Mainstreaming nutrition is one of the HPNSDP priorities. This should (eventually) result in a country-‐wide comprehensive system of nutrition services delivery. The National Nutrition Service (NNS) OP aims to improve the nutritional status of women and children and has formulated targets for five nutrition outcomes. If these are achieved, Bangladesh will be well on the way to reducing under-‐nutrition. The OP has prioritized ten activities/components, progress of which is monitored through 12 output/process indicators. During the first year of implementation, nine of these (75 percent) outputs were achieved. One of the outputs not achieved is the development of the nutrition information system and merging thereof with the current HIS. NSS has started developing this, but even in the best of circumstances this takes several years to achieve. The output in terms of capacity development is very substantial in terms of health staff trained at all levels, particularly considering that NSS has only been fully functional since early 2012. Whether training translates into improved nutritional services is difficult to assess in the absence of nutrition data in the routine HIS. Moreover, the NNS is highly dependent on health staff under other directorates including Hospital Services Management (HSM), Maternal, Neonatal, Child and Adolescent Health (MNCAH), Maternal, Child, Reproductive and Adolescent Health (MC-‐RAH), Community Based Health Care (CBHC), and UPHCP for the delivery of nutrition services.
Conclusions and Recommendations Policy level
1 In pursuance of article 18 (A) of the constitution (Improvement of the Nutrition of the people and public health) the Government of Bangladesh developed a Nutrition Policy aimed at improving the nutrition status with a particular focus on women, children and vulnerable groups and reducing severe malnutrition through food safety, security, supply, and nutrition education. The National Food and Nutrition Policy was formulated in 1997; this policy was split into two parts in 2006 when the section on Food Policy was updated. There is a need to update the National Nutrition Policy.
2 The need for multi-‐sectoral coordination to improve nutrition has been recognized; development partners and several ministries, including the Ministries of Agriculture, of Livestock and Fisheries, of Education, Food and Disaster Management, Industries are represented in the Nutrition Steering Committee under the lead of the MOHFW. The effectiveness of the Steering committee could be further improved by preparing subjects in smaller forums consisting of primary stakeholders, for decisions on programmatic collaboration.
3 Because for most activities NNS depends on other services for actual service delivery, all relevant services should include in their OPs, nutrition outcomes and – where they are responsible for the actual service delivery – outputs, indicators and activities, and made accountable for their achievement. When adjusting the current OPs, this should be a priority. Inclusion of nutrition indicators makes visible that mainstreaming nutrition needs a concerted effort and that the ultimate desired outcome of mainstreaming is integration.
4 Steps need to be taken to implement the decision of the Honourable Prime Minister (as per Her letter of 8th March 2011) to appoint a nutritionist in all hospitals (district hospitals and UHC).
Programme level
1 NNS has elaborated both a comprehensive strategy and a plan of action for training health service providers. In order to successfully mainstream nutrition within the regular health services, capacity building of a very substantial number of staff at all levels is required. This cannot realistically be achieved by NNS alone. Therefore, nutrition should be integrated in all in-‐service and pre-‐service conducted by DGHS and DGFP training, and, under the leadership of MOHFW, included in all medical (training) institutions.
2 Capacity at CC level, consisting of three staff working part time (translated in two full time equivalent posts), is limited in view of the (many) activities as well as the increasing population,
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making it very challenging to adequately provide services including home-‐visits. In view of the need to increase nutrition services in particular at CC level, it is recommended to incorporate more nutrition workers for quick fulfillment of the HR gap, and gradually incorporate them in the revenue. In hard to reach areas, collaboration with NGO’s using the NGO partnership model should be pursued.
3 Reducing the prevalence of anaemia by one third in women in reproductive age and children is unlikely to succeed in view of the high needs and a food consumption pattern low in iron, unless a concerted multi-‐sectoral effort is made. The latter should include fortification of rice. MOHFW services should scale up supplementation of iron/folic to include all females of reproductive age and children under five.
Operational level
1 The NNS OP prioritises growth monitoring and promotion (GMP), but lacks output indicators specifically related to GMP. It is recommended to include an output indicator for GMP when the OP is revised. Health workers, in particular at CC level, need to be prioritized for capacity building in GMP. Monitoring of weight (and in a second phase height) should go hand in hand with both individual and group counselling on IYCF including EBF and the use of iodised salt, with a view to raise awareness on adequate nutrition as (one of the) crucial determinant(s) of children’s healthy growth.
2 Ongoing mass media campaigns to improve IYCF practices, complementing facility based and community based nutrition education, should be intensified and research on the impact and modalities of mass campaigns on exclusive breastfeeding should be conducted to inform the ongoing campaign on IYFC as well as other mass campaigns. IEC and BBC need to be strengthened.
3 Treatment of children suffering from severe acute malnutrition in nutritional rehabilitation units in hospitals and priority UHCs needs to be effectuated. To this end the following is recommended: (1) scale-‐up training in management and control of severe acute malnutrition; (2) accelerate the distribution of measuring equipment and; (3) ensure availability of F-‐75 and F-‐100 (to be imported as an interim measure, with permission from MOHFW). Without easy to prepare F-‐75 and F-‐100 formula, treatment of the severely malnourished within the regular health services is simply not feasible.
4 The sheer effort of mainstreaming nutrition warrants a step-‐by-‐step approach (as already foreseen for such activities like inclusion of nutrition data in the HMIS and management of severe acute malnutrition). It is better to proceed systematically, and more slowly, and adjusting interventions when needed, than jeopardising the effectiveness of nutrition activities.
2 . 7 MN C H A N D F AM I L Y P L A N N I N G ( I N C L U D I N G H UM A N R E S O U R C E S )
Bangladesh over the past decade has registered dynamic changes in the social and economic sectors. Recent national surveys (BDHS and BMMS) report remarkable progress on a good number of health, family planning and MDG indicators, which are on track to achieve targets by 2015. Contributions from the public, private, and GOB partnership with the Development Partners (DPs) and NGO community must be appreciated. Other indicators are progressing relatively well but will require some level of acceleration, in terms of increased efforts, investment, planning specific health interventions, and removing health care delivery system bottlenecks by thinking outside the box.
Results and Achievements Despite impressive gains in maternal, neonatal, and child health indicators, provision of services in government health facilities remains a major challenge. The provision of EmOC at UHC level is limited and the ones already in place are not functioning 24/7 as expected, mainly due to HRH issues like vacancies against sanctioned positions. The pair of gynaecologist and anaesthetist is not always
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functional in the only Upazila visited during the IRT visit. It would be important to have a more comprehensive analysis of the status in all Upazilas where the pair should be. The Demand-‐Side Financing (DSF) is a laudable initiative and needs to be examined within the framework of equity and targeting to address the urban/rural and rich/poor disparities.
At the community clinic levels, the Female Welfare Assistant (FWA), Health Assistant (HA), Community Health Care Provider (CHCP) and those who qualified to become Community Skilled Birth Attendants (CSBAs) have the tremendous potential to make significant contributions to further improving the health status of the people and improving a good number of MDG indicators. However, their work must be coordinated and guided within the process of developing a yearly Local Level Plan. The work and potential of CSBAs are important but extremely limited at the present time and must be scaled up to the national level in the shortest possible timeframe. Efforts to meet the commitment of Honourable Prime Minister at UN General Assembly to train and deploy 3,000 Midwives is critical in enhancing the facility and skilled deliveries and given that an estimated 21,154 midwives2 will be needed to cover Bangladesh’s population of 150 million people.
The family planning related OPs have made progress but it is not clear whether they will achieve the shift from temporary to long acting and permanent methods. Again effective partnership with the private and NGO sectors would help to achieve them. The Family Planning Field Service Delivery (FPFSD) needs to revise its baseline data and set new targets.
Challenges and Constraints The public sector faces some key and, at the same time, chronic challenges. By and large, the quantity and quality of human resources is the principal sector challenge, followed closely by limited programme monitoring and supervision. The human resource challenge is complex and a sustainable solution difficult to develop and achieve for it deals with major policy issues such as decentralization and civil service reform. Health sector HR development and management plan to deal with employment, rational deployment, retention, and incentives to personnel posted to rural and less attractive duty stations must be in place. Some concrete suggestions are made in the consolidated 2012 APR Report. The challenge is for the MOHFW to take this as the highest system priority and set clear deadlines and benchmarks that can be monitored by development partners and allocate sufficient funds from either or both development and revenue budgets.
As far as institutional performance appraisal is concerned, there are already some elements of it in place such as the monitoring of OP implementation by process indicators, as well as the indicators to monitor the Disbursement for Accelerated Achievement of Results (DAAR) and the Governance and Accountability Action Plan (GAAP). The challenge will be the regular use of the information generated by normal administrative records for management purposes.
Local Level Planning is popular amongst most of the OPs but shows limited coverage because it is partly implemented, monitored, and supervised. However, the resource backed LLPs developed in Joint GOB-‐UN and NGO MNH Initiatives in 29 districts with proper financial support are very encouraging. Good practice and lessons learned could be applied to the implementation of LLP in most OPs.
Local Level Planning at the community clinic level would address some issues of decentralisation and more importantly it has the unique potential to encourage functional integration of health and family service providers under the ownership of the Community Clinic staff to ensure reasonable levels of leadership and accountability. If good coverage is achieved, it will contribute to making further progress in achieving the process and impact indicators not only in the OPs but also with the HPNSDP Results Matrix indicators.
2 One midwife for approximately 175 annual births in the context of Bangladesh with 150 million people (WHO).
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None the four OPs reviewed as part of the MNCH-‐FP Thematic Area assessment considers programme information communication or behaviour change communication as priorities. The OP communication priorities are set by the IEM and BCC Operational Plan and there is no evidence the health services and family planning OP LDs had participated in defining behaviour change priorities and therefore communication strategic priorities to help the OP to achieve its programme objectives for the communication component is part and parcel of programme management.
Principal Recommendation Short Term
‒ Human resources: Institutionalize short-‐term emergency measures such as task shifting, local recruitment, contracting, partnership with NGOs.
‒ Ensure DGHS and DGFP functional integration by enhancing LLP at community clinic level, in addition to Upazila and District.
‒ Implement the Neonatal Health Strategy focused to activities at community level. ‒ Midwifery training and deployment at DH and UHCs should be given priority. ‒ The training and deployment of CSBA must be accelerated and proper supervision, monitoring
and mentoring. ‒ Strengthening FP activities especially at the low performing and HTR areas enhance CPR and
reduction of TFR. ‒ Accelerate to reach 20 percent share of long acting and permanent methods (LAPM) by involving
OB-‐GYNAE specialists at MCH, DH, and private facilities through orientation, supply of logistics. Increasing IEC activities at all level, supportive supervision and monitoring, fixing monthly target for field workers.
‒ Strengthen IEC to support the delivery of key health and family planning services, focused on improving facility deliveries, community essential newborn care and LAPM.
‒ Expand both C-‐ IMCI and F-‐ IMCI, training of service providers on newborn care, and supply of drugs and logistics. HBB may be very effective.
‒ Some OPs could be revised to ensure quality and relevance of indicators to measure implementation progress over the next year. It is recommended to include at least one nutrition related indicator.
Medium Term
‒ Developing a Human Resources Development Plan with proper demographic projections, recruitment, and reallocation of staff.
‒ Developing and regularly updating the Human Resource Information System. ‒ Based on field experience already available in the country, develop a TQM Procedures and
Manual to be used by public, private sectors, and NGOs
Long Term
‒ Develop an accreditation system and enhance capacity at the pre-‐service training institutions to fulfil workforce needs.
‒ Address major policy issues such as civil service reform and decentralization.
2 . 8 U R B A N H E A L T H ( I N C L U D I N G P O P U L A T I O N A N D N U T R I T I O N )
Last year’s national census reported that out of a population of more than 150 million, approximately 30 percent live in one of the rapidly expanding cities and towns (as opposed to 2 percent about a century ago). It is believed that this urban population will be increasing by 6 percent a year as millions of people leave rural areas in search of work.
It is obvious that this anticipated situation will have a great impact on all sectors in society, be it agriculture, industry, water, infrastructure, housing, as well as on the ‘health, population and nutrition’ sector. Even in the likely event of continued economic growth, which usually has multiple
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positive effects on a country’s health status, it remains to be seen whether future public service budgets will be sufficient to meet the growing demand for badly needed basic facilities in urban areas, like education, water, electricity, housing, nutrition, health, as well as for effective health promotion activities. Should these enormous challenges not be met, the majority of the population (with the poor in particular) will end up being exposed to increasing social and health risks, the nature of which will be alarming for society.
Results and Achievements Available studies and policy documents (such as the DHS, Urban Health Survey of 2006, the 6Th FYP, 2011 National Urban Health Sector, the Urban Health Strategy and recent Stakeholder Consultation) confirm that health services in most urban areas are inadequate, both qualitatively and quantitatively. It is estimated that approximately 40 percent of the urban poor (approximately 17 million people) are currently not covered by primary health care. With the costs of health services and citizen’s demand for them rising on the one hand and a limited capacity to pay on the other, this will inevitably lead to a decrease in access to quality urban health care.
By incorporating urban health in the 2011-‐2016 HPNSDP and making it a thematic area, the MOHFW has made a commendable first step in recognizing the structural nature of the problem and all future challenges going with it. It is encouraging to note that there is also increasing realization within the MOHFW and MOLGRD that ultimately health services in urban areas will have to be funded, organized, and managed differently.
However, many of the rather ambitious plans anticipated under the 2011-‐2016 HPNSDP towards developing a more rational and service delivery system (i.e. mapping exercise), addressing existing overlap and fragmentation in service delivery (i.e. development of referral guidelines), rationalizing the service delivery system (i.e. strengthening public private partnerships), and building up a solid PHC health infrastructure at urban level (i.e. resource plan) are still in their infancy and need further strengthening as a matter of urgency.
Under component 3 of the 2011 “Essential Service Delivery” (ESD) Operational Plan of Directorate General of Health Services / GHS), the following objectives/targets were to be achieved in 2011/2012: (a) provide PHC services to the urban population, (b) ensure proper utilization of resources for urban primary health care activities, (c) provide PHC services to the urban poor, (d) ensure strong coordination between MOLGRDC and the MOHFW, (f) define an adequate referral system between the various urban health dispensaries (Government Outdoor Dispensaries, GODs) and the second and third level hospitals, and (g) explore feasibility of introducing General Physician System. As discussed in the concluding section of this chapter, MOHFW’s principal role in urban health is as “steward”, providing commodity and technical support where required and policy guidance and good practice to the principal service providers.
The FPFSD OP under DGFP included some activities aimed at strengthening FP services in urban slum and (a) registering couples, (b) domiciliary and door to door distribution, (c) counseling and motivation, (d) establishing referral linkages between urban slum and FP service centers, (e) arranging FP package programs, and (e) orientation and coordination meeting. Little progress in these areas is reported in the 2012 APIR of the latter two OPs on urban health.
Challenges and Constraints Assessing progress to date of the ESD and FPFSD OP’s against 2011/2012 targets, results are somewhat disappointing. Apart from some training, orientation workshops, and seminars, the 2012 APIR does not show much evidence that the core issues pertaining to urban health, have been properly and fully addressed.
Underachievement is due to a variety of reasons:
‒ Short-‐term (operational) targets have not been properly derived from earlier agreed conceptual framework,
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‒ And activities are not worked out in an effective way and defined as the drivers of outputs.
Furthermore, it looks as though DGHS and DGFP are not in the best position to perform most of the activities planned for, since these are related to the mandate, role and functions of the line Ministries.
Nonetheless, experienced weaknesses during the first year of implementation, there is good potential for building up a first level of care system in urban areas along with the MOLGRD. The results from previous (policy) studies and project ‘lessons learnt’ within the NGO sector could be used to this effect. At the same time, an increasing number of DP’s has expressed interest to provide targeted technical and financial assistance in such process.
The report also argues that improved partnership between the MOHFW and the MOLGRD, as well as between the public and private /NGO sector is indeed required to yield better results.
Considering the variety of (institutional, administrative, organizational and managerial) issues which need addressing under the Programme, it is recommended to adopt a step-‐by-‐step approach and deal with identified challenges more systematically, rather than spreading out existing capacity too thinly.
A series of actionable recommendations are made for the MOHFW to consider for future policy development and planning purposes. For each of the OP’s, specific activities are listed, some of which could be implemented shortly, while others will be more time-‐consuming.
Recommendations Lead OP Priority Comments
Agreeing on clear strategy, responsibilities, and management structures between MOHFW and MOLGRD
SWPMM Short-‐term Senior management of MOHFW to initiate the process
Developing policies, plans and guidelines for linking PHC services in urban areas with clean water, housing, sanitation, and environmental pollution etc.
SWPMM Medium-‐term
In consultation with other line Ministries
Revitalizing Joint Urban Health Technical Committee to ensure that strategic issues pertaining to urban health be adequately translated in policies and plans
SWPMM Short-‐term Strong involvement of MOLGRD/ City Corporation, LD of ESD and FP/FSD desired
Urban Health Task Force between MOHFP, MOLGRD and DP’s to periodically discuss and review for urban health policies, plans, and resource strategies
SWPMM Short-‐term
Define the principles and modalities of ‘outsourcing’ PHC services from large to small municipalities with a clear accreditation mechanism
SWPMM Short-‐term In coordination with MOLGRD, City Corporations and relevant NGO’s
Prepare an national urban health coverage plan SWPMM Medium-‐term
In coordination with MOLGRD/ City Corporations
Recruit the services of a consultant to facilitate the process of policy development and mainstreaming urban health in the core activities of the MOHFW and MOLGRD
SWPMM Short-‐term
Strengthen referral system between urban PHC centers and secondary/tertiary health centers
ESD Medium-‐term
In coordination with MOLGRD, City Corporations, relevant DP’s and NGO’s
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2 . 9 I E C & B E H A V I O R C H A N G E C OMMUN I C A T I O N S
The review of information, education, and communication (IEC) and behaviour change communication (BCC) products and processes in HNPSDP involved an assessment of a very wide range of materials and observation of communication activities. The IRT members studied strategy documents and implementation reports; visited a number of NGOs and media agencies active in IEC and BCC; interviewed a number of key informants from inside and outside the Ministry of Health and Family Welfare (MOHFW); and made a field trip to Pabna District.
The focus was on two operational plans (OPs): Health Education and Promotion (HEP) of the DGHS and the Information, Education and Communication (IEC) of the DGFP. The key objectives of the review were to assess achievements made during the first year of HPNSDP operations, identify opportunities and challenges, and make recommendations for possible improvements in IEC/BCC strategies and activities – which would enhance the achievements of all the programme’s health and family planning service delivery objectives.
Achievements and Results Bangladesh’s successes in family planning programmes have resulted in a dramatic reduction in fertility and its service delivery strategies have made its health indicators on a par with or better than its South Asian neighbours. The IRT believes these achievements are, to a significant degree, due to the design and development of IEC materials.
Both OPs reviewed by the IRT are broadly on track to achieve their targets, as shown in the 2012 Annual Programme Implementation Report (APIR). The IRT notes that the range of output indicators of both OPs contribute to the achievement of service delivery outcomes arrayed in the programme’s Results Matrix. However, the output indicators could be made more precise by defining the content of materials to be produced or the nature of the activities to be conducted – and the target groups.
The IRT has reviewed a very wide range of materials: posters, flipcharts, flash cards, leaflets, TV and radio drama series and ‘infomercials’, and videos for use in the extensive network of health facilities across the country. The team has also considered the use of mobile phones and websites in the promotion of health education and the training of front-‐line health workers. There is, then, a rich array of available IEC materials covering all the priority topics of the HPNSDP and leading towards the achievement of indicators concerned with increased utilization of essential HPN services and improved awareness of healthy behaviours.
Many of these print and electronic materials have been designed and disseminated in collaboration with social marketing NGOs, media houses, private companies, and often funded by development
Ensure provision of communicable disease services
CDC Short-‐term In consultation with MOLGRD
Define performance and output indicators related to urban health services
ESD and FP/FSD
Short-‐term
Update urban health survey TRD/NIPORT Short-‐term
Conduct operational research on best practices for outsourcing urban PHC services to NGO sector with a view to developing a generic model for use by City Corporations
TRD and Planning DGHS
Provide support to City Corporations in local mapping and preparation/ use of urban health development plans, in consultation with all providers
SWPMM Short-‐term In coordination with City Corporations and MOLGRD
Conduct operational research on alternative financing mechanism
SWPMM Medium-‐term
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partners. In this regard, the IRT finds that the regulating and coordinating functions of the MOHFW, through its Technical Committee (in order to ensure consistency of health messages and avoid overlaps) have been carried out effectively and without cramping creativity. There are, though, concerns expressed about the sometimes slowness of the approval process. But if there is a key problem, it is not to do with the availability or quality of IEC materials – it is more to do with their use. From observation of health education sessions in health facilities in Pabna District, from confirming reports from key informants, we conclude that most teaching – or even counselling – is conducted in a transmittal and directive, as opposed to participatory manner. Moreover, the settings for these health education sessions are not conducive for interactive and discussion-‐based communication. The IRT submits that behaviour change is usually the result of more complex and, even, challenging communication modes, such as force field analysis, positive deviance, and the confrontational approaches used in community-‐led total sanitation (CLTS) that was pioneered in Bangladesh. It is in the main in relation to this crucial issue that the IRT has made a number of recommendations concerned with strengthening the BCC initiatives under the HPNSDP.
Principal Recommendations 1 When approving IEC materials the MOHFW’s Technical Committee should develop and apply a
set of criteria for appraising the design and production qualities of submitted materials. This is in addition to what they are doing now: that is, ensuring that the health care and family planning messages are consistent, overlaps are avoided, and the content is in keeping with the values and practices of Bangladeshi culture. (Short-‐term)
2 Though the IRT recognises the complexity and sensitivity involved in appraising some IEC materials – particularly with scripts of TV or radio drama series – nevertheless, mindful of the production deadlines and funding conditionalities that production houses are faced with, it is suggested that the Technical Committee should consider ways of completing its work as expeditiously as possible – even building in a ‘no objection’ clause that, if a review is not completed within a period of, say, two months the submission would be considered approved. (Short-‐term)
3 The IRT recommends that an intensive module should be designed for those expected to train both health facility staff and front-‐line family welfare assistants and family welfare visitors. Such a module should contain a toolkit of experiential and interactive facilitation and counselling methods. It should last at least two weeks and should allow sufficient opportunity for the participants to practise the BCC skills. Ideally, the module should include follow-‐up sessions during which the participants could raise issues encountered in their own training and supervision activities. Finally, refresher workshops should be planned for at suitable intervals – further opportunities for reflection on challenges encountered and lessons learnt. (Medium-‐term)
4 The proposed BCC module should include advice on how to use videos as trigger material for discussion of key health issues, whether in health facility or community settings. (Medium-‐term)
5 Concerning the mobile vans of the MOHFW, the IRT suggest that they could be turned into ‘caravans’ or road shows, involving a broader range of performances. It would increase their appeal and deepen their educational impact if, along with playing recorded music and videos, they could promote performances of live street theatre and songs in local dialects – using, whenever possible, local popular artists. (Medium-‐term)
6 Part of the emerging health strategy should be to engage with community and religious leaders in order to inform them about key health-‐related initiatives and make them allies in such campaigns as those related to girls’ education, early marriage, dowry, and violence against women – by involving them in campaigns and including them in TV and radio drama or infomercials. (Short-‐term)
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7 The BHE and IEM units should be ready to engage with those health education NGOs and media agencies that are willing to experiment with multi-‐media programmes and packages (using TV, websites, mobile phones and newspapers) that have a potential for scaling up through the extensive infrastructure and widespread personnel of the MOHFW. (Medium-‐term)
In order more effectively to link the work of the BHE and IEM units with IEC and BCC initiatives being taken outside the MOHFW – and to assist other OPs of the HPNSDP in availing IEC materials and BCC approaches – it would be of great benefit to both units if they had IEC/BCC advisors, who could work across the OPs when designing their communication strategies and activities. (Short-‐term)
2 . 1 0 O V E R A L L C O N C L U S I O N A N D R E C OMM E N D A T I O N S : K E Y T E C H N I C A L I S S U E S , C H A L L E N G E S A N D O P P O R T U N I T I E S
The review of the eight Thematic Areas by the IRT consultants shows that significant progress has been made in implementation of the HPNSDP but, as would be expected, there are a number of programmatic and management issues that have been identified which the IRT believes, if the recommendations are implemented, will lead to the achievement of both Operational Plan outputs as well as contribute to the achievement of Results Framework outcome and impact level results. In addition to the key issues raised each of the Thematic Area Technical Reviews noted above, this concluding chapter also raises several overarching issues related this first Annual Programme Review under the new SWAp, including the two new HPNSDP components, Urban Health and Nutrition, as well the focus on managing for development results. Finally, while this year’s APR substituted the Stakeholder Consultation for a formal review of the Gender, Equity, Voice and Accountability (GEVA) thematic area, the Team Leader undertook a limited review in collaboration of the GEVA Task Group and provides a brief summary of the analysis and principal findings and recommendations below.
Urban Health Urban health was singled out for special attention for a number of reasons under HPNSDP, including both moral and practical ones. Moral, in the sense that the significant numbers of the poor are increasingly found in urban centers and particularly urban slums and that, as the principal Ministry responsible for health care and services, the poor in urban slums need to be continued and focused assistance, particularly given the equity focus of the new SWAp; and, practical, in the sense that many of the principal HPNSDP RFW national level impact results (NMR, stunting) are being brought down by the low health indicators of the urban poor requiring renewed targeting.
The Ministry of Health and Family Welfare recognizes that its principal role in urban health is to act as the Government of Bangladesh’s principal steward as it does in all such health sector wide initiatives; and, as a critical partner, along-‐side the Ministry of Local Government and Rural Development, in the governance of urban health activities. MOLGRD is responsible for primary health care delivery services to urban inhabitants, including slum dwellers and does this largely through NGOs with the support of development partners, often outside of SWAp boundaries. This is the reality, and the responsibility, therefore, of the Ministry is not as an implementer of PHC services, but rather as a facilitator and provider of technical support to concerned City Corporations, including good practice, commodities (family planning) and technical assistance and training on the one hand, while ensuring overall sector policy guidance, standards and norms on the other.
The IRT has noted a number of key issues, but the two of the more important are: 1) the need for MOHFW to take a proactive role in reinvigorating the multi-‐sectoral forum of concerned health service providers in urban areas; and (2) establish written guidance on the MOHFW’s role in urban health for the OPs and ensure that they up-‐date their individual strategies to reflect their role in urban health, including one or more indicators to measure this role.
Nutrition Mainstreaming Nutrition has gone from a discrete programme, often unrelated to other health activities and surely not given the highest priority in earlier SWAps, to a major new component of the HPNSDP through
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its mainstreaming of activities in relevant Operational Plans under both the Director Generals of Health Services and Family Planning. The IRT has found that good progress is being made in this mainstreaming effort and that the National Nutrition Service has taken the lead in promoting both the importance of nutrition in service delivery activities across the HPNSDP, and coordinating with other OPs to ensure that they assess and undertake their activities in such a way that nutrition is taken as a priority alongside their normal activities. In addition to the recommendations noted above under the Nutrition Thematic Area Technical Review, the IRT would like to emphasize the following here:
‒ The NNS is a relatively new service and requires strengthening, including additional staff with the right mix of skills and their ongoing in-‐service and specialized training. This includes the LD and concerned staff, as well as frontline workers from the Upazila to Community Center levels.
‒ Secondly, it is critical that each concerned OP not only add indicators to reflect the nutrition outputs that they will now promote as a normal part of their activities, but also better understand how to integrate and mainstream nutrition interventions into their respective OP strategies. The IRT’s recommendation in this regard is a major strategic planning effort for concerned OPs to think through what they will do to promote nutrition, how they will do it, both technical approach and methodology, and most importantly with whom in terms of both coordinated activities with other OPs but also with NGOs and the private sector.
Monitoring and Evaluation: Managing for Development Results The IRT noted with interest the significant emphasis that SWAp documentation, from the PIP to relevant Task Group TORs and Operational Plans, placed on the importance of managing for development results. In the review of the M&E Thematic Area, the team highlighted the critical role that the Planning Wing plays in ensuring that results at both the RFW and OP levels are achieved, as well as promoting a performance-‐based and accountability framework among the OPs. The concerned IRT M&E Thematic Area Review did raise several issues including: 1) the weak link between the OP outputs and RFW results that indicated the possibility that while OP indicators could be achieved, there was no necessary conclusion that this would ensure that concerned RFW results were achieved; 2) the APIR is based on self-‐reporting of OPs and is thus, not an independent review of OP implementation; and 3) the PMMU is best placed to support the PW’s responsibility in the management, monitoring, and reporting on OP and RFW results but lacks the human resources, both in numbers and expertise to fulfill this key function. The IRT, thus, posed three principal recommendations to address these key issues:
1 Develop two to three “intermediary results” for each OP based on the relevant log-‐frame purpose level result, that bridge the weak link found between the OP and the RFW;
2 The APIR should be based on an independently monitored review based on of OP results-‐reporting to the PMMU in its role as PW/MOHFW oversight body, including existing indicators and new intermediary results’ indicators; and,
3 Strengthening the PMMU, including adequate number and expertise level of its staff, to undertake this independent oversight role for the PW/MOHFW.
Gender, Equity, Voice and Accountability (GEVA) Thematic Area GEVA was the ninth Thematic Area to have been reviewed by the IRT. However, the decision was made by the HPNSDP to not conduct a full review this year, rather viewing the Stakeholder Consultation as an adequate vehicle to assess GEVA progress and thus contribute to the 2012 APR review. The Team Leader reviewed the draft Stakeholder Consultation and found it inadequate either to the needs of the GEVA Task Group or as an independent assessment of stakeholder views that would feed into the IRT’s work by providing a means to triangulate the findings of the APIR and IRT member individual analyses. The following brief discussion provides the TL’s analysis of GEVA thematic area in two parts: (a) stakeholder consultation and (b) GEVA going forward.
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Stakeholder Consultation (ShC)
The ShC provided little if any discussion, whether findings or analysis, of gender, equity, or accountability. It did of course provide a voice for concerned HPNSDP stakeholders, but not on issues that were of use to either the IRT or GEVA. The conclusion is that, as currently constituted, the ShC has very little relevance to either GEVA or future APRs. The IRT recommendation in this regard is the following:
‒ The purpose of the ShC needs to be rethought including whether one is needed at all. If it is needed then a relevant methodology needs to be developed. It is recommended that GEVA review this issue and bring it forward to the HPNSDP SC. If a decision is made to go forward with a ShC in the future, competitive bidding process should be used to choose an organization to develop such methodology.
GEVA Going Forward
The brief review and analysis of GEVA TG indicates that its mandate is far too broad; anyone of these areas (e.g., gender, equity, voice and accountability) could easily take up the efforts of a Task Group, let alone all four. Additional findings that are relevant to all four GEVA thematic interests include:
‒ Gender considerations, including analysis and strategies, are largely absent from all OPs and the RFW, as are indicators to measure gender equality;
‒ An equity-‐focused approach has not been translated into most OP strategies and there are few indicators or disaggregations to measure an equity-‐focused approach;
‒ There has been mixed effectiveness of Community Clinic Management Group in the planning, management, and oversight, etc. of community clinics (CCs); and,
‒ There has been little NGO–private sector participation in SWAp forums, particularly where joint planning takes place.
It is the TL’s conclusion that GEVA TG has a critical role to play in moving HPNSDP forward and with the greatest potential pay-‐off among any of the Task Groups in promoting the achievement of HPNSDP results at OP and by extension the RFW level. To seize this opportunity GEVA needs to become more focused and proactive. Specifically, it is recommended that:
‒ At a minimum, gender and equity should be disaggregated for all relevant OP and RFW indicators; ‒ Develop GEVA TG strategy, which focuses on the community level where gender, equity, and
voice issues play out; ‒ Conduct a gender assessment of HPNSDP and integrate the results into GEVA and OP strategies; ‒ Conduct a bottleneck analysis of inequity drivers in HPNSDP and integrate the results into GEVA
and OP strategies; ‒ Conduct an in-‐depth assessment of the community clinic management groups’ role in CC
planning, oversight, etc., and integrate results into GEVA and OP strategies; ‒ Engage a gender specialist under SWPMM to provide Technical Assistance to OPs; ‒ Create a forum or use existing Steering committee as a means for NGOs and the private sector to
participate in overall SWAp planning and integrate representatives into Task Groups; and, ‒ In the next APR conduct a GEVA Thematic Area review.
Overall IRT Conclusion on Progress Against Objectives In conclusion, the IRT feels that the Thematic Areas are poised to improve their ability to contribute to HPNSDP objectives through the adoption and implementation of the principal recommendations made in the individual Thematic Area Technical Reviews. The above noted key issues were fully discussed with concerned HPNSDP stakeholders and it is our view that the majority of the IRT’s recommendations will be addressed.
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3 O V E R A L L C O N C L U S I O N S A N D R E C OMM EN D A T I O N S : A R E C O N D I T I O N S I N P L A C E F O R A S U C C E S S F U L P R O G R AMM E
In this concluding chapter, the IRT addresses four of the principal requirements of the overall APR 2012 Terms of Reference, that is, the review and analyses of (a) the Updated Results Framework; (b) the Governance and Accountability Action Plan; (c) the Disbursement for Accelerated Achievement of Results; and (d) Updates on the Risk Assessment. In addition, a discussion of institutional constraints in implementation, including any updates to the Risk Assessment are provided, and a financial Framework for the sector including DP funding. The chapter concludes by assessing the second principal APR requirement: do start-‐up measures implemented to date ensure the successful implementation of SWAp activities over the remaining four years of the programme?
3 . 1 R E V I EW , A N A L Y S I S A N D U P D A T I N G O F T H E H P N S D P R E S U L T S F R AM EWO R K
The HPNSDP Result Matrix presents the indicators that were defined in the Project Investment Plan for use in measuring progress against the results articulate for the HPNSDP, the targets of which are expected to be completed no later than the end of the SWAp in 2016. The RFW also presents the baseline data and the expected targets to be achieved by 2016.
Annex 3, provides the complete review and analysis of each RFW indicator. In undertaking this review, the IRT took the updated RFW found in the 2012 Annual Programme Implementation Review and applied an Annual Indicator Change Rate (AICR) methodology to determine whether or not the concerned indicators were on track or required acceleration. We provide, in our analysis of the indicators requiring additional acceleration, why that is the case. We note the following principal findings:
‒ Two of eight (one-‐quarter) goals or impact level indicators, that is, NMR and stunting, require acceleration;
‒ Eleven of 33 (one-‐third) outcome indicators require acceleration if they are to meet the 2016 targets set out for them
‒ Three indicators have already been achieved by the end of the first APR. Consideration should be given to reviewing these indicators and determining whether the targets were set too low.
As a general recommendation, concerned Task Groups should review the IRT findings and analysis to determine how they will go forward in achieving the targets established by the PIP.
3 . 2 P R O G R E S S O N K E Y A R E A S O F T H E G O V E R N A N C E A N D A C C O U N T A B I L I T Y A C T I O N P L A N
As the PAD notes, the GAAP outlines the governance and accountability risks and mitigation actions to ensure the success of key aspects of the project which may otherwise be adversely impacted by these risks. The GAAP has recommendations in support of improving financial management, strengthening weak internal controls, improving procurement management, and strengthening the M&E capacity.
Annex four contains the complete analysis of the GAAP. The IRT has reviewed all 21 of the GAAP Key Objectives, including MOHFW updates, and has provided specific comments on each of them. As a general conclusion, the IRT can say that the majority of Key Objectives are on track but that addressing the specific recommendations made in the GAAP analysis will ensure that they will be met as intended and thus promote the achievement of results both at the OP and RFW levels. We make the following overall observations concerning GAAP Key Objective performance:
‒ The principal area of concern is one that has been recognized in previous APRs and which was again highlighted in the individual Thematic Area Technical Reviews conducted by individual IRT members, that is, the problem of ensuring an adequate number of health force workers, with the
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right mix of skills, in the posts where they are most needed. This includes the issues of frequent transfers, as well as the non-‐filling of sanctioned posts.
‒ As we discuss below, there has been both an issue with the timely release of funds as well as the overall lower than planned allocation of funds to the OPs as planned in the PIP.
3 . 3 D I S B U R S EM E N T F O R A C C E L E R A T E D A C H I E V EM E N T O F R E S U L T S
To accelerate progress on key areas of the HPNSDP, the development of a DAAR modality was put into place. On an annual basis, GOB and DPs jointly agree on key priorities and indicators. These indicators are then linked to incentive payments based on achievement. On a regular basis, the Local Consultative Group meets to review progress. Annex 5 contains the complete analysis of the DAAR indicators
In 2011, three DAAR indicators on (1) Maternal health/health system-‐Human Resources, (2) Maternal health/FP/child health, and (3) Nutrition were achieved fully and two indicators on Health systems-‐budgeting and planning and Fiduciary were achieved partially. This resulted in a disbursement of US$ 7.16 million from the DAAR fund. The APR team believes that the DAAR indicators chosen were appropriate and feasible. The MOHFW clearly has the capacity to implement these indicators.
In 2012, good progress has already been made on the selected indicators. The GOB feels that they are able to achieve most of the DAAR targets fully. Our discussion with DPs also indicates that there is comfort in the capacity of the MOH to achieve the 2012 targets.
Overall, it appears that the DAAR indicator system incentivizes the acceleration of progress in key areas. The targets chosen thus far are feasible and the MOHFW has the capacity to achieve them. The verification of some targets should receive continued attention.
3 . 4 I N S T I T U T I O N A L C O N S T R A I N T S I N I M P L EM E N T A T I O N , I N C L U D I N G R I S K A S S E S SM E N T U P D A T E
The IRT has reviewed the Operational Risk Assessment Framework (ORAF) in which the main risks identified included: (a) inherent weaknesses in financial management, procurement and monitoring and evaluation; (b) high rates of absenteeism of health professionals; (c) shortage of drugs and equipment; (d) frequent transfers of staff in MOHFW; and (e) weak governance and accountability framework. Our review of the ORAF around these issues is as follows:
In most cases, the risks remain as they were noted in the PAD and the IRT has commented on many of them in the individual Thematic Area Technical Report. It is our conclusion, that there has been no increase in the risk in any of the ORAF risk categories and that the risk mitigation actions remain appropriate. The one area that the IRT does feel additional actions need to be taken concerns the overall monitoring and evaluation of the HPNSDP. We have noted, in the M&E report, that the current method of monitoring outputs in the OPs relies on the self-‐reporting of the OP Line Directors. The findings of the APIR are also dependent on this self-‐reporting. The IRT does not think this is adequate and has recommended that a strengthened the Programme Management and Monitoring Unit, set up under the Planning Wing of the MOHFW, is the proper entity within the Ministry to develop an “independent” monitoring and management system that provides oversight of OP performance and progress. The Planning Wing has taken this recommendation under advisement and we believe it will be a key action that will improve results reporting to the concerned HPNSDP stakeholders.
As an overall comment, the IRT notes that the Planning Wing of the MOHFW, through the Sector-‐wide Programme Management and Monitoring Operational Plan, has been doing a very effective job in undertaking the four principal responsibilities, including M&E, under its jurisdiction, with a minimum of staff to accomplish them. The IRT believes that for the SWAp to be successful, the
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Planning Wing could use additional staff particularly in the area of planning, budgeting and in the PMMU as noted in the M&E report and Key Issues noted in Chapter 2.0, above.
3 . 5 F I N A N C I A L F R AM EWO R K F O R T H E S E C T O R , I N C L U D I N G D P F U N D I N G
The IRT has reviewed Financial Framework for the sector including DP funding. The IRT’s overall finding is that there is serious resource gap to fulfill HPNSDP requirements as found in the Project Investment Plan. Several of the more important specific findings related to the framework include:
‒ There were late fund releases because of initial delays in the approval of the PIP and OPs; ‒ Only 60 percent of overall OP provisions for 2011/2012 were allocated in the Revised Annual
Development Plan (RADP), which is understandable since there was a delay in the start-‐up of programme implementation;
‒ The principal short-‐fall in funding has been in the development budget; ‒ The actual utilization by OPs during 2011/2012 implementation was less than 53 percent, which
again is understandable considering the six month delay in HPNSDP start-‐up and OP implementation; and,
‒ The trend in underfunding HPNSDP as per the PIP has continued in year two with only 58.5 percent of OP provision for 2012/2013 in the ADP.
OP provision for the entire program
OP provision for 2011-‐12
RADP allocation for 2011-‐12
% of OP provision
% of RADP provision
% of OP provision
Total 22176 3786 2270 60 87.7 52.6
GOB 87603 1325 790 60 94.9 56
PA 13573 2461 1480 0 16.4 50
The IRT’s conclusion is that the short-‐fall in PIP indicative funding will necessitate: 1) a more efficient planning and tracking of available resources; 2) additional resources being committed to HPNSDP as previewed in the PIP; and 3) both more efficient planning and additional resources committed. Specifically, we conclude:
‒ Transparency in DPA and parallel funding allocations and reporting must improve; ‒ Transparency in NGO/INGO financing and reporting must improve; ‒ The alignment of development and non-‐development budgets is needed; ‒ The IRT strongly recommends that resource tracking and reporting must be a systematic and
routine part of annual sector management, not ad hoc activities conducted every few years.
Concerning DP Funding, the following table shows actual DP self-‐reported Allocations and Disbursements. What we can say is that these disbursements and allocations differ from those figures PIP and could have implications for the future funding of the HPNSDP.
Development Partner Self-‐Reported Allocation and Disbursements
Donor Fiscal Year Pool Allocation
Pool Disbursement
DPA Allocation
DPA Disbursement
Off-‐budget Allocation
Off-‐budget Disbursements Notes
World Bank IDA Credit July-‐Jun $358,9000,00 $92,000,00 $0 $0 $0 $0
Netherlands Jan-‐Dec $5,126,000 $0 $0 $0 $4,485,250 $3,422,246
Ausaid July-‐Jun $8,029,000 $8,029,000 $0 $0 $15,488,200 $15,488,200
UNICEF Jan-‐Dec $0 $0 $10,848,963 $3,646,963 $1,836,424 $1,836,424
WHO Jan-‐Dec $0 $0 $7,400,000 $5,300,000 $250,000 $200,000
CIDA Apr-‐March $0 $0 $9,794,295 $9,794,295 Incomplete $3,327,847
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JICA Apr-‐March $64,512,000 $10,099,200 $0 $0 $0 $0 In kind not reported
SIDA Jan-‐Dec $12,160,000 $12,160,000 $228,000 $0 $3,617,600 Incomplete
DFID Apr-‐March $40,312,500 $40,312,500 $11,287,500 $10,465,125 $322,500 $262,838
USAID Oct-‐Sept $8,000,000 $8,000,000 $0 $0 $53,483,000 $53,483,000
GIZ Jan-‐Dec $0 $0 $0 $0 $0 $0 In kind only
KFW No response
UNDP No response
UNAIDS Jan-‐Dec $0 $0 $0 $0 $320,722 $242,415
Total $497,039,500 $170,600,700 $39,558,758 $29,206,383 $79,803,696 $78,262,969
3 . 6 T E AM L E A D E R ’ S T H O U G H T S O N F U T U R E A N N U A L P R O G R AMM E R E V I EW S
Having now completed this first APR for GOB and Development Partners, it is hard not to come away without some thoughts on the process and how it might be done better in the future.
The principal issue to consider is whether APRs need to be conducted every year? There are pros and cons to consider in this regard:
There is nothing like a review (or evaluation, assessment, etc.) to focus everyone’s mind on the subject at hand. This is probably one of the most important reasons to conduct an APR annually. It is as much about the process, or the journey, as it is about the outcome, or arriving at a planned destination. APRs bring all the concerned stakeholders together to participate in what is essentially a joint problem solving exercise, and this is a healthy thing. The IRT acts as both facilitator and catalyst on behalf of the stakeholders. Furthermore, reviews are an opportunity for the different parties to send messages to each other via the independent reviewers who are hopefully skilled enough in being able to discern those messages about which something can be done, or at least to present them in such a way as they can be more readily accepted by the intended recipient. Many messages were sent via the IRT and perhaps a few were received positively.
Is there a need for a 16 person IRT every year? The answer from this TL’s perspective is no, it seems unnecessary and should rather be determined by the function that a given APR is expected to fulfill.
Is three weeks for the Thematic Area experts enough time to conduct the APR? With better planning – having scheduled meetings for the first week prior to the IRT’s arrival – more logistics support (see below), three weeks is adequate to do reasonably in-‐depth analysis of a given Thematic Area.
Is it necessary to review all nine thematic areas every year? Again, the answer would be no. As noted in the overall recommendation below, it may be necessary to review each thematic area every other year, but this would really depend on whether all nine thematic areas merit such a full review. It is rather suggested that in years two and four (the out years), for instance, that three-‐to-‐five specific topics such as health insurance or local level planning be taken up as operations research efforts to address specific problems encountered in implementation during the preceding year(s); or, pick two or three thematic areas and do in-‐depth reviews on them.
Is it necessary to pair national and international experts? Most definitively, yes. National team members bring local knowledge and context that even international experts with long-‐term Bangladesh experience do not possess. And, in some cases, they are also able to open doors that an international member simply cannot. International team members’ principal value is bringing internationals good practice and policy in their areas of thematic expertise, which when applied with good analysis can sometimes lead to interesting insights and recommendations. One recommendation would be, however, to mix the background of national consultants so that there
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are more members with an NGO and private sector experience, in addition to those with previous MOHFW experience. Similarly, it might be useful to engage international consultants who may have less years of experience but who may have more relevant and timely experience and a record of innovative and practical thinking and problem solving.
Consider (strongly) a counterpart for the team leader and a dedicated logistics / administrative person. This would be a mental health kindness for the next team leader not to mention permitting her or him to more effectively use her or his time for substantive rather than process tasks. Sixteen consultants, each with his or her own individual TOR (and personal) requirements (and idiosyncrasies) cannot be coordinated or effectively directed without significant time and effort being expended. Placing a bulletin board up on a wall and expecting the rationale and effective use of time and four or five vehicles by 16 consultants is unrealistic; having a logistics person for the first two weeks would make a world of difference in the way the team and team leader function. And, there is no reason to believe that the TL is any more omniscient concerning the socio-‐cultural dynamics of Bangladesh than any other international team member; having the counsel of an experienced and professional Bangladesh counterpart would help to avoid the inevitable contretemps that working in a highly sensitive and cross-‐cultural setting is certainly a small price to pay given the potential damage to the review that a poorly handled situation can cause.
Overall Recommendation Full reviews should take place in year 1 to set the SWAp baseline and make sure that all conditions are in place for the successful conduct of the next two years of the programme; in year 3, the MTR fulfills the APR function in which an assessment of actual against planned results achieved is undertaken; and, finally, in year 5 to evaluate the actual impact of the SWAp in terms of outcomes and impacts.
3 . 7 O V E R A L L C O N C L U S I O N S A N D R E C OMM E N D A T I O N S F O R T H E A P R 2 0 1 2
The IRT concludes that the progress of HPNSDP is roughly where it should be at the end of the first year of the programme, taking into consideration the late start experienced; given the magnitude of the SWAp, the many stakeholders involved, and the normal hiccups associated with the commencement of most new initiatives, the IRT finds the initial delays understandable.
Both the APIR and this APR have identified the on-‐going crisis in human resources and weak SWAp monitoring and supervision as two of the principal issues that will have a likely impact on the programme’s successful achievement if not addressed immediately; both issues carry-‐over from previous health sector programmes. In this regard, the IRT concludes that:
‒ The Human Resource Management (HRM) OP is best placed to lead the Ministry’s efforts in addressing this health sector-‐wide problem. However, it currently understaffed and urgently requires both additional personnel and those with the right mix of skills and expertise to permit the OP take the lead in coordinating HPNSDP’s response to the current and continuing HR crisis. Furthermore, when the current workforce study being undertaken by the MOHFW with DFID support is completed, HRM OP, under the guidance of Senior Secretary, and in collaboration with the HR Task Group, should convene a sector-‐wide workshop to identify short-‐term solutions while the longer-‐term reforms of the GOB across all sectors continues to take hold. Each of the TATR’s has reviewed HR issues in their particular domain and made recommendations concerning temporary measures that should address the workforce constraints in the short-‐term.
‒ In terms of improved monitoring and management of the SWAp, the SWPMM OP through the Planning Wing plays a critical role, particularly in resource planning and tracking and Inter-‐OP coordination. In this regard, the IRT singles out for special attention the PMMU, which needs to urgently engage additional staff so that it can support the Planning Wing’s critical role in independently monitoring the performance of Operational Plan’s, not relying simply on LD
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reporting. While LD meetings were viewed as very useful, there appeared to be inadequate time to discuss inter-‐OP coordination particularly in areas of overlap or cross-‐cutting issues such as nutrition, urban health, IEC/BCC, or human resource needs.
Several other conclusions, largely related to the SWAp’s institutional arrangements are worth noting:
‒ Several new organizational entities or oversight tools were designed to increase the financial and management oversight of this SWAp including, the Financial Management and Audit Unit (FMAU), the PMMU, the Procurement and Logistics Monitoring Cell (PLMC), and Interim Unaudited Financial Report (IUFR). Each of them has shown initial effectiveness during the programme’s start-‐up and this APR has pointed out where additional support is needed to make them fully functional
‒ The IRT has been particularly impressed with the governance structure of HPNSDP and has seen it in full operations during the APR, from the initial Task Group meetings, to the Local Consultative Group’s interactions through to the Steering Committee and culminating in the Policy Dialogue. The Task Groups are the key to the technical success of the programme and should meet regularly with well-‐articulated TORs and strategies; the IRT encourages them to continue their important work after APR.
While the IRT understands that HPNSDP is a limited SWAP in terms of whole of sector stakeholder participation, each IRT expert, from his or her own perspective, felt that there could be greater coordination with and participation of major health care providers that are not covered under the SWAp, particularly NGO and private sector health providers. This is particularly true since the public sector, through the MOHFW, covers only 30 percent of health service delivery throughout the country, while the remaining 70 percent is covered by a combination of the private sector and NGOs, with future projections placing the ratio of public sector to private/NGO sector coverage at 10 percent and 90 percent respectively. The IRT urges strong consideration, therefore, for creating a new cross-‐sector service provider platform that brings together current HPNSDP stakeholders with representatives of other non-‐member HPNSDP organizations, including from the NGO and private sectors and, where appropriate, into the Task Group structure, to undertake joint planning and information sharing exercises
The obvious concern, recognized by all HPNSDP stakeholders, is the underfunding of the SWAp. This however, is meta-‐level concern that probably falls outside of the manageable interests of any of the current parties to address. The IRT would note that the conditions, that is, the institutional arrangements, systems and procedures, are for the most part in place to move the Programme forward to the Mid-‐term Review where adjustments, if necessary can be made. This assumes that the HPNSDP Steering Committee and the Policy Dialogue accept the more important of the principal recommendations that have been made in this report and the full Thematic Area Technical Review found in Volume II, Annexes.
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A N N E X 1
T H EM A T I C A R E A T E C H N I C A L R E V I EW R E P O R T S
Nine Thematic Areas under APR 2012 Review
1 Gender, Equity, Voice and Accountability (No formal review)
2 Monitoring and Evaluation
3 Procurement and Supply Chain Management
4 Financial management with Planning and Budgeting
5 MNCH and Family Planning (including human resources)
6 Nutrition (including human resources)
7 Disease Control (including human resources)
8 Urban Health (including population and nutrition)
9 IEC & Behavior Change Communications (BCC)
Human Resources was a principal crosscutting issue addressed by each of the 8 Thematic Area Technical Reviews.
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A N N E X 2
R E V I EW A N D A N A L Y S I S O F T H E U P D A T E D R E S U L T S F R AM EWO R K
Introduction The overall APR 2012 IRT TORs called for a review, analysis, and updating of the HPNSDP Results Framework. The following analysis looks at each of the 41 results and corresponding indicators in the RFW to determine whether they are on track or not for completion by 2016. The IRT uses the updated data found in the APIR to perform its analysis using the Annual Indicator Change Rate methodology discussed below. Table 2.B, below, provides the overall analysis of each result.
Methodology The Annual Indicator Change Rate (AICR) is a calculation of historical progress made in the indicator from the baseline data to the latest data available and divided by the number of years it took to achieve them which yields an estimate of average progress in one year. Assuming that indicators will make progress at the same historical pace, it is possible to calculate the progress it is expected in the remaining years of the plan, in this case 2016.
Example: Infant Mortality Rate
Target for 2016: 31
Baseline: 52, BDHS 2007
Latest available data: 43, BDHS 2011 Number of years between base line (2007) and latest available data (2011): 4 years. AICR: 52-‐43/4= 2.25 per year
Number of Years between latest available data, in this case between 2011 and 2016: 5 years. Based on the AICR and the number of years between 2011 and 2016, a projection is made on what the indicator will look like in 5-‐years time: AICR x 5 years. 2.25 x 5 = 11.25 in five years. The next step is to subtract the projected reduction of 5 years from the latest available data: 43-‐11.25 =31.75 or round to 32. Final calculation: comparison between target to be achieved in 2016 (31) and projected figure (32). Both are very close and therefore it considered to be on track.
The Analysis: Health, Population and Nutrition Sector Development Plan (HPNSDP)-‐ 2012-‐2016 Component 1: Service Delivery Improved.
‒ Result 1.1. Increased utilization of essential HPN services. ‒ Result 1.2. Improved equity in essential HPN service utilization. ‒ Result 1.3. Improved awareness of healthy behaviour. ‒ Result 1.4. Improved PHC CC systems.
Component 2: Strengthen Health Systems
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‒ Result 2.1. Strengthened planning and budgeting procedures. ‒ Result 2.2. Strengthened monitoring and evaluation systems. ‒ Result 2.3. Improved human resource planning, development, and management. ‒ Result 2.4. Strengthened quality assurance and supervision systems. ‒ Result 2.5. Sustainable and responsive procurement and logistic system. ‒ Result 2.6. Improved infrastructure and maintenance. ‒ Result 2.7. Sector management and legal framework. ‒ Result 2.8. Decentralization through LLP Procedure. ‒ Result 2.9. SWAP and improved DP coordination (delivering on the Paris Declaration). ‒ Result 2.10. Strengthened financial management systems (funding and reporting).
The HPNSDP Result Matrix presents the indicators it will be used to measure progress against the results listed above. It also presents the baseline data and the expected targets to be achieved by 2016.
Assuming that progress will continue at the same historical pace (progress between baseline and latest available update), it is possible to mathematically estimate whether achieving the indicator by 2016 is realistic and on track or not.
Using the average Annual Indicator Change Rate (AICR) achieved from the baseline data to the latest data available and divided by the number of years it took to achieve them will yield an estimate of average progress in one year. Assuming that indicators will make progress at the same historical pace, it is possible to project the indicator by 2016 and then compare this figure with the Results Matrix targets.
Based on the IACR, the Results Matrix indicators were examined to determine whether they are on track to achieve the desired target by 2016, recommend some level of acceleration or revision of indicators.
It has therefore been found that 17 (45) % indicators are on track and 13 (34) % are not. Some level of acceleration will be required. Five (13%) indicators will need to be revised and 3 (8%) will need new targets as current target has already been met by 2010/11.
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A D D I T I O N A L C OMM E N T S T O H P N S D P R E S U L T S M A T R I X I N D I C A T O R S
SI # Indicator Status Comments
GI 3 Neonatal mortality rate (NMR)
Acceleration Required.
Acceleration should be possible for all the policies and the National Neonatal Health Strategy are in place. The gradual removal of HRs, particularly at the community level, HAs, FWAs, CHCP, and CSBAs and strengthening field supervision and monitoring will need to be addressed.
GI 6 Prevalence of stunting among under-‐5 children
Acceleration Required
Interventions in the health sector are generally weak to address chronic malnutrition. Strong multi sectorial coordination will be required to address issues of food production, food price, fertilizer subsidies, cash transfer to the poor.
1.1.1. % of delivery by skilled birth attendant
Acceleration Required
This will require a full scale training of CSBAs and FWA to increase number of home deliveries assisted by a trained health worker. At present is very modest 4.4%. However, the raining curricula, the trainers had been trainers and country is ready to scale up to nationally agreed coverage (1 CSBA/FWA: population ration) It will also require adequate funding from development, revenue or both budgets.
1.1.2. Antenatal care coverage (at least 4 visits)
Acceleration Required
This is very ambitious target. Considering that most services are available, reaching the target will require an aggressive communication campaign to encourage mothers to come forward to ANC services, particularly in the last trimester. However, one must take into consideration the additional demand for services when the health sector key bottleneck is availability of human resources.
1.1.3. Postnatal care within 48 hours (at least 1 visit)
Acceleration Required
As above.
1.1.4. Contraceptive prevalence rate (CPR)
Acceleration Required
The historical annual change rate was rather small albeit the APIR reported a number of indicators as “achieved”. However, this might not be enough to ensure the achievement of the HPNSDP Results Matrix indicator. Extra effort and investment must be made and consider going beyond the OP annual target if not revise them.
1.1.7. % of under-‐5 children with pneumonia receiving antibiotics
Change of target for 2016
The Results Matrix has already been met as reported by BDHS, 2011. The new target should be to increase the proportion of 5-‐children with pneumonia receiving antibiotics to at least 80%.
1.1.8. % of children (6-‐59 months) receiving Vit-‐A supplementation in the last 6 months
Acceleration Required
Acceleration is required based on the mathematical model of projection. However, it is felt that from latest Vit A campaigns have been reflected in the latest BDHS.
1.1.9. TB case detection rate
Modest target set PA change of indicator is proposed to “TB notification Rate since the denominator is uncertain for TB case detection rate.
1.3.2. % of children 6-‐23 months fed with appropriate IYCF16 practices
Acceleration Required
This indicator, based on past performance has been deteriorating and it requires careful examination of causes. It will require properly managed nutrition interventions supported with adequate communication and mass media efforts.
1.2.2. Use of modern contraceptives in low performing areas
Acceleration Required
Sylhet requires acceleration.
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1.2.3. # of Upazilas with women targeted by improved voucher scheme14 for having institutional deliveries
Change of target for 2016
The Results Matrix has already been met as reported by BDHS, 2011. The new target should be at least 65 Upazilas.
1.3.1. Rate of exclusive breastfeeding in infants up to 6 months
Change of target for 2016
The Results Matrix has already been met as reported by BDHS, 2011. The new target should be at lest 75%
1.3.2. % of children 6-‐23 months fed with appropriate IYCF16 practices
Acceleration Required
All policies and strategies are in place.
1.4.1. # of Community Clinics (CC) with increasing number of service contacts over time
Close monitoring is required.
Data is not available to project indicator in 2016.
1.4.2. % of upgraded union-‐level facilities able to provide basic EmOC services18
This indictor actually decreased between 2007 and 2011
Very optimistic target given the HR constraint. However, policies and strategies are in place.
2.1.1. % of MOHFW budget allocated to Upazila level or below
This indictor actually decreased between 2007 and 2011
No comments.
2.3.1. Proportion of service provider positions functionally vacant at district level and below, by category
Acceleration is required.
Key indicators. It will require policies and short, medium, and long term strategies
2.3.3. Number of comprehensive EmOC facilities with functional 24/7 services covering all districts
No assessment is possible due to different sources of data.
Important indicator and should be measured as proportion of districts with functional 24/7 CEmOC services
2.5.1. % of health facilities, by type, without stock-‐outs of essential medicines at a given point in time
Modest target. Consider new target to achieve at least 85% of health facilities by type without essential medicine stock outs.
2.5.2. % of facilities without stock-‐outs of contraceptives at a given point in time
Acceleration required.
See recommendation of the Procurement review team.
2.8.1. # of Districts/Upazilas having functional LLP procedures
No assessment is possible with data available.
This is key indicator particularly for Community level clinics and target should be 100% by 2016.
2.9.1. # of non-‐pool DPs submitting quarterly expenditure reports
Target is 100% This is fundamental principle of SWAp and should be achieve long before 2016.
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H P N S D P R E S U L T S M A T R I X A N A L Y S I S
SI # Performance Indicator Means of Verification & Timing
Baseline & Source
Update 2012
Target 2016 Annual Rate (AR)
Projection to 2016
Status/ On track /acceleration
Goal: Ensure quality and equitable health care for all citizens of Bangladesh.
GI 1 Infant mortality rate (IMR) BDHS, every 3 yrs 52, BDHS 2007 43, BDHS 2011 31 2.25 32 OK
GI 2 Under 5 mortality rate BDHS, every 3 yrs 65, BDHS 2007 53, BDHS 2011 48 3.0 38 OK
GI 3 Neonatal mortality rate (NMR)
BDHS, every 3 yrs 37, BDHS 2007 32, BDHS 2011 21 1.25 26 Acceleration required
GI 4 Maternal mortality ratio (MMR)
BMMS, every 5 yrs 194, BMMS 2010 194, BMMS 2010 <143 14.22 137 OK
GI 5 Total fertility rate (TFR) BDHS, every 3 yrs 2.7, BDHS 2007 2.3, BDHS 2011 2.00 0.1 1.80 OK
GI 6 Prevalence of stunting among under-‐5 children
BDHS, every 3 yrs 43.2%, BDHS 2007 41.3%, BDHS 2011 38% 0.48 38.90 Acceleration required
GI 7 Prevalence of underweight among under-‐5 children
BDHS, every 3 yrs 41%, BDHS 2007 36.4%, BDHS 2011 33% 1.15 30.70 OK
GI 8 Prevalence of HIV in MARP Sero-‐Surveillance (SS), every 2 yrs
<1%, SS 2007 <1% (0.7%), SS 2011 (9th round)
<1% <1 <1 OK
Program Development Objective: Increase availability and utilization of user-‐centered, effective, efficient, equitable, affordable and accessible quality HPN services. Strategic Objective: To improve access to and utilization of essential health, population and nutrition services, particularly by the poor.
Component 1: Service delivery improved
Result 1.1: Increase utilization of essential HPN services
1.1.1. % of delivery by skilled birth attendant
BDHS, every 3 yrs 26.%, UESD 2010 18%, BDHS 2007
31.7%, BDHS 2011 50% 3.43 48.80 Acceleration required
1.1.2. Antenatal care coverage (at least 4 visits)
BDHS, every 3 yrs 19.9%, UESD 2010 20.6%, BDHS 2007
25.5%, BDHS 2011 50% 1.23 31.63 Acceleration required
1.1.3. Postnatal care within 48 hours (at least 1 visit)
BDHS, every 3 yrs 20.9%, UESD 2010 18.5%, BDHS 2007
27.1%, BDHS 2011 50% 2.15 38.85 Acceleration required
1.1.4. Contraceptive prevalence rate (CPR)
BDHS, every 3 yrs 61.7%, UESD 2010 55.8%, BDHS 2007
61.2%, BDHS 2011 72% 1.35 61.2 Acceleration required
1.1.5. Unmet need for FP BDHS, every 3 yrs 17.1%. BDHS 2007 11.7%, BDHS 2011 9.0% 1.35 4.95 OK
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SI # Performance Indicator Means of Verification & Timing
Baseline & Source
Update 2012
Target 2016 Annual Rate (AR)
Projection to 2016
Status/ On track /acceleration
1.1.6. Measles immunization coverage by 12 months
CES, annual 82.4%, CES 2009 87.5%, BDHS 2011 90% 2.55 100 OK
1.1.7. % of under-‐5 children with pneumonia receiving antibiotics
BDHS, every 3 yrs 38.0%, UESD 2010 37.1%, BDHS 200711
71.4%, BDHS 2011 50% 8.58 Target for 2016 already met on 2011. Revise target
1.1.8. % of children (6-‐59 months) receiving Vit-‐A supplementation in the last 6 months
BDHS, every 3 yrs 82.6%, UESD 2010 88.3%, BDHS 200712
59.5%, BDHS 2011 90% Decreased and needs to increase by 6.1% per
year
Acceleration required
1.1.9. TB case detection rate NT Program, annual 74%, NTP 2009 70.5%, NTP 2010 75% Decreased and needs to increase by 1% per
year
Modest Target It is also Proposed change indicator to notification rate due to uncertainty over denominator
Result 1.2: Improve equity in essential HPN service utilization (MDGs 1,4,5 and 6)
1.2.1. Proportion of births in health facilities by wealth quintiles
BDHS, every 3 yrs Q1:Q5 = 8.0:59.5, UESD 2010 Q1:Q5* = 4.4:43.4, BDHS 200713
Q1:Q5 = 9.9:59.8, BDHS 2011
Q1:Q5 = <1:4 1:13 (2004) 1:8 (2007) 1:6 (2011)
1:4 OK
1.2.2. Use of modern contraceptives in low performing areas
BDHS, every 3 yrs Syl: 35.7%, Ctg: 46.8%, UESD 2010 Syl: 24.7%, Ctg: 38.2%, BDHS 2007
Sylhet: 35.2% Chittagong: 44.5%, BDHS 2011
Sylhet & Chittagong:
50.0%
Syl: 2.63
Ctg: 1.58
Syl: 48.4
Ctg: 52.4
Sylhet: Acceleration required
1.2.3. # of Upazilas with women targeted by improved voucher scheme14 for having institutional deliveries
DSF Monitoring Reports, annual
31 DSF Upazilas (+9 universal), DSF Monitoring Report 2010
53 Upazilas (7 MNH upazilas), DSF Monitoring Cell 2012
50 DSF Upazilas15
11 Target for 2016 already met on 2011. Revise target
Result 1.3: Improved awareness of healthy behavior (MDG 1,4,5)
1.3.1. Rate of exclusive breastfeeding in infants up to 6 months
BDHS, every 3 yrs 43.0%, BDHS 2007 63.5%, BDHS 2011 50% Target for 2016 already met on 2011. Revise target
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SI # Performance Indicator Means of Verification & Timing
Baseline & Source
Update 2012
Target 2016 Annual Rate (AR)
Projection to 2016
Status/ On track /acceleration
1.3.2. % of children 6-‐23 months fed with appropriate IYCF16 practices
BDHS, every 3 yrs 41.5%, BDHS 2007 20.9%, BDHS 2011 52% Decreased and needs to increase by 6.2% per
year
Acceleration required
Result 1.4: Improved PHC-‐CC systems
1.4.1. # of Community Clinics (CC) with increasing number of service contacts over time
CC Project/ MIS/MOHFW, annual
Registers and forms supplied to CCs in June 201217
NA 13,500 Close monitoring required
1.4.2. % of upgraded union-‐level facilities able to provide basic EmOC services18
Health Facility Survey (BHFS), every 2 yrs
15.5%19, BHFS 2009 4.3%20, BHFS 2011 50% Decreased and needs to increase by 9.1% per
year
Acceleration required
Component 2: Strengthened Health Systems
Result 2.1: Strengthened planning and budgeting procedures
2.1.1. % of MOHFW budget allocated to Upazila level or below
Public expenditure review, annual
52%, PER 2006/2007
47%, PER 2008/2009
60% Decreased and needs to increase by 2.6% per
year
Acceleration required
2.1.2. % of annual work plans with budgets submitted by LDs by defined time period (July/Aug)
Administrative records from the Planning Wing, annual
NA21 100%, Planning Wing 2012
100% (target by 2013)
OK
Result 2.2: Strengthened monitoring and evaluation systems
2.2.1. MIS reports on service delivery published and disseminated22 annually
HIS & eHealth and MIS-‐FP, annual
NA23 Both Directorates have published but not disseminated
100% OK
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SI # Performance Indicator Means of Verification & Timing
Baseline & Source
Update 2012
Target 2016 Annual Rate (AR)
Projection to 2016
Status/ On track /acceleration
2.2.2. Performance report of OPs reviewed with policy makers, MOHFW, Directorates and DPs, six months and annually24
Planning Wing, six monthly (Jul-‐Dec-‐>Feb), (Jul-‐Jun-‐>Aug)
NA 100% (FY 2011-‐12 annual performance25 will be disseminated under APIR 2012), Planning Wing 2012
100% (achieved by
2013)
OK
Result 2.3: Improved human resources – planning, development and management
2.3.1. Proportion of service provider positions functionally vacant at district level and below, by category
DGHS/DGFP MIS, annual BHFS, every 2 yrs
Physicians: 45.7%; Nurses: 24.7%; FWV/SACMO/MA: 16.9%, BHFS 2009
Physicians26: 46.1%, Nurses: 19.59%, FWV/SACMO/MA: 21.2%, BHFS 2011
Physicians: 22.8%; Nurses: 15.0%;
FWV/SACMO/MA: 8.5%27
Physicians: vacancy rate increased Nurses: annual
reduction 4.06%
Physicians: vacancy rate needs to
decrease by 4.7%
Nurses: will achieve 15.53
vacancy rate.
Acceleration required
2.3.2. # of additional providers trained in midwifery at Upazila health facilities
HRD/MOHFW, annual
NA 115 3,000 OK
2.3.3. Number of comprehensive EmOC facilities with functional 24/7 services covering all districts
MIS/EOC BHFS, every 2 yrs
132, MIS/DGHS 2009
8528, MNCAH LD, 2012
204 (DGHS Voice of MIS Feb, 2009)
Important indicator and should be measured as proportion of districts with functional 24/7 CEmOC services
Result 2.4: Strengthened quality assurance and supervision systems
2.4.1. Case fatality rate among admitted children with pneumonia in Upazila health complex
DGHS MIS, annual 8%,29 Health Bulletin 2009
NA (Proper data source is being identified)
6.2%30 OK
Result 2.5: Sustainable and responsive procurement and logistic system
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SI # Performance Indicator Means of Verification & Timing
Baseline & Source
Update 2012
Target 2016 Annual Rate (AR)
Projection to 2016
Status/ On track /acceleration
2.5.1. % of health facilities, by type, without stock-‐outs of essential medicines at a given point in time
BHFS, every 2 yrs 66.1%,31 BHFS 2009 74%, BHFS 2011 75% Modest target
2.5.2. % of facilities without stock-‐outs of contraceptives at a given point in time
BHFS, every 2 yrs 58.1%,32 BHFS 2009 55.1%, BHFS 2011 70% 1.5 63 Acceleration required
Result 2.6: Improved infrastructure and maintenance
2.6.1. % of facilities (excluding CCs) having separate, improved toilets for female clients
BHFS, every 2 yrs 5%, BHFS 2009 44.5%, BHFS 2011 75% 19.75 100 Remarkable progress in two years
Sl # Performance Indicator Means of Verification & Timing
Baseline & Source
Update 2012
Target 2016
Result 2.7: Sector management and legal framework
2.7.1. Regulatory framework for accreditation of health facilities including hospitals (both in the public and private sectors) reviewed and updated33
MOHFW 1982 Regulatory Act Accreditation of public hospitals is under process, HSM OP 2012
Reviewed (by 2012)
OK
Result 2.8: Decentralization through LLP procedures
2.8.1. # of Districts/Upazilas having functional LLP procedures
Respective agencies, annual
NA 07 districts (including 14 pilot upazilas)
Piloting completed
and reviewed for scale-‐up.
This is key indicator particularly for Community level clinics and target should be 100% by 2016
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SI # Performance Indicator Means of Verification & Timing
Baseline & Source
Update 2012
Target 2016 Annual Rate (AR)
Projection to 2016
Status/ On track /acceleration
Result 2.9: SWAp and improved DP coordination (deliver on the Paris Declaration)
2.9.1. # of non-‐pool DPs submitting quarterly expenditure reports
Planning Wing FMAU
Irregular 1 out of 15 (only USAID)
100% Key to achieve 100% within the SWAp framework.
Result 2.10: Strengthened Financial Management Systems (funding and reporting)
2.10.1. % of project aid fund (e.g. development budget) disbursed annually and quarterly
FMAU 79.4%,34 FMAU 2009/2010
60% (FY 2011-‐12), APIR 201235
100% (by 2013)
OK
2.10.2. % of OPs with spending >80% of ADP allocation (annually)
FMAU/ Planning Wing
44.7%,36 FMAU 2003-‐2011
59.4% (with 80% or more); 50% (with >80%), Planning Wing 2012
100%* (by 2013) *Target set as 100% to ensure
efficient fund utilization
OK
2.10.3. % of serious audit objections settled within the last 12 months
FMAU 7%, FMAU 2007/200837
39%, FMAU 201238 >80% OK
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A N N E X 3
G O V E R N A N C E A N D A C C O U N T A B I L I T Y A C T I O N P L A N
As the PAD notes, the GAAP outlines the governance and accountability risks and mitigation actions to ensure the success of key aspects of the Project, which may otherwise be adversely impacted by these risks. The GAAP has recommendations in support of improving financial management, strengthening weak internal controls, improving procurement management, and strengthening the M&E capacity.
This annex contains the complete analysis of the GAAP. The IRT has reviewed all 21 of the GAAP Key Objectives, including MOHFW updates, and provided specific comments on each of them. As a general conclusion, the IRT can say that the majority of Key objectives are on track but that addressing the specific recommendations made in the GAAP analysis will ensure that they will be met as intended and thus promote the achievement of results both at the OP and RFW levels. We make the following overall observations concerning GAAP Key Objective Performance.
‒ The principal area of concern is one that has been recognized in previous APRs and which was again highlighted in the individual Thematic Area Technical Reviews conducted by individual Team members, that is, the problem of ensuring an adequate number of health force workers, in with the right mix of skills and in the posts where they are most needed. This includes the issues of frequent transfers, as well as the non-‐filling of sanctioned posts.
‒ As we discuss below, there has been both an issues with the timely release of funds as well as the overall lower than planned allocation of funds to the OPs as noted in the PIP.
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U P D A T E O N G O V E R N A N C E A N D A C C O U N T A B I L I T Y A C T I O N P L A N ( G A A P )
Draft IRT Review: 02/10/2012
Bangladesh Health Sector Development Project (HSDP) Error! Unknown document property name. Governance and Accountability Action Plan Date: April 19, 2011 [Updated on 22 September 2012]
Key Objectives Key Activities Responsible Agencies
Key Indicators Reporting Frequency/ Timeframe
Expected Results MOHFW Update 2012
APR 2012 Comments
1. Sector Governance/Enabling Environment
1.1 Multi-‐year perspective in fiscal planning, expenditure policy and budgeting
• Synchronize OPs with MTBF using MTBF resource envelopes.
• Three months prior to the
start of each related fiscal year, MOHFW will share the proposed ADP with the co-‐financiers for review to support the OPs for the following fiscal year.
• Predictability in the
availability of funds.
MOHFW, MOF • Rolling/Forward budget prepared for the Program.
• Synchronized budget between MTBF, OP and ADPs.
• Pooled funding
partners to provide indicative commitments by January 31 of each year.
Annually [CHANGE TO: Revision of OPs for synchronization will take place during MTR] Annually Annually
Budget allocated based on MTBF. Predictability of DPs funds for the sector
Yearly allocation of OPs synchronized with MTBF projection (but the ADP allocation deviated). Shared with DPs. Pool Fund partners provided indicative commitments for FY 2011-‐12. Commitment for FY12-‐13 will require to be obtained soon.
This is an important objective. IRT believes that single work plan that includes DPA and parallel funds is also needed to understand overall resource envelope.
1.2 Public access to key fiscal information: Implementation of transparency and disclosure measures
• Ensure regular public disclosure activities through website (and appropriate media (e.g. the Strategic Plan and budget, procurement advertisement, EOI, RFP, Survey and Evaluation reports).
MOHFW, DGHS, DGFP, CMSD, HED
• There is sufficient flow of information for stakeholders
• Website is active
Once/ Continuous Listed information related to HPNSDP implementation is kept in the public domain by adhering to the Right to Information Act 2009
Program documents, MIS/Survey reports available from the following websites: HIS-‐DGHS, MIS-‐DGFP, MOHFW Health budgets available in MOF website EOI/RFP published in various portals like DG Market, UN and CPTU websites.
Appears to be on track.
2. Stakeholder
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2.1 Ensuring stakeholder consultation/social audit
• Adequate budget provision for stakeholder consultation/ during APR in the OPs
• Community planning and
management mechanisms such as Community Clinics will ensure the representation and participation of Community representatives
• Clients’ Charter of Rights
(CCR) and duties will be displayed in the health facilities.
MOHFW/ HEU • Stakeholder’s consultation done during APR
• A local level
accountability mechanism will be developed in participation with community people and local NGOs
• Citizen’s Charter
for health service delivery displayed.
Annually Progress reviewed during APR
Results are independently evaluated and corrective actions taken for any reported deficiencies Mainstreamed voice and accountability mechanisms into the governance and stewardship functions of the overall program.
Stakeholder Consultation for APR 2012 completed on time HIS & eHealth initiated feedback system using mobile phones; CC Management Support Groups established with NGOs/organizations (e.g. Eminence, Plan BD, StC, CARE, JICA, GAVI). Citizen Charter displayed in all health facilities; Hospital Management Committee in place.
IRT validates the Stakeholder consultation was completed. Whether it is relevant to the needs of the APR as conducted is another question. See APR The CC offer tremendous potential for community participation. IRT’s review indicates that effective participation is mixed … IRT recommends close monitoring of this initiative While the Charters are not binding, they do provide a moral tie between the service provider and clients assuming they are posted. The IRT members did see several on their field visits to three Divisions and Dhaka
3. Implementation Capacity/Institutional Capacity
3.1 Ensuring adequate capacity development of institutions and human resources strengthening to effective implementation of HPNSDP
• Annual workplans and budgets to incorporate capacity development initiatives for different levels of staff
MOHFW and all key institutions at central, division, district and local levels engaged in health service delivery .
• Budget execution of the planned activities.
Annually during APR Improved implementation capacity and progress towards the results.
APIR found overall progress satisfactory (65% of the OP indicators achieved target in FY 2011-‐12)
While the APIR notes 65 percent of OP indicators achieved their targets, this is not a good measure for the Key Objective which is targeted to HR and institutional capacity. HRM OP for instance is not meeting and is not likely to achieve its results if it continues as is. APIR as well as all IRT Thematic Reviews have raised the problem of HR issues as one of the principal if not principal constraint to achieving RFW results. Furthermore, it is the team’s view that too much emphasis may be given to training as an activity and output … the link with RFW results and OP training outputs is not always a given in an RBM framework. See IRT recommendation
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3.2 Ensuring adequate number and diversity of health workforce as per norms set by MOHFW
• Annual Development Program preparation and approvals.
MOHFW, DGHS, DGFP
• Diversity of staff increased
Annually during APR Effective utilization of the health workforce
ADP prepared and approved on time Substantial augmentation took place at community level workforce, e.g. CHCP, FWV, FWA, HA, nurse-‐midwives. Diversity is being promoted by MOHFW (e.g. NASP, TB-‐LP, Community Clinic, FP).
The IRT would prefer to keep the second activity and an additional indicator that measures vacancy rates and transfer rates. As the APIR and the IRT’s analysis shows, HR is still in crisis in Bangladesh and is one of the principal constraints to achieving indicator targets in a significant number of OPs Having said that we also acknowledge that vacancy rates of sanctioned positions have improved from SWAp to SWAp.
3.3 Improving quality of health services
• Updating of the standard operating procedures and clinical protocols.
• Conduct client and provider satisfaction survey every two years.
MOHFW, DPS • Improvement in satisfaction of clients and providers
Every two years, HFS Improved quality of health services.
SOP update in progress Health Facility Survey collects info on client and provider satisfaction in every two years
No change proposed.
4. Financial Management
4.1 Adequate and timely financial management at central, district and health facility level
• Customize and expand iBAS for timely preparation and submission of quarterly FM reports covering sector accounts.
MOHFW/ MOF • Quarterly reports of adequate quality and coverage submitted for smooth disbursement of funds to the program.
IUFRs on quarterly basis
Financial statements of HNPSDP prepared through the iBAS
iBAS connectivity established with FMAU.
IRT believes that customization of IBAS is not the appropriate strategy. IBAS is a government-‐wide accounting system, the reporting needs should come from a financial management system. IRT recommends building upon the ADP Monitoring tool for reporting requirements.
4.2 Timely fund execution
• Conduct regular review of ADP implementation.
MOHFW/MOF • Ensure disbursement of Q1 funds for the health sector.
By August of each FY
Efficient expenditure Management
Done on monthly basis. IRT believes this is a key objective, given the underfunding of the HPNSDP vis-‐à-‐vis the PIP.
4.3 Improve the quality of asset management
• Install inventory software for fixed assets
MOHFW/All Directorate
• At least piloted in one tertiary hospital.
By June 2012 Safeguard assets and Inventory
Propose to delete The IRT believes this Key Objective should be maintained and not deleted as it responds to real problems that exist in the program at all levels. A national level database for medical equipment over a certain value should be installed and maintained. Two previous databases were already developed but never used. This is not inventory software (all fixed assets are in the inventory software of CMSD) but asset management software.
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4.4 Establish effective Internal Audit
• Outsourced audit firm to carry out internal audit
• Develop in-‐house capacity
to carry out internal audit function and phased out the outsourced internal audit function.
MOHFW/ FMAU
• Provision for adequate budget and initiate the procurement process.
• Identified qualified
staff and developed capacity (including report writing skill) to carry out internal audit.
By April 2011 From July 2011
Safeguard of resources. Capacity developed to conduct in-‐house internal audit.
Firm outsourcing is at EOI stage. Training on FM and auditing going on by FMAU.
IRT believes this is on track. FMAU is suffering from lack of human resources, and will therefore rely on outsourced internal audit until this gap can be filled.
4.5 External Audit: Scope, nature and follow-‐up
• Strengthening Audit Committee
• Develop an Audit Strategy
outlining the coverage, focus of audit and steps for effective and timely follow up on audit observations.
MOHFW/FMAU,C&AG and PAC
• Co-‐opt member from MOF and CGA and organize meeting at regular intervals
• Timely resolution of audit observations.
July 2011 December 2011
Pending audit observations settled in a timely manner.
Audit monitoring system already in place. To be initiated
IRT believes this is important, especially in light of unresolved audit objections raised by FAPAD.
4.6 Adequate Funds ensured for operation and maintenance of medical equipment and hospital buildings
• Adequate budget provision kept for Operation and Maintenance (O&M )for maintenance of medical equipments, and hospital buildings
MOHFW, • Optimum uses of equipment and facilities for improved service delivery.
Annual
Adequate funds ensured for O&M
Budget provision for O&M falls under revenue budget. The budget is being increased every year.
International medical equipment studies budget annually between 7 and 15% of purchase price for maintenance of larger medical equipment. Study should be done here and budget should be linked to study outcomes.
4.7 Improving institutional strengthening of the MOHFW in collaboration with SPEMP
• Identify focal person for establishing coordination with the SPEMP
MOHFW/DPs • iBAS customized to capture financial date of expenditure.
Continuous MOHFW’s capacity developed in expenditure management and in the area of fiduciary oversight.
Focal person identified (JS-‐FMA)
IRT witnesses excellent collaboration between these two important partners
5. Procurement
5.1 Establishment of PLMC at the beginning of the program
• Adequate budget provision kept in the OP for PLMC
• Initiate the procurement
process to hire consultants for the entire project life.
MOHFW • Consultants are hired by December 2011
• PLMC functional
PLMC in place by December 2011
All contracts approved within timeline given in PPR Improvement in quality of procurement process and documents and the capacity developed
PLMC formally established Hiring of consultants ongoing
PLMC established 26 August 2012. Not fully operational yet. May take another 6 months before they can fully assume their role as described in their terms of reference.
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5.2 TA provided for procurement consultants for the procuring agencies.
• Individual procurement consultants assigned to CMSD and DGFP, either through Bank financing or parallel TA from other DPs
MOHFW • All documents show improvement in quality of bidding documents, evaluation reports and complaint handling
Comprehensive review during each APR
Contracts are awarded within the initial bid validity period.
Propose to delete as the PLMC will take care of these activities
PLMC will indeed give technical support to the procuring entities. IRT would suggest, however, that this indicator remains for another year and be reviewed again in 2013 APR as not all e-‐management tools or standards have been developed.
5.3 Introduce E-‐GP at major 3 procuring entities (CMSD, DGFP and HED)
• Piloting e-‐GP for CMSD, DGFP and HED in collaboration with CPTU
• Make necessary resources and logistics available for e-‐GP implementation
MOHFW/CPTU • At least one contract per agency procured through e-‐GP in 2nd year of the project (2012-‐13)
Progress to be reviewed during APR
More competition in HED contracts; Lower bid prices for CMSD and DGFP contracts
Propose to delete as the eGP established in MOF will take care of these activities
Indicator should remain as e-‐GP has not yet been done nor are the discussions with CPTU to access the GOB e-‐GP web portal in an advanced stage. Availability of resources and logistics remains the responsibility of the MOHFW.
5.4 Procurement Audit
• Provision for adequate budget and initiate the procurement process
• Outsourced audit firm to
carry out procurement audit
MOHFW/JS (Dev & ME)
• Audit performed and report disseminated
By April 2012 (contract out auditors for the first 2 years) By April 2014 (contract out auditors for the remainder 3 years)
Improved procurement management.
Budget available and firm contracting initiated
No procurement audits have been done to our knowledge but we may be incorrect. Will follow up with JS. I do not think that the expected result of an audit can be improved procurement management. However, if the audit report is followed by the development of a procurement risk mitigation plan and this is applied, it may improve.
5.5 Introduce Framework contract
• Framework contracts for pharmaceuticals, medical supplies, contraceptives and repeated commodities
MOHFW • No repetitive procurement for off shelf goods.
By July 2012 No stock out of consumables or non-‐technical goods and reduce the number of procurement transaction.
Agreement for framework contract is being developed
Agreed. Effort is made to make the framework contract eligible for GOB and all DPs. Better to take more time than to rush in to it as the final document may be used for years to come.
6. Environmental and Social (including safeguards)
6.1 Improving and expanding Health Care Waste Management
• Procurement of equipment and accessories relating to health care waste management (HCWM) done on time and supplied to all facilities.
• HCWM activities at the
upazila levels rolled out in phases
• Training provided to all staff dealing with HCWM
LD-‐IHSM and LD-‐ESD
• HCWM activities regularly monitored and annual reviews undertaken to measure implementation progress
Continuous Environmental degradation due to health care waste prevented.
Will be initiated from FY 2012-‐13
The APR 2013 should confirm that the key objective has been initiated
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6.2 Ensure compliance of safeguard policies relating to resettlement and land issues
• All civil works are screened to identify possible social safeguard issues
• Any issues arising out of the civil works are mitigated as per the guidelines set out in the Social Management Framework.
HED and PWD • People affected by the civil works are compensated appropriately.
Continuous Issues relating to land acquisition and resettlement minimized/ mitigated
Civil works adhere to GOB’s safeguard policies No safeguard issue triggered
To date this has not been a major issue as there has been no major construction that would trigger the safeguard, e.g., a resettlement action plan. The problem does play out however with real consequences for the achievement of results throughout the OPs as relates to the land that is donated by communities for the construction of CCs. The land is often far from population centers and thus inaccessible by the majority of the population; the IRT witnessed several newly constructed CCS that were either abandoned or underutilized
6.3 Specific needs of the tribal/ethnic people are addressed appropriately
• Recommendations and activities outlined in the Tribal Health, Nutrition and Population Plan implemented
MOHFW (LD-‐ESD)
• Implementation progress reviewed at least annually by the GOB Task Force
Continuous Ensuring equitable access of tribal/ethnic people to HNP services without compromising their cultural/ traditional norms
4 workshops on tribal health conducted at national and regional levels.
The IRT has reviewed the THNNP and found it to be relevant and a good guide for going forward. We however have some concern that the implementation of the Plan will not be given the priority it deserves, in much the same way that the Team sees issues of gender, equity, voice and accountability given secondary status in HPNSDP implementation. The IRT recommends that the GEVA Task Group place the monitoring of this Key objective on its agenda
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A N N E X 4
D A A R A N A L Y S I S
To accelerate progress on key areas of the HPNSDP, the development of a DAAR modality was put into place. On an annual basis, GOB and DPs jointly agree on key priorities and indicators. These indicators are then linked to incentive payments based on achievement. On a regular basis, the LCG meets to review progress.
In 2011, three DAAR indicators for 2011 on Maternal health/ health system-‐Human Resources, Maternal health/FP/child health, and Nutrition were achieved fully and two indicators on Health systems-‐budgeting and planning and Fiduciary were achieved partially. This resulted in a disbursement of US$ 7.16 million. The APR team believes that the DAAR indicators chosen were appropriate and feasible. The MOH clearly has the capacity to implement these indicators.
In 2012, good progress has already been made on the selected indicators. The GOB feels that they are able to achieve most of the DAAR targets fully. Our discussion with DPs also indicate that there is comfort in the capacity of the MOH to achieve the 2012 targets.
Overall, it appears that the DAAR indicator system incentivizes the acceleration of progress in key areas. The targets chosen thus far are feasible, and the MOHFW has the capacity to achieve them. The verification of some targets should receive continued attention.
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D A A R I N D I C A T O R S F O R Y E A R 1 ( J U L Y -‐ D E C EM B E R 2 0 1 1 )
Sl. No. Priority areas Year 1 Inputs
1. Maternal health / health system (HUMAN RESOURCES)
Obgyn and anesthetist pair present in 2 pre-‐identified Upazila health complexes in 5 low performing districts with high maternal mortality rates.
1. Selection of low performing districts & Upazilas.
2. Trained service providers (for each Upazila : 2 doctors in obs., 2 doctors in anesthesia & 3 nurses in EOC )
2. Maternal health /FP/ Child health
Availability of 12 pre-‐identified obstetric drugs and semi permanent FP methods in 2 Upazila health complexes/FP facilities in 5 low performing districts with high rate of maternal and child mortality.
1. Selection of low performing districts & Upazilas.
2. Identification of essential drugs by competent committee in consultation with OGSB.
3. Need assessment of identification of essential drugs on the basis of case load and treatment load.
4. Placement of demand and procurement of identified amount of drugs/ contraceptives
5. Supply according to need.
3. Health systems (budgeting and planning)
Resource allocation formula for the non-‐salary recurrent budget is adopted to be applied to the FY2012-‐13 budget.
1. Sharing Draft Resource Allocation formula with key stakeholders.
2. Conduct workshop to discuss and reach consensus among key stakeholders on the resource Allocation formula developed by HEU.
3. Organize TOT training and provide training to relevant staff of the selected cost centers and budget personnel at directorates on applying the formula.
4. Nutrition Nutrition Implementation Coordination Committee headed by the DGHS is established and at least 2 meetings are held to monitor nutrition activities in the concerned LD (PHC, MNCH, IPHN, and Community Clinics) & relevant stakeholders.
1. Formation of steering committee headed by Secretary, MOHFW with TOR.
2. Formation of Nutrition Implementation Coordination Committee headed by DGHS with TOR especially focusing the mainstreaming of nutrition.
3. Approached by MOHFW issuing a GO circulated to concern LDs, DPs & others.
4. Committee would be reflected in NNS OP.
5. Fiduciary GOB iBAS adapted to meet health sector financial reporting requirements.
1. Identify whether the reporting options are available from GoB iBAS system.
2. Identify the difference between the transactions recorded in iBAS system and in the Line Directors record, which is supposed to be addressed through regular reconciliation process.
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P R O G R E S S O N 2 0 1 2 D A A R I N D I C A T O R S ( A S O F S E P T EM B E R 1 2 , 2 0 1 2 )
Priority Areas DAAR Indicators 2012 Implementation Responsibility Progress
1. Financial Management
a) Financial management support in place in FMAU and selected LDs.
b) iBAS connectivity established with FMAU.
FMA Wing, MOHFW
‒ Recruitment of a Firm is under process. Request for Proposal (RFP) has been distributed among short listed firms. The deadline for submission of RFP is 16 September 2012.
‒ iBAS connectivity has been established with FMAU.
2. Procurement a) Staffed and functioning Procurement, Logistics And Monitoring Cell (PLMC).
b) Procurement Web Portal is ready for trial.
Dev.& ME Wing, MOHFW
‒ PLMC was established on 26 August 2012 ‒ Trial of procurement Portal has been done.
3. Monitoring and Evaluation
Establishment of PMMU (with 6 fully assigned staff), and Annual Program Implementation Report (APIR) completed on time to feed into APR.
Planning Wing, MOHFW
‒ PMMU was established on 14 December 2011 (vide notification no. 45.184.136.00.00.27.2011-‐112).
‒ Since establishment, 2 Programme Management Officers (PMO) are working at PMMU. Operational support to PMMU is being provided through ICDDR,B with funding of Sector-‐Wide Program Monitoring & Management (SWPMM) Operational Plan. Staffing of PMMU with 3 Senior Assistant Chief/Assistant Chiefs and 1 Deputy Chief was made in September 2012.
‒ Dissemination of APIR with Line Directors was held on 12 September 2012 with Senior Secretary, MOHFW in the chair.
4. Human Resources & Supplies
A pair of Obgyn and Anesthetist, and 3 nurses trained in EOC present in 10 UHCs in 5 new low performing districts on the basis of maternal health and child mortality.
LD (MNCAH), DGHS; Director (Admin), DGHS; Director, DNS; and Administration Wing, MOHFW.
[10 upazilas in 5 new districts (Madaripur : Shibchar, Rajoir; Netrokona: Kolmakanda, Kendua; Cox’s Bazar: Teknaf, Chokoria; Narail: Kalia, Lohagora; Habiganj: Baniachong, Ajmeriganj) were selected in July 2012 and the responsible parties were informed accordingly.] ‒ Posting progress of a pair of Obgyn and Anesthetist may be seen
in Annex-A. ‒ Posting of nurses trained in EOC in 10 UHCs in 5 new low
performing districts is under process.
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5. Nutrition
a) Rollout plan for SAM is finalized and approved b) Bi-‐monthly NICC meetings and quarterly SC meetings taking place
LD (NNS), DGHS; and PH&WHO Wing, MOHFW.
‒ Rollout plan for SAM is Finalized and approved and is now at implementation phase (Progress of SAM activity is detailed in Annex-B)
‒ NICC was formed in December, 2011 and from January three meetings took place.
‒ Three SC meetings took place after formation of the Steering Committee in December, 2011.
6. Stewardship: Local Consultative Group
a) LCG WG-‐Health quarterly meetings took place b) Task Groups formed (verified by notification) and functioning (verified by at least 2 meetings per year)
Planning Wing, MOHFW
‒ Quarterly LCG WG-‐Health meetings are taking place regularly. The 4th meeting was held on 24 May 2012. The 5th meeting is scheduled to be held on 25 September 2012 during APR 2012.
‒ Nine Task Groups (TGs) were formed on 24 May 2012 (vide notification no. MOHFW/Health-‐7/HPNSDP-‐task Group/2012-‐104). Since then, meetings of different TGs have been held. Two rounds of meetings are scheduled to be held during APR 2012.
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A N N E X 5
T E AM L E A D E R T E RM S O F R E F E R E N C E
Terms of Reference INDEPENDENT TEAM LEADER
for Annual Program Review (APR): 2012
Health, Population, Nutrition Sector Development Program (HPNSDP), 2011-‐2016 Ministry of Health and Family Welfare (MOHFW)
Bangladesh 1. Background
Ministry of Health and Family Welfare (MOHFW), Government of Bangladesh (GOB) has been implementing the Health, Population and Nutrition Sector Development Program (HPNSDP) for a period of five years from July 2011 to June 2016, with the goal of ensuring quality and equitable health care for all citizens in Bangladesh by improving access to and utilization of health, population and nutrition services. After Health and Population Sector Program (HPSP) (1998-‐2003) and Health, Nutrition and Population Sector Program (HNPSP) (2003-‐2011), HPNSDP is the third sector program prepared following the sector-‐wide approach (SWAp) in the health sector of Bangladesh, through an extensive consultative process building on the lesson learned of the previous sector programmes for overall improvement of health, population and nutrition sub –sectors. The priority of the programme is to stimulate demand and improve access to and utilization of HPN services in order to reduce morbidity and mortality, particularly among infants, children and women; reduce population growth and improve nutritional status, especially of women, children and vulnerable population.
2. Introduction and Objectives of the Annual Program Review (APR)
APR is a management instrument designed for both the Government of Bangladesh (GOB) and Development Partners (DPs) to monitor progress in the implementation of the program and to verify that management and policy responsibilities are met in the health sector program (HPNSDP). The 2012 APR is the first for HPNSDP, and will focus both on institutional and service delivery issues. The overall intention of the APR is to:
‒ Review implementation of HPNSDP in the light of an up-‐to-‐date results framework using the latest data, indicators and targets as provided in the APIR3;
‒ Assess initial progress of the program during the first months (including independent perspectives on the DAAR indicators4 and the GAAP5);
‒ Review the financing arrangements and assess how well the GOB and DP support meets the priorities and requirements of the HPN sector;
‒ Undertake analysis in thematic areas (see below), to set the baseline / document the building blocks related to the key health systems identify issues/challenges concerning effective delivery of services, and recommend ways to improve progress.
3 Annual Program Implementation Report 4 Disbursement for Accelerated Achievement of Results 5 Governance and Accountability Action Plan
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As HPNSDP (2011–2016) moves to its first year of implementation, the 2012 APR provides an opportunity to assess progress and focus on key priorities in the following thematic areas:
1 Voice and Accountability 2 Monitoring and Evaluation 3 Procurement and Supply Chain Management 4 Financial management with Planning and Budgeting 5 MNCH and Family Planning (including human resources) 6 Nutrition (including human resources 7 Disease Control (including human resources) 8 Urban Health (including population and nutrition) 9 IEC & Behavior Change Communications (BCC)
The APR is expected to (i) be more focused on key program initiatives in the HPNSDP where early results / or the lack thereof are evident; (ii) develop shared problem analysis and solutions using existing institutional structures, e.g., the joint GOB–DP task groups and other working committees; (iii) focus on implementation level realities – with focus on HPN outcomes, specifically HPN service utilization, nutrition issues and initiation of important reforms. Specifically, the 2012 APR aims to:
‒ Review the progress of start-‐up measures essential to meet the objectives defined in the policy and planning documents, and whether adequate measures have been proposed for effective implementation of HPNSDP;
o Review the progress in service delivery as laid out in the Program Implementation Plan (PIP) of HPNSDP based on Results Framework (RFW);
o Assess the progress of the establishment of PMMU, PLMC, IUFR, institutional arrangement of FMAU etc. of HPNSDP;
o Identify TA requirement for the smooth implementation of the program focusing particularly on key system areas such as Financial Management, Human Resources, Procurement, M&E, Governance and stewardship;
o Review the financing of the sector in the previous year in terms of commitment and contributions of GOB and DPs (including parallel support), fund utilization, reporting, and overall efficiency achieved;
o Review and highlight health system issues and challenges in delivering on HPN outcomes, and capacity building measures initiated;
o Assess progress of implementation of DAAR and take stock and revise GAAP;
o Assess the progress of procurement (goods and services) and provide recommendation on procurement performance.
o Review the working arrangement between DPs and government and how well DP support (including parallel financing) is presently supporting the HPNSDP 2011-‐2016. This will also include a stock take of the funding commitments of HPNSDP.
The APR Steering Committee has primary responsibility for the oversight of the process, and is chaired by Government (Joint Chief, Planning Wing, MOHFW) and inclusive of DP representatives. The Committee will lead the process of ensuring the main deliverables which include:
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a. An Aide Memoire, agreed between Government and DPs
b. Updated Results Framework and GAAP using the latest data and information to inform baselines and targets
c. Thematic Analytical Reports that inform the Aide Memoire and form the baseline of analysis for determining future progress.
3. Description of the APR Process
The APR process includes several steps (technical review, task group meeting, field visits, stakeholder consultation, policy dialogue, preparation of action plan and wrap-‐up meeting) as detailed below.
a. The Technical Review will be carried out by an Independent Review Team (IRT) comprised of international and national consultants that will analyze data generated from routine data sources of MOHFW as well as available surveys, analytical studies, qualitative data, and conduct fact-‐finding activities to review the progress of HPNSDP. The Annual Program Implementation Report (APIR) will be prepared by the MOHFW and made available to IRT prior to the Technical Review. The IRT will:
‒ Review available information and assist the Task Groups in analyzing data and recommending next steps (TORs pertaining to specific thematic areas has been developed separately). The IRT will prepare a technical report (IRT Report) drawing on various inputs, including the reports mentioned in (b), (c), (d) below and the other sources of information described in section 4, to be discussed in the Task Groups. Based on these discussions, an action plan will be developed to be followed up in the next year;
‒ Review implementation of the HPNSDP and provide a detailed analysis of a selected thematic areas of the program, focusing on Health Services Utilization and Nutrition to highlight the challenges and possibility of achieving the objectives and targets of HPNSDP (including those relating to reducing inequities);
‒ Review the risk assessment of HNPSP and set the baseline for HPNSDP.
b. Nine (9) task groups (viz. Equity, Gender and Voice; Monitoring and Evaluation; Procurement; Financial Management; Human Resources; Nutrition; Health Financing Resources Group; MNCH-‐FP and Sector Management) and ‘task groups’ have been formed under the HPNSDP, which comprise members from GOB and DPs. The issues identified in the technical review, stakeholder consultation and field visits will form the agenda for discussion in the Task Groups. Each Task Group will identify a set of actions, with time lines and responsibilities. These actions will be consolidated for further discussion and endorsement at the higher level of MOHFW.
c. APR will include field level discussions to understand implementation realities at the field level. 7-‐member teams comprised of 3 MOHFW, 3 DPs and 1 IRT representatives will visit field with a focus on identifying solutions to service delivery bottlenecks to improve utilization of services. During the field visits, emphasis will also be given to strategies to improving utilization of HPN services and including nutritional status of poor women and children on the basis of discussions at the field levels. The process is to be managed by the PW of MoHFW and a brief report on issues identified during the field visit will be included in the IRT Report. A separate TOR for field visit will be developed in consultation with DPs and IRT team leader.
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d. Stakeholder Consultation will be carried out under the APR to elicit views on service delivery and utilization from various stakeholder groups including academicians and civil society organizations. In order to carry out the consultation and prepare the consultation report, an independent agency will be contracted. Stakeholder consultations will be conducted in seven divisions feeding into a discussion at the division HQ level. This year, the Stakeholder review, while focusing on health service utilization, will have an additional schedule to probe issues related to nutrition and will elicit views of stakeholders including poor pregnant women, HPN service users, and HNP service providers from NGO, public, and private sectors. Based on these consultations and focused group discussions (FGDs), the agency will prepare a Stakeholder Consultation Report that will feed into the APR process.
e. On the basis of the IRT report, a Policy Dialogue will take place between the senior representatives of MOHFW and the DPs. The Key Objectives of the policy dialogue will be defined by the APR SC with the aim to:
‒ Discuss key findings and recommendations proposed by the IRT report; ‒ Discuss MOHFW’s and DP comments on IRT’s report; ‒ Prioritize HPNSDP issues and recommendations to prepare the action plan; and ‒ Agree on proposed actions required for moving the HPNSDP forward and to achieve
the program objectives and targets.
f. The Aide Memoire for the 2012 APR will be jointly written by the GOB and DPs. A drafting committee will deliver the first draft for discussions to the MoHFW. The final Aide Memoire will be discussed and agreed upon in the Wrap up meeting. The LCG -‐Health group will be appraised of the overall situation.
g. Following the policy dialogue and an agreed Aide Memoire with an Action Plan will be developed and agreed upon. Action Plan implementation might require revision of Operational Plan, budget and procurement plan for the following year. LCG -‐ Health group will review progress of implementation of agreed upon Action Plan following the APR.
4. Tasks of the Independent Team Leader for the APR
The Team Leader for the 21012 APR will report directly and ultimately to the Senior Secretary of Health in the MoHFW, and to the Local Consultative Group for Health. S/he will take lead responsibility for the overall APR process and the production and quality of the main reports, most specifically the Technical Review Report and the coordination, consensus, and final production of the aide memoire (as detailed above).
The Team Leader will assist in the selection of the independent reviewers for the thematic studies mentioned above. In addition s/he will provide overall supervision, guidance, and production of the main outputs of the APR process (outlined below under deliverables). The Team Leader will be provided with administrative assistance from the World Bank Health Team to ensure logistics are available to complete the work in a consultative manner and on time. Towards this the Team Leader will produce a schedule of activities and meetings early in the process (by 18 September) which includes a consolidated plan for field visits by those working on thematic areas, as well as consultations on other elements outlined above.
Particular emphasis should be on actions which provide strategic direction and lesson learning to the sector programme, and most especially in relation to adjustments to
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operational plans which could enhance results and performance. Reports should provide recommendations based on findings and the AIR, a risk assessment, reflections on the results framework and DLIs, and a commentary on actions taken in relation to the GAAP. The final report should also make recommendations in relation to processes for future APRs.
The Team Leader will be expected to use methodologies which are inclusive of a wide range of stakeholders, and to hold regular, well-‐planned discussions with senior Government officials, Development Partners, and non-‐state actors. S/he will be expected to familiarize him/herself with the range of background documents, and to participate in Task groups, LCG meetings, and/or other meetings as appropriate. All stakeholders will avail information to the Team Leader openly.
5. Deliverables
‒ The Team Leader of IRT will submit a written report to the APR SC. The final version of the report will include:
‒ A report containing concise information on the key issues to be discussed during the policy dialogue; the main report should be a maximum of 20 pages. This will include: (a) progress against objectives and main findings of thematic reviews; (b) updated results framework (c) institutional constraints in implementation including any updates required on the Risk Assessment; (d) priority actions for follow-‐up for the remainder of HPNSDP; (e) financial framework for the sector including DP funding; (f) progress on key areas of GAAP.
o The background reports of all Thematic Reviews and key findings from the stakeholder consultation meeting will be attached in an annex to the main report. These should form an important analytical baseline for this sector programme.
6. Availability:
The Team Leader should be available for a ten-‐day visit to Bangladesh in mid-‐July and full time in Bangladesh from 15 September though 12 October 2012.
7. Information available for the APR 2012
The following resource documents and reports/sources of information will be available to be used in the APR6:
‒ Strategic Plan for HPNSDP ‒ Program Implementation Plan (PIP) of the HPNSDP ‒ Operational Plans relevant to the selected 9 thematic areas ‒ Governance and Accountability Action Plan ‒ Stakeholder Consultation Report 2012 ‒ Project Appraisal Document (PAD) of Health Sector Development Program (HSDP) ‒ Annual Program Implementation Report 2012 ‒ Bangladesh Demographic and Health Survey 2007 and 2011 ‒ Bangladesh Maternal Mortality Survey 2010 ‒ Utilization of Essential Delivery Services Survey 2008 and 2010 6 Following the first visit of the Team Leader additional areas of analytical work will be initiated in consultation with the APR SC and respective Task Group as an input into the APR process – this October involve follow up on specific aspects of HPNSDP e.g. review of Technical Assistance, Health Care Waste Management and Tribal plans.
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‒ Bangladesh Health Sector Profile 2010 ‒ National Health Accounts 2007–08 ‒ Health Facility Survey 2009 and 2011 ‒ Public Expenditure Review 2008-‐9 ‒ Joint Assessment of the Implementation of HIV/AIDS Targeted Interventions in
Bangladesh 2008 ‒ Environment Management Plan of MoHFW ‒ Bangladesh Health Watch Report 2007, 2009 and 2011 ‒ Review Missions/Evaluation reports of GFATM/GAVI/DP Support program (where
available) ‒ Rapid Assessment of Demand Side Financing Scheme 2008 ‒ Economic Evaluation of Demand-‐Side Financing for Maternal Health in Bangladesh
2010 ‒ Costing of Maternal Health Services in Bangladesh 2010 ‒ Public Expenditure and Financial Assessment (PEFA) of the Health Sector as well as the
overall Sector 2010 (check) ‒ World Bank’s Procurement Assessment 2010 (check) ‒ Aid Modality Assessment (check).
8. Independent Review Team (IRT)
‒ Team Leader ‒ Gender, Equity, and Voice Specialist ‒ M&E Specialist ‒ Financial Management Specialist ‒ Procurement Specialist ‒ MNCH&FP Specialist ‒ Nutrition Specialist ‒ Disease control Specialist ‒ Urban Health Specialist ‒ IEC & BCC Specialist
9. Reporting
The Team Leader (TL) of the Independent Review Team (IRT) will work under the guidance of the Chair of the APR Steering Committee (APR SC). The TL will report for all purposes to the APR SC.
10. APR Secretariat
MOHFW Planning Wing/ PMMU will act as the secretariat for the APR 2012.
11. Support Team:
The support team will facilitate the APR process.
‒ Two officials from the MOHFW Planning Wing ‒ World Bank Bangladesh HPN team