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BANGLADESH COUNTRY REPORT

BANGLADESH COUNTRY REPORTAn assessment of the political economy factors that shape the prioritisation and allocation of resources for essential

health services for women and children

Ian Anderson, David Hipgrave and Midori SatoFebruary 2015

unite forchildren

Ian Anderson, David Hipgrave and Midori SatoDecember 2014

BANGLADESH COUNTRY REPORTAn assessment of the political economy factors that shape the prioritisation and allocation of resources for essential

health services for women and children.

AcknowledgementsThe authors are grateful to UNICEF Bangladesh, particularly to Drs. Lianne Kuppens (Chief of Health) and Shukhrat Rakhimdjanov (Health Manager), and to Drs. Douglas Noble and Nuzhat Rafique at the UNICEF Regional Office for South Asia, for their support to this assessment, participation in the mission and comments on drafts of this paper. The team also thanks government officials, bilateral and multilateral agency official, NGO officials and academics in Dhaka who gave their time to inform this assessment.

The views expressed in this paper and all responsibility for the content of the study rests with the authors.

ContentsAcknowledgements Acronyms Currencies and exchange rates

1 Executive Summary

2 Background 2.1 Context 2.2 Methodology, frameworks used and report structure

3 RMNCH situation of the country 3.1 RMNCH achievements despite low income and high poverty. 3.2 Political, economic and development context 3.2.1 Health-focussed political, economic and administrative history 3.2.2 Social, cultural and other determinants relevant to health and MNCH 3.2.3 Development partner context

4. Structure and function of the health sector and RMNCH at national and sub-national levels 4.1 Health systems context 4.1.1 Health system structure, governance and stewardship 4.1.2 Health Financing 4.1.3 Health and MNCH priority-setting at national and sub-national levels 4.1.4 Service Delivery and quality 4.1.5 Human resources 4.1.6 Procurement and logistics. 4.2 Appraisal of health sector performance in relation to RMNCH

5 Analysis and Recommendations 5.1. Analysis 5.2 Recommendations

6. Conclusion

References

Annex Annex one: definitions of political economy Annex two: approach and methodology Annex three: Inception report for Bangladesh Annex four: List of those interviewed in Bangladesh

Cover Picture© UNICEF/NYHQ2012-1684/xxxxxxx

7BANGLADESH COUNTRY REPORT

Acronyms

ANC Antenatal CareAL Awami LeagueBDHS Bangladesh Demographic and Health Survey BNP Bangladesh Nationalist PartyBRAC Bangladesh Rural Advancement CommitteeDFID Department for International Development (UK) DFAT Department of Foreign Affairs and Trade (Australia)DGFP Directorate General Family PlanningDGHS Directorate General Health ServicesEBPB Evidence-based Planning and BudgetingEPI Expanded Programme on ImmunizationGIZ Gesellschaft für Internationale Zusammenarbeit (GIZ) GDP Gross Domestic ProductHDI Human Development IndexHMIS Health Management Information SystemHPNSDP Health, Population and Nutrition Sector Development PlanKII Key Informant InterviewLGSP Local Government Strengthening ProjectMMR Maternal Mortality RatioMNCH Maternal, Newborn and Child HealthMDGs Millennium Development GoalsMoHFW Ministry of Health and Family WelfareMoF Ministry of FinanceNCDs Non-Communicable DiseasesNGO Non-Governmental OrganisationODA Official Development AssistanceOPs Operational PlansORS Oral Rehydration SolutionOOPE Out of Pocket ExpenditurePEA Political Economy AnalysisPPP Purchasing Power ParityRMNCH Reproductive, Maternal, Neonatal and Child HealthSWAP Sector Wide ApproachTFR Total Fertility RateUNICEF United Nations Children’s FundUNDAF United Nations Development Assistance FrameworkUSAID United States Agency for International DevelopmentUHC Universal Health CoverageVAT Value Added TaxWB World Bank

Currencies and exchange ratesAll $ are current United States dollars unless otherwise specified.1 Bangladeshi Taka = $US 0.012 in September 2014$US 1 = Bangladeshi Taka 77.2 in September 2014

1 Executive summary

Background and methodology

Decisions on the allocation of scarce resources are rarely made purely on the basis of technical criteria: political and other factors also shape decision-makers’ choices. It is therefore important for development partners to understand how and why governments in developing countries prioritise and allocate their own resources (as well as those of development partners), if countries are to achieve outcomes that are financially, politically and institutionally sustainable.

Since 2011, the Australian Government has been providing development assistance to improve reproductive, maternal, newborn and child health (RMNCH) outcomes in Bangladesh, Indonesia, the Philippines and Nepal. The approach focuses on improved use of local data in the prioritisation, planning and allocation of resources at district level. The main objective has been to develop, through district-level pilots, an ‘investment case’ to encourage sub-national governments to fund RMNCH as a key area of human development. Australian aid funding was channelled through UNICEF and other partners working with governments at national and district level in the four countries.

To deepen its understanding of the political economy of health and RMNCH in those four countries, UNICEF undertook an analysis during August-September 2014. A mixed methodology was used, drawing on expert recommendations from academia and development experts. A questionnaire was developed based on a review of the relevant peer-reviewed and grey literature. Local data was gathered and interviews conducted in-country. This report provides the findings for Bangladesh.

Situation analysis

Bangladesh is a low income country with a Gross National Income of $900 per capita in 2013. Just over three quarters (76%) of the population lived below the $2 a day poverty line, and 43.2% lived below the $1.25 a day poverty line in 2010. At 920 people per square kilometre Bangladesh is the most densely populated country in the world. It is also vulnerable to natural disasters and climate change. Limited domestic employment opportunities have meant that remittances account for more than 10% of GDP. Bangladesh ranks low on global measures of human development, budget transparency, and corruption control. Its political situation has been described as “inter-elite contestation for access to patronage resources, with voters deployed as pawns during elections and ignored in between” (1). Evolution and implementation of new policy is slow.

It is thus surprising that Bangladesh has made excellent progress on the Millennium Development Goal targets on reducing fertility, maternal and child mortality, poverty

and even undernutrition (although the latter is still very high). The targets in these and other areas either have been, or are likely to be, achieved. A striking feature is the historically strong role of community-based and non-government organisations (NGOs) in development and health care, often supported by funds from international development partners. Bangladesh has more NGOs per capita than any other developing nation providing social services, microcredit and other services. The Bangladesh Rural Advancement Committee (BRAC), for example, reaches around 110 million people through 64,000 village health workers. These NGOs fill the void left by weak public services and many enjoy good relationships with both major political parties. Widespread application of evidence-based basic health technologies have been key to rapid reductions in maternal and under-five mortality. Investment in girls’ education has also contributed to dramatic improvements in RMNCH.

The political economy of the health sector and RMNCH in Bangladesh

In general, health and RMNCH enjoy a high level of bipartisan political commitment in Bangladesh, but this does not translate into government prioritisation or the allocation of substantive resources. Despite the political rhetoric, public financing for the health sector (just 1.2% of GDP) is very low both in absolute and relative terms. Increases in total health expenditure are driven mostly by households’ direct out of pocket expenditure, a barrier to essential care for the poor and a source of inequity for others. National plans for universal health coverage (UHC) reflect the constitutional right to health care. However this will mainly be financed by government, and as such will require dramatically increased sources of public revenue and improved public stewardship and regulation of private providers. There is little sign of these changes occurring. Another indicator of the challenges facing the health sector is the weak planning process, which is highly centralised, complex, fragmented and based on historical norms rather than needs. The fixed-formula budget allocation does not account for changing populations or disease burdens, new evidence, or emerging priorities. It is also inequitable. Private healthcare is not considered in the development of annual budgets. However, decision-makers in Dhaka have little incentive and are currently under no pressure to relinquish the power and patronage they possess through their control of the national health sector budget. Development partners have only limited influence on establishing more evidence-based and fairer allocation of scarce resources.

Government’s aim of achieving UHC by 2032 is a strategic opportunity for improving outcomes in the health sector and RMNCH in particular. For example, Bangladesh can build on the remarkably successful collaboration with community-based NGOs to address the unfinished agenda of under-

8 9BANGLADESH COUNTRY REPORT BANGLADESH COUNTRY REPORT

nutrition and the new challenges of non-communicable diseases (NCDs). However there will be challenges. Bangladesh will need to find new ways to generate, pool and use much needed additional financial resources to achieve UHC. Addressing the existing burden of newborn deaths and the rising burden of NCDs can involve new technical interventions and be more complex from a health systems perspective than earlier programs such as child immunisation. The increasingly complex demands of UHC will require improved management of the public health sector and better governance, stewardship and regulation of the private health sector.

Summary and recommendations

Despite very low allocation of public resources, Bangladesh has made remarkable progress in RMNCH to date. Current arrangements, including the collaboration between government and NGOs, have served the country well. However inequity in access to healthcare and health outcomes, persisting high rates of newborn mortality and under-nutrition, a rising burden of NCDs, the move to UHC and the financial distress and impoverishment arising from high out of pocket expenditures all suggest that more investment and policy reforms are needed. These are not just technical issues: political economy factors will be critical to deciding priorities and allocation of scarce resources. To improve outcomes government should make more effective, efficient and equitable use of existing health resources in both the public and private sectors. Priority setting and resource allocation should be more needs-based, ideally with a bigger role for local government. New approaches, policies, and skills are needed to reduce the impact of NCDs and improve RMNCH

within health facilities. Bangladesh should also increase public expenditure on health, especially in the context of establishing UHC. Investments and policies outside the health sector will also be important, including a greater focus on child nutrition, sanitation, reducing tobacco smoking and continued investments in girls’ education.

Donors and development partners working in Bangladesh need to be aware of the opportunities and limitations that are evident in both the public and private spheres. An effective and acceptable strategy may involve support for strengthening government processes and systems while using NGOs as supporting partners at community level. Development partners need to move away from traditional, stand-alone, “project” approaches and instead work to help government strengthen its own approach to policy development and implementation of UHC. It will be particularly helpful and strategic for development partners to support studies on the cost of prevention and treatment of key health burdens at different levels of the health system. Supporting impact evaluations on what works, for whom, at what cost and under what circumstances is also a strategically valuable investment that can help improve the quality of Government’s own decision making. Such studies and donor impact more generally will take time. Development partners in Bangladesh should use their technical expertise and bureaucratic political capital to commit to long term support.

Finally, this report reconfirms the important message that a country’s political context must always be taken into account. Technical agencies must be astute in presenting messages accurately but clearly, and at times in the political, policy and budgeting cycles where such messages are most needed and most useful.

2 Background

2.1 Context

Social and economic development processes involve much more than technocratic approaches: ‘political economy’1 factors usually determine the fate of reforms. This finding is clear from the international literature (2-13). More specifically, how - and why - governments make and implement decisions; prioritise the allocation of scarce financial and human resources; resolve trade-offs; regulate the private sector; achieve accountability; and interact with civil society and development partners is an essential key to understanding the process of international development. Understanding how governments use – or don’t use – evidence to shape policies and prioritise the use of their own scarce resources is increasingly important. That is particularly true as more and more countries achieve middle income status2, albeit with large burdens of poverty (14) and aid programs become progressively smaller.

Development partners need to increasingly understand the political economy of decision making and resource allocation if they are to have impact. Traditional forms of Overseas Development Assistance (ODA) have become relatively less important in much of Asia as those economies expand and some development partners withdraw. For example, total ODA in all sectors now constitutes less than one per cent of government expenditure in Indonesia. While ODA can be helpful and catalytic in supporting reforms, the key to improved outcomes will be how countries prioritise and use their own resources. The ‘country-driven development’ vision of the Paris Declaration and Accra Agenda for Action further point unmistakably to the importance of national planning and budgeting, however uncomfortable that may be for development partners increasingly seeking visibility, ‘quick wins’ and avoidance of corruption from their own aid dollar. Development partners have their own political economy incentives and drivers. Those partners wishing to support more evidence-based priorities and resource allocation decisions by developing country governments must identify more sophisticated – but legitimate – entry points of influence.

Understanding the political economy of Reproductive, Maternal, Newborn and Child Health (RMNCH) is a particularly important issue. That is partly because there remains a large but preventable RMNCH burden globally, including in Asia and the Pacific: 2.5 million children under

five died in this region in 2013, 41% of the global burden (15). Understanding the political economy of RMNCH is also important because proven, affordable, interventions that dramatically improve RMNCH outcomes have been successfully implemented at scale in some low income Asian countries decades ago (16). Yet if the scientific evidence base, cost-effectiveness and affordability for improving RMNCH have been so clear, for so long, why have so many countries failed to invest accordingly? Why, despite the political commitments and rhetoric, do several countries in Asia have the lowest absolute and relative levels of government expenditure going to health, and especially RMNCH? How can RMNCH be prioritised and resourced in countries which are rapidly decentralising political and economic decision making to sub-national districts and even to villages? Conversely, can sub-national prioritisation influence national decisions on fund allocation? Political economy analysis can help provide insights into these issues for the benefit of governments and their development partners.

This report builds on recent collaborative work between Australia and UNICEF aimed at improving the evidence base for investment decisions for RMNCH in Asia. More specifically, the Australian Government’s aid program3 has been funding an initiative – known as the Investment Case Approach - in Bangladesh, Indonesia, Philippines and Nepal since June 2011. Led by UNICEF and its partners, the goal has been to demonstrate a new and systematic way of producing evidence that enables policymakers and planners to: 1) assess the extent to which RMNCH services are equitably distributed, using locally gathered data; 2) identify the constraints hampering the scale-up of cost-effective interventions that affect RMNCH; 3) design realistic strategies to address those constraints and 4) estimate the expected mortality and morbidity impact and costs associated with implementing the strategies proposed. The approach sought to influence national policymakers and other stakeholders, including development partners, by highlighting financing gaps within national health systems and in specific geographic areas, as well as gaps in governance of the health sector. But the approach also focuses on improving the evidence base for sub-national planning and budgeting. That is because some of the greatest RMNCH needs occur in geographically and economically disadvantaged areas, where the evidence and capacity for good decision making is weakest.

1 Some useful definitions of ‘political economy’ as they apply to international development are set out in Annex One. 2 The World Bank classifies countries as “middle income” if they had a GNI per capita of more than $1045 but less than $12,746 in 2013. Within the middle income category, those countries with a GNI per capita of less than $4125 are classified as lower middle income, while those above are classified as upper middle income. 3 Originally AusAID and from 2013 the Department of Foreign Affairs and Trade (DFAT).

10 BANGLADESH COUNTRY REPORT

UNICEF commissioned this report to better understand the political economy of decision making in Bangladesh, with particular reference to RMNCH. This report responds to UNICEF’s and DFAT’s wish to better understand the overarching strategic factors that drive priority setting and resource allocations for RMNCH and the health sector more broadly at both the national and sub-national levels in Bangladesh. This can, in turn, then inform UNICEF and other stakeholders how they might need to recalibrate their approaches so as to increase their impact on RMNCH and the health sector more broadly. Similar reports are being prepared for three other countries of interest to UNICEF and DFAT - Indonesia, Philippines and Nepal – where UNICEF and DFAT have been supporting evidence-based planning in support of women and their children. The original Terms of Reference for this report are available on request. The political economy reports are in addition to a quite separate exercise that evaluates the outputs and outcomes of the Investment Case approach.

2.2 Methodology, frameworks used and report structure

There are numerous analytical tools and approaches that could be drawn on to examine the political economy of health and RMNCH in developing countries, as they are reflected in priority setting, planning and budgeting by Governments. These include a “How to” note on political economy analysis by the UK Department for International Development (DFID) (17) and the World Bank (18); the approach by the Overseas Development Institute (19); and the World Bank’s “problem driven governance” framework presented by Fritz et al. (20). There are also numerous tools and approaches that can be applied to political economy analysis including “Theory of Change”; “Drivers of Change” “Most Significant Change”. All of these tools and approaches have something to offer, but because there is great variety between, and within, the four countries captured in this study, we have not adhered to one in particular. Indeed, it would be remarkable if any one analytical approach could be applied coherently and comprehensively to all four countries, especially given the focus of the work on sub-national level, which has not been analysed very widely, especially in Asia (21). Having said that, this analysis of the political economy of RMNCH in Bangladesh, and the other three countries, did draw on the methodological framework employed by DFID’s “How to” note, and Fritz’s “problem driven governance” as they had the most applicability to social sector situations. Further details, including a schematic overview of the approaches used by DFID, as well as Fritz et al, are in Annex 2.

The specific methodology used for each of the four countries was as follows. The two independent consultants4 first reviewed different approaches to political economy analysis, especially as it applies to the health and social sectors, in peer reviewed and / or grey literature. They then reviewed peer reviewed, grey literature, and open access data bases to identify the main political economy characteristics of each country’s health and development sectors. The literature review and data base analyses were then used to develop an inception report for each country, summarising the key political economy characteristics of the country. The Inception Report also set out the proposed methodology and analytical approach, including ethical issues; a proposed standard questionnaire for interviews; and a recommended program of field level interviews. The Inception Report for Bangladesh is available at Annex 3. Once UNICEF had reviewed and approved the Inception Reports and methodology, field level interviews were conducted involving one or two week visits to each of the four countries over 7 weeks during July – September 2014. In Bangladesh the two consultants interviewed 34 stakeholders from government, civil society including research institutions, and development partners over the period 31 August to 6 September 2014. A list of those interviewed in Bangladesh is at Annex 4. The two consultants were accompanied and actively supported in all interviews by Drs. Lianne Kuppens, UNICEF Chief of Health, Dhaka, and Shukrat Rakhimdjanov, Health System Strengthening, of the UNICEF office in Dhaka.

The country level visits and interviews involved a mixed method approach. This involved:

a. Discussions with local staff on the findings of the desk review and exploring its implications for their local activities (in health and other sectors).b. Interviewing experts from government (in the finance, planning, health and other social sectors, and the equivalent of the office of the prime minister or president)c. Discussions with the major development partners and academics who have previously assessed the political economy of social sector issues d. Gathering and analysing quantitative data on social sector spending, disbursement and sub-sectoral allocations (infrastructure, human resources, advocacy / communications), as well as local analysis on related policy direction

This report is structured as follows. Section 3 provides a summary and analysis of the RMNCH situation of Bangladesh. Section 4 summarises the political economy of the health sector and RMNCH at the national and sub-national level. Section 5 provides analysis and recommendations. Section 6 provides a short conclusion.

1 Ian Anderson, Director, Ian Anderson Economics Pty Ltd and Dr Midori Sato, independent consultant, now with UNICEF.


Source: IGME (2013)

3.2 Political, economic and development context

3.2.1 Health-focussed political, economic and administrative history

Political context: Bangladesh has had a turbulent political history and political institutions are still evolving. Bangladesh gained independence in 1971 as a result of the liberation war with Pakistan. After enduring decades of political turmoil, including political assassinations, one party rule, military rule (1975-90) and political instability, some stability was seen with the Awami League overwhelmingly defeating the Bangladesh Nationalist Party (BNP) in the elections of late 2008. Bangladesh formally has a multiparty parliamentary democracy with two major political parties, and a largely ceremonial presidential head of state. Administratively, it is divided into 7 divisions, 64 districts, and 496 sub-districts (upazillas) and further divided into unions and lastly wards, the lowest administrative level. The oath of Prime Minister was again taken in 2014 by the League’s Sheikh Hasina, daughter of Sheikh Mujibur Rahman, nationalist leader and first president of Bangladesh, after the major opposition parties boycotted the general election. Political institutions are still evolving. Political violence and strikes are common. One reports notes:

“For a number of reasons, the current system of government (in Bangladesh) might more aptly be

described as electoral autocracy, rather than liberal democracy. Political competition is largely inter-elite contestation for access to patronage resources, with voters deployed as pawns during elections and ignored between elections. Competition is fierce and can be violent, as it is a zero sum game and the winner takes all. Once a government is elected, there are few checks on its power, as the opposition is neutered by institutional design, and ordinary voters lack effective accountability mechanisms …. Political parties in Bangladesh are well developed, but not very democratic …. Their leadership … tends to be dynastic, with the children and grandchildren of early leaders expected to follow in their parent’s footsteps. Since there is seldom turnover in leadership, policy change is glacially slow. Campaigning is based primarily on feudal ties and patronage, and appeals to historical grievances, rather than advancing a programmatic agenda for addressing current and future challenges.” (1)

Socio-economic context: As noted previously, Bangladesh is a densely populated, low income, country. While it has already achieved the MGD target of halving the rate of poverty (i.e. those living on less than $1.25 a day) since 1990, some 67 million people (43% of the population) still live below the $1.25 a day poverty line. A striking feature of Bangladesh is the historically strong role of community based organisations and Non-Government Organisations (NGOs) in development and health care. Bangladesh has more NGOs per capita than any other developing country (27). Grameen Bank, the BRAC and other NGOs

have supported microcredit programs to over 33 million poor Bangladeshi women, and have now expanded into broader banking, education and retail services. Community mobilization also occurs for political reasons. It is common to have demonstrations and strikes before, during and after each election. The World Bank estimates that the political turmoil and strikes in the last quarter of 2013 inflicted a value added loss of about $1.4 billion on the economy (41).

Macroeconomic and fiscal context: Bangladesh has experienced steady economic growth, averaging more than 6% real (adjusted for inflation) increase in gross domestic product (GDP) in the last three years. Limited employment opportunities has resulted in a high level of remittances from overseas workers: $14.3 billion worth of remittances were received in 2013 compared to just $1.3 billion in foreign direct investment (42). Government expenditure has consistently exceeded government revenue since 2000 with the gap projected to be around 5% of GDP in 2014 (41). Bangladesh has a large informal sector so the capacity to increase income tax revenue is limited: the total tax revenue to GDP ratio is 9.9% in 2011 compared to an average 12.8% in low income countries globally (43). Net ODA was 11.7% of government expenditure in 2011, down from a peak of 29% in 2003 but still relatively high (43). Despite ambitions of achieving middle-income status, Bangladesh faces some key constraints including poor infrastructure, especially in the power sector, weak investment, a difficult business climate and inefficient finance sector and capital market, corruption, weak skills and climate change impacts(41). Bangladesh scores a pass mark (3 out of 6) for efficiency of revenue mobilisation; quality of budget and financial management; and quality of public administration under the World Bank’s Country Policy and Institutional Assessment (CPIA). Bangladesh does better, scoring 3.5 out of 6 for equity of public resource use; fiscal policy; macroeconomic management; and social inclusiveness categories. Bangladesh scores lowest (2.9 out of 6) for public sector management and institutions (43).

3.2.2 Social, cultural and other determinants relevant to health and MNCH

Demographic and social determinants. Bangladesh is a relatively homogenous society with 98% of the population ethnic Bengali. Around 90% are Muslim and 9% Hindu. The population is relatively young, with a median age of 24 years. Having the highest population density in

the world and a national language means that service delivery of health and education can be achieved relatively cost-effectively. Government documents (24) state that Bangladesh has already met some very important MDG health and social goals9 and is “on track” to achieve others.10 However Government also acknowledges that other important health and social goals “need attention”. 11

Gender. Bangladesh is experiencing profound social changes in terms of traditional gender roles. Conditional cash transfers have encouraged more girls to access education. Increasing globalisation has created over 1.5 million new jobs in the burgeoning ready-made garments factories, mostly for women, with important implications for poverty and women’s economic empowerment (44). Increased formal employment of women is associated with a preference for fewer (but healthier and better educated) children, a dilution of the traditional son-preference, and increased interest and participation in politics (40). On the other hand, gender discrimination is still prevalent. Child marriage has been illegal in Bangladesh since the 1920s, yet three-quarters of girls are married by their 18th birthday(40).

3.2.3 Development partner context

Bangladesh is supported by an active group of development partners. At the government level, Bangladesh has established a Joint Cooperation Strategy to Enhance Development Effectiveness (2010 – 2015) with 18 development partners: Asian Development Bank, Australia, Canada, Denmark, European Union, Germany, the Islamic Development Bank, Japan, Republic of Korea, Netherlands, Norway, Spain, Sweden, Switzerland, the United Kingdom, the United Nations, the United States, and the World Bank. The World Bank provides the largest share of development assistance with an IDA commitment portfolio of $ 6.5 billion at August 2014, with infrastructure and human development each accounting for around one third of that portfolio (25). Bangladesh was one of the earliest countries to adopt a Sector Wide Approach (SWAP) for Health (45) which interviews suggested was only partially successful. Bangladesh is not a member of IHP +. Development partners, and civil society organisations, have also actively supported the strong NGO movement in Bangladesh, as well as providing support for internationally recognised research institutions such as the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR – B).

9 MDG goals already met include those relating to the poverty gap ratio; ratio of girls to boys in primary and secondary education; under- five mortality; proportion of population with advanced HIV infection with access to antiretroviral drugs; proportion of children sleeping under insecticide treated nets in high risk malaria areas; detection rate, and cure rate, of TB under DOTS. 10 MDG goals “on track” include prevalence of underweight children; ratio of girls to boys in tertiary education institutions; infant mortality rate; proportion of 1 year olds immunised against measles; maternal mortality ratio; HIV prevalence; deaths of malaria per 100,000 population; prevalence and deaths of TB; and proportion of children with fever treated with appropriate drugs. 11 MDG goals that “need attention” include proportion of pupils starting grade 1 who reach grade 5; literacy rate of adolescent and older males and females; share of women in wage employment in the non-agricultural sector; proportion of seats in Parliament held by women; proportion of births attended by skilled birth attendants; contraceptive prevalence rate; unmet need for family planning; and antenatal coverage.

Chart 2: Reduction in under-five mortality among high burden countries

Many countries have made, and are still making, tremendous strides in lowering child mortality

Sour

ce: I

GM

E 20

13.

High-mortality countries* with greatest percentage declines (≥ 50%) in under-five mortality rate from 1990–2012

*Countries with an under-five mortality rate of 40 or more deaths per 1,000 live births in 2012.

0 25 50 75 100Benin

MyanmarYemen

ZambiaIndia

Lao People'sDemocratic Republic

The GambiaGuinea

SenegalSouth Sudan

UgandaMozambiqueMadagascar

RwandaNiger

EritreaBhutan

Bolivia (PlurinationalState of)

EthiopiaTimor-Leste

United Republicof Tanzania

LiberiaNepal

MalawiBangladesh


4. Structure and function of the health sector and RMNCH at national and sub-national levels

It is evident from the foregoing that many factors militate against the likelihood of Bangladesh doing well in the social sectors, yet it has performed surprisingly well in RMNCH. In this section we present the major influences on the political economy of health and RMNCH at national and sub-national levels in Bangladesh, drawing on the WHO building blocks as a framework for our analysis.

4.1 Health systems context

4.1.1 Health system structure, governance and stewardship

Like most government systems in Bangladesh, the health sector is heavily centralized. Top officials in government such as the Minister, the heads of the Directorate General of Health Services (DGHS) and Family Planning (DGFP), and the Health Secretary make all final decisions. The system is hierarchically structured with the ward level health facility (the Union Health and Family Welfare Centre, overseen by the DGFP) providing primary health care through an essential service package. Moreover, at central level there is weak coordination and parallel (and overlapping) monitoring and evaluation systems are maintained by these two Directorates. At next layer above, the Upazilla Health Complex (housing both DGFP and DGHS units) provides inpatient and outpatient care, RMNCH services and disease control. The District Hospital (DGHS) and Mother and Child Welfare Centres (DGFP) are the top layer of the health care pyramid at district level. Medical colleges (DGHS) and post-graduate institutes also offer a wide range of specialty services at this level.

Several efforts at decentralisation have been attempted, with little effect. Article 11 of the Bangladesh Constitution states: “The Republic shall be a democracy in which effective participation by the people through their elected representatives in administration at all levels shall be ensured.” Since independence in 1971, several decentralization reforms have been attempted but management and control by the central government administrative structures continues. The MoHFW envisions management of service delivery with proper participation of the community and delegation of financial and administrative power and autonomy to the upazilla (sub-district) level through establishment of an Upazilla Health System (UHS). The UHS will be

linked with the government policy through Local Level Planning (LLP) and is expected to introduce alternative financing models to meet the financing gaps and improve fiduciary arrangements. Similarly, hospital autonomy is being promoted, first to delegate maximum financial and administrative authority to the tertiary level specialized hospitals (medical college hospitals). UNICEF disbursed funds for MNCH and immunization to eight districts based on LLP. While the effect on service efficiency and utilization by target populations is unknown, monitoring of utilization against allocation is occurring. Meanwhile, a large non-government sector is engaged in service delivery that is tailored to local needs. The strong role of NGOs partly reflects their historically important role during and shortly after the Liberation war, the governance and service delivery ‘space’ left by limited government services, and the choice of some development partners to support NGOs rather than run the risk of leakage and corruption in using government systems.

The right to health care was enshrined in the Constitution of Bangladesh (1972). Key policies influencing RMNCH programming include the Population Policy (1976), Drug Policy (1982) and the Sector Wide Approach (SWAp, 1998; currently the third SWAp (HPNSDP 2011-2016) is being implemented). The remarkable success in reducing fertility was largely driven by a strong family planning sector infrastructure and large scale NGO service delivery mechanisms at the community level. The DGFP was established in 1974 as a separate entity due to high-level political commitment during the founding of the nation. Since then, the government built the upazilla health service delivery system and trained a large number of family planning workers. An attempted unification of the DGHS and DGFP in 1998 failed due to mistrust between the Directorates.

Overall, weak governance, feeble legal frameworks and insufficient institutional capacity of regulatory functionaries in and outside the health sector have weakened the stewardship role of the government (for example, the weak legal framework against child marriage). Reviewing and revitalizing the structure and mandate of the professional and parastatal associations12 such as the Bangladesh Medical Association (BMA), Bangladesh Medical Research Council (BMRC) and Bangladesh Medical and Dental Council (BMDC) is a key priority for improving government stewardship.

12 Other important councils with licensing functions are:, Bangladesh Nursing Council (BNC), Bangladesh Pharmacy Council (BPC) and State Medical Faculty (SMF). Other parastatal organizations / associations with regulatory functions in specific fields are: Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh College of Physicians and Surgeons (BCPS), Bangladesh National Nutrition Council (BNNC), Bangladesh Homeopathy Board and Bangladesh Unani and Ayurvedi Board for alternate medical care, in teaching and medical education.


Moreover, in striving for universal health coverage (UHC), the MoHFW plans to extend its regulatory functions to the NGO and the private sectors in regards to service quality and pricing (i.e. introducing fixed fee schedules for services in both the public and private sectors; social health insurance etc.).

4.1.2 Health Financing

Bangladesh spends little on health in absolute and relative terms. As shown in Chart 3, Bangladesh spends less on health from all sources than other low income countries globally; other South Asian countries; or the other three countries in the UNICEF study. Total per capita health expenditure was $26 in 2012, just lower than the $30 average for low income countries (43) Moreover, Bangladesh has consistently had the lowest rate of growth of health expenditure. Total health expenditure in 2012 was just 3.5% of GDP, lower than the average of 5.3% for low income countries globally, or even the 6.4% average for developing countries in Sub-Saharan Africa (43). Importantly public expenditure on health was just 1.2% of GDP in 2012. This is important, given that the WHO finds that UHC “usually is attained in countries in which public financing of health is around 5% of gross

Chart 4: Sector-wide resource distribution (Non-development and development budget: 2013-14)

Chart 3: Total health expenditure in Bangladesh compared to other countries and regions

Health expenditure per capita, constant (2005) in PPP International dollars.

1000.0

900.0

800.0

700.0

600.0

500.0

400.0

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200.0

100.0

0.0

1995

1997

1999

2011

2003

2005

2007

2009

2011

South Asia countries

Lower middle income

Low income countries

Philippines

Nepal

Indonesia

Bangladesh

Source: World Development Indicators 2014 (43)

domestic product” (46). Similarly, the recent Chatham House report on health financing recommended that that “Every government should commit to spend at least 5 per cent of gross domestic product (GDP) on health and move progressively towards this target, and every government should ensure government health expenditures per capita of at least $86 whenever possible” (47).

Government expenditure on health is low in absolute and relative terms. Recent Government documents confirm that “only $4.20 per person per year is spent on health from the government budget.” (48). In 2013/14, the government allocated only 4.1% of its total budget to the health sector (Chart 4). This is much less than the 10% target laid down in the Health, Population and Nutrition Sector Development Programme (HNPSDP) Results Framework, and lower than the 7% allocated in 2008/9 (49). The 4.1% allocation is also lower than the share allocated to most other sectors including: education and technology (11.3%); public administration (10.6%); transport and communication (9.0%); fuel and energy subsidies (6.9%); rural development and local government (6.6%); defense (5.6%) social security and welfare (5.1%) and energy and power (5.1%).

Total health expenditure is increasing, but driven almost entirely by increased household expenditure. According to the latest National Health Accounts, total health expenditure in Bangladesh more than doubled in real terms between 2001 and 2007 (51). However most of the increase came from higher household expenditure (Chart 5). Public expenditure on health increased in absolute terms, but declined from 0.98% of GDP in 1997 to just 0.8% GDP in 2007, a low figure by international standards.

High household expenditure on health has implications for inequity and impoverishment. The World Bank notes that “although the better off spend more in absolute terms, as expected, poorer groups spend more as a share of their income. Approximately 12 per cent of households in Bangladesh spend over 10 per cent of household income on health—an often-used threshold above which health expenditures are considered to be catastrophic; however, this measure potentially underestimates the extent to which financing is a barrier to accessing care …. A quarter of those who fell ill and did not seek care stated that high cost was the reason for non-treatment”. (52)

Bangladesh has a very ambitious agenda for scaling up UHC. The Health Economics Unit of the Ministry of Health and Welfare concedes that only 1% of Bangladesh’s population is covered by some form of health insurance in 2012. However the Government has a stated goal of providing Universal Health Coverage (UHC) by 2032. A scale up of that nature is extremely ambitious requiring good policies, regulations, and increased health workers and supplies to meet increased demand. Scaling up UHC also requires a strong and sustainable financing platform so as to collect, and pool, premiums. That will be particularly challenging in Bangladesh when the Health Economics Unit advises that 85.7 million people in Bangladesh work in the informal sector, 48 million people are below the official poverty line, and only 18.8 million people in Bangladesh work in the formal sector. Ensuring that payment systems align health worker incentives with public health objectives is also a challenging issue under UHC roll out.

Source: Budget in Brief 2014-2015 (Ministry of Finance, 2014)(50)


Chart 5: Health expenditure by source

180

160

140

120

100

80

60

40

20

01997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

External Financiers

NGO

Private Firm

Households

Public

Source: National health Accounts 1997-2007

Development aid to the health sector from both multilateral agencies and donor countries reached about US$9 billion and US$13 billion, respectively, in 2010 (16). UNICEF’s indicative contribution to the HNPSDP (2011-2016) was the largest among the multilateral donors (8% of total development partner contributions, with a majority budgeted for RMNCH and nutrition) and the fourth largest after the assistance provided by the World Bank, USAID, and DfID. The contribution from partners is estimated to be US$1.8 billion, close to two thirds (61%) of the national development budget (17, 18), with the remainder coming from government revenue. According to the Programme Implementation Plan of the HNPSDP, the budget for RMNCH-related activities (combining the budgets of the Operational Plans (OPs) for both the DGHS and DGFP) is the second highest (17.6%) after the Plan for Physical Facilities Development (22%).

Bangladesh was an early adopter of the SWAP, including the Health Nutrition and Population Sector Development Programme (HPNSDP) (1998–2003). This aimed to streamline over 100 separate donor-funded projects into 25 Operation Plans. There are now

32 such Plans and development partners have only just become aware of many other other Operational Plans hitherto not shared by government. Currently the third SWAp (HPNSDP 2011-2016) is linked to the government’s Sixth Five Year Plan for 2012-20. However there is some evidence that development partners are replacing Government expenditure, at least with respect to the development budget. A recent World Bank report notes for example that:

“Reliance on external partners for the Annual Development Program (ADP)13 has increased. This was not unintended and remains roughly in line with second Revised Programme Implementation Plan for the entire HNPSDP period (2003–2011)…. Over the period 2003–07, the implementation of the SWAp has facilitated almost a 10-fold increase in pooled funding, while parallel [government] funding has remained relatively stable. According to the Public Expenditure Review, the development partner contribution to per capita MOHFW development spending increased by 14 per cent, ultimately accounting for 61 per cent of total development spending in 2006/07.”(52)

Government documents, and independent analysis, confirm the lack of strategic planning in health financing. For example, a recent analysis from the Health Economics Unit of the MoHFW concludes that “Bangladesh hitherto has not adopted a deliberate health care financing strategy. Health financing interventions and programs are either driven by supply side pressures (salaries for nurses and physicians; medicines and supplies for facilities), while pilot activities are often initiated in response to emergencies or following international trends. A comprehensive health care financing strategy is critical to meet the challenges confronting the health sector now and in the future.” (53) Furthermore, a review of planning, budgeting and financial management in the Bangladesh health sector concludes that:

“Systems for comprehensive resource planning and tracking do not exist…. Bangladesh has had a historic disconnect between the development and non-development budgets in health, which still exists today. The planning wing is responsible for the preparation of the development budget, with almost no interaction with the Financial Management and Audit Unit which prepares the non-development budget. This lack of coordination has led to sub-optimal resource allocation …. MoHFW continues to follow separate procedures for preparation, monitoring, and approval of the revenue and development budgets …. There is no effective mechanism to coordinate the two processes. As a result, it is difficult for decision makers and managers to take a holistic view on the allocation of resources. Such compartmentalized budgeting systems risk duplication and under-allocation of resources in priority areas.” (54)

4.1.3 Health and MNCH priority-setting at national and sub-national levels

The planning and budgeting system in Bangladesh is complicated, and lacks strategic direction and cohesion. As the recent World Bank Public Expenditure Review noted “Bangladesh remains a country with two parallel budgets: a ‘revenue budget’ for regular and ongoing programs and the Annual Development Program (ADP) mainly for new initiatives (increasingly funded by development partners)(55). The planning wing within MoHFW is responsible for preparation of the development budget, but does so with little or no interaction with the financial management unit which prepares the revenue budget. The revenue budget is essentially based on a fixed formula approach. Each upazilla (sub-district) receives an equal amount of resources based on criteria such as the number of beds and staff numbers on the ground

13 In effect, the main investment program for new initiatives and priorities, as distinct from regular and ongoing expenditure.

irrespective of the health status or needs of the catchment population and service utilization. The development budget is developed by the DGHS and DGFP, each writing their own Operational Plan budgets which are subsequently compiled by the planning wing of MOHFW. There are currently at least 32 such Operational Plans14 covering different vertical diseases and programs (HNPSDP 2012-2016). Interviews confirmed that each is developed in isolation, with little coordination or strategic prioritising between them. Fragmentation of planning and budgeting across two different budget processes, and into 32 or more Operational Plans, reduces the capacity for scarce resources to be reprioritised and reallocated to meet highest or changing needs. Field-level interviews also confirmed that there is little cost consciousness or systematic requirement, even within Ministry of Finance, to assess efficiency of operations or value for money.

It is also very difficult to reallocate resources between – and even within – programs to respond to new priorities. There is little opportunity to transfer resources between the 32 Operational Plans. Nor is there much incentive to do so as Directors then lose authority, possibly staff, and the opportunity for exercising patronage and receiving paybacks. The Directors interviewed confirmed that there was little flexibility to reallocate resources to meet new priorities because budget line items were firm. Budget increases exceeding 10% had to be resubmitted to Cabinet: a resource-intensive and slow process. Not surprisingly, several interviewees observed that Directors in the Ministry would prefer to approach development partners for additional funds for new priorities, rather than try to use their own government system. Development partners did tend to comply with such requests, possibly facilitating ‘trained helplessness’ that encourages officials to avoid using and reforming their own systems. This aligns with an earlier analysis of planning and financing in Bangladesh’s health sector, which concluded that:

“Revision of delegation of financial and administrative authority at the district level is needed. Limited delegation hampers local level allocation of resources. The (Review) team frequently heard about situations where basic supplies could not be obtained or repairs could not be completed at the local level without permission from Dhaka, which often resulted in long delays (sometimes even years). The delegation of financial and administrative authority will be critical if local level planning is to be fully operationalized, yet we have seen limited movement towards delegation, even after major efforts….”(54)

14 Interviews suggested that there may well be a further 24 Operational Plans that development partners are not aware of.


It is also clear that, as in all countries, health priorities can be politicised. The “winner takes all” approach to government and the see-sawing power of the major parties means large investments can be initiated or overturned by incumbents. In 1996, the then Government of Bangladesh established 18,000 community clinics across the country to expand the scope of primary health-care services, especially in rural areas. By 2001, 10,723 community clinics were constructed, of which 8,000 started functioning. After a change of government in 2001, all the clinics were closed and remained so until the Awami League government returned to power in 2008. Since then, their revitalisation has been given priority and 11,816 were functional by 2012 (56). Another example was establishment of 3,000 midwifery positions when there was no institution available to train them, no sanctioned positions to recruit, and limited budget allocation. This kind of ‘political announcable’ rather than substantive strengthening of the health system was deplored by several of those interviewed for creating volatility and uncertainty, and for the evident political point-scoring involved. Finally interviewees also observed that the current Prime Minister had taken a personal interest in autism, creating a ‘Centre for Neuro-development and Autism in Children’ providing different services free of cost. However it is not clear that this is the best use of scarce resources in a country where 41% of children are stunted. Resource allocation is not based on need. Interviews confirmed that plans and the allocation of resources are essentially developed on the basis of historical norms, rather than burden of disease, poverty, or population changes. Interviews confirmed that resources allocation decisions were also largely determined in Dhaka, with little real input from local level implementers. This is consistent with the findings of a recent analysis of planning and resource allocation systems in Bangladesh: “The Development Budget is prepared on the basis of multiyear plans. Allocations are often made without making field level needs assessments on an annual basis. Cost centres at the field level virtually have 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. 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 recommendations, the LLP plans were still not linked to budget allocation, thus very little practical impact of LLP is evident….”(54)

Health public resources are also not allocated equitably, either from a geographic or income perspective. Bangladesh already suffers from overall inequity. The estimated Gini coefficient15 is 0.31 which classifies the country as “high inequity”. UNICEF analysis provides evidence of some severe inequality of access and outcomes, especially at the sub-district and village level (35). Against that background, it is of concern that scarce public resources are not allocated more equitably. As the recent Public Expenditure Review noted:

“The share of recurrent spending that goes to the 16 poorest districts is less than what goes to the 16 wealthiest districts. The traceable share of development spending accruing to the wealthiest districts has declined over time, but gains were not shifted to the poorest districts. Instead, the second poorest districts benefited. Furthermore, public subsidies (for curative care) in health also remain skewed to the non-poor. In almost all cases, the rich received a greater share of subsidies than the poor, with inequities being starker at the tertiary-care level for in-patient care. These disparities have resulted in widely divergent health outcomes, although other (cultural) factors may have also played a role. Reaching the poor and improving their health status remains a major challenge.” (55)

The use of evidence in planning is mixed, but there are some good examples of experimentation and lesson-learning. For example, research institutes such as the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR-B) helped establish the evidence base for the importance of ORS and zinc for the treatment of severe diarrhoea. That evidence base has then been applied through a system of strong implementation, monitoring, supervision, accountability and lesson-learning in the process of scaling up programs. Similarly, young, educated women provided family planning services directly to the homes of couples in the Matlab district of Bangladesh. The effect on fertility reduction was noted almost immediately. After testing and modification to assess feasibility and success, the programme was gradually scaled up across the country (56, 57).

Evidence on health financing has also influenced policy. Interviews also found examples of evidence on health financing and resource allocation through the Government’s National Health Accounts informing and shaping debates about health services. See Box 1.

Box 1: Using evidence

The Bangladesh National Health Accounts display the sources as well as the uses of health expenditure. The latest National Health Accounts (NHA) clearly showed that most health expenditure was ‘out of pocket’ and therefore a barrier to health care for the poor. This led to a policy discussion about the importance of social protection and health insurance. The NHA also showed that around 60% of health expenditure was going to pharmaceuticals. This, in turn, led to a policy discussion and decisions about a national protocol to control misuse of pharmaceutical drugs etc.

The Bangladesh Health Economics Unit (HEU) made proactive use of media to help disseminate the key results of the NHA. Recognising that NHA documents are technical, the HEU provided a short informal training course to media journalists. This resulted in more accurate, informed, coverage and debate about where health money was coming from and what it was being spent on.

15 The Gini coefficient is a statistical estimate of inequality. A score of one means all wealth is owned by one person, a score of zero means there is no inequality.

On the other hand, evidence is not always available - or used - in determining key priorities, birth registration being one example. UNICEF states that ‘Bangladesh is among the 10 countries with the largest numbers of unregistered under five children in the world. Some 10 million children under five in Bangladesh do not officially exist’(58). It is hard to claim that the conditions for evidence based planning are present when over half of all children are not registered and do not legally exist.

Allocating priorities and resources without taking into account the private sector is another strategic gap in evidence based planning. The majority of clinical health contacts are with private sector providers, including private pharmacies – whether qualified and regulated or not (Chart 6). However, interviews confirmed that

priorities are set, plans developed, and budgets allocated with very little regard to the existing role and coverage of services provided by the private sector. There was no clear explanation as to why this is the case, although the absence of hard data on the coverage (and quality) of private sector services makes it difficult to take them into account when planning and prioritizing budgets. Others interviewed noted that dual practice meant that it was difficult to define precisely where the public sector stopped and the private sector began. Some also noted the importance – but difficulty in practice – of distinguishing between the for-profit private sector and the not-for-profit NGO sector. Some suggested that it was simply easier, and the traditional approach, to focus on what the public sector was delivering when developing priorities, plans and budgets.

Chart 6: Health sector contacts by source of treatment

100

90

80

70

60

50

40

30

20

10

0Urban

Pharmacy/Dispensary

Compounder

Pharmacy/Dispensary

Compounder

Government Doctor(Private Practice)

Government Doctor(Private Practice)

Government Doctor (Institution) Government Doctor (Institution)

Homeopathic Doctor Homeopathic Doctor

Other Other

Private Doctor Private Doctor

Rural

Government Doctor

NGO Doctor

Source: National Health Accounts (2010)


There continue to be major constraints to decentralization of decision making and LLP within the Health sector. Bangladesh has been discussing and trialling plans for more decentralised planning and delivery of services since the late 1980s, with very little progress. Interviews suggested this was because there had been very little sustained training and capacity building at the local level, exacerbated by staff turnover. UNICEF’s recent work on LLP in the health sector has focused on this issue, and is intended to build capacity for a more decentralized decision making process among managers and the system as a whole. Pilots are expected to inform the central government on the potential capacity for district level planning and equitable budgeting based on local needs, and for monitoring results using data from an improved health management information system, to be institutionalized within the health system. Early findings also suggest that district authorities feel empowered and incentivised by the process. However, challenges in implementation of LLP remain, especially limited human resources, inadequate readiness of government facilities and authority at local level that is inadequately decentralized to implement locally adjusted plans. Other interviewees also believed that each incoming government has been preoccupied with maintaining their own power base against rival political groups, and did not wish to loosen control of power or resources to local levels. Some experienced development partners believed that successive governments were particularly reluctant to devolve power and decision making in the MoHFW, given the opportunities for political patronage in staffing appointments, and the opportunities for corruption kickbacks through large centralised health procurement and capital investments. These same experienced development partners also believed that the 32 Operational Plans in the Ministry, each with its own Director, was a “jobs machine” for government patronage, and an incentive for each of those Directors (and their staff) to retain power in Dhaka. Choudhury and colleagues come to similar conclusions in their review of planning, budgeting and financial management in the Bangladesh health sector (54).

By contrast, the Ministry of Local Government is overseeing a large scale, innovative, performance based pilot of decentralised decision making and planning that extends down to the local village level. It provides direct block grants – and decision making authority – to the lowest administrative unit in Bangladesh the “Union Parishads” or villages to support financing of local development projects. The program is supported by a second World Bank credit valued at $290 million and is intended to reach 135 million people. The project “supports rigorous audits and open budget presentations to create greater transparency and good governance. A key new feature … is the introduction of performance-

based grants in addition to expanding the amounts and coverage under the current block grants supported by initial project. Recognizing the major contribution of women, in local level development, it earmarks about 30 per cent of the grants for local schemes prioritized by women”.

Government is considering a new resource allocation formula, but this remains a work in progress. The Government recognises that the current system for allocating scarce resources needs reform. More specifically, the Health Economics Unit of the MoHFW notes that “Public funding for health care … to geographic areas is currently based on norms related to the size of facilities. Such allocations often do not reflect population need since health facilities and staffing patterns are often distributed in a way that fails to take account of changing demographic and epidemiological requirements”. The Health Economics Unit is therefore providing analytical background work and an institutional forum for discussions about a revised and more policy oriented formula, based on demography, health needs, and other criteria. One proposal is that the revised resource allocation formula be trialled on selected budget items first. These might be the line items for ‘Supplies and Services’ of the revenue budget and later extended to the ‘Repair and Maintenance’. The impression created is that the revised allocation formula will be rolled out slowly and carefully, even tentatively. Further details on the revised resource allocation formula are available at the Health Economics Unit website16.

4.1.4 Service Delivery and quality

RMNCH service delivery is divided into a number of parallel structures that dilute and duplicate services, with limited coordination among the line directors, program managers and focal points. The MoHFW proposes functional integration of RMNCH services at district and sub-district levels to reduce inefficiency, but this has not yet happened. Moreover, local procurement and hiring of human resources is restricted by centralized governance and rigid control of funds. The availability of infrastructure for delivery of key services is limited: Bangladesh has an average of 0.2 hospitals, and 6 hospital beds per 10,000 people, which is lower than the ratio for low income countries globally (0.8/10,000 and 6/10,000 respectively) (59). Quality of health services is mixed. One study found that few sick children under age five years seeking care at first level health facilities in one district of Bangladesh were fully assessed or correctly treated, and almost none of their caregivers were advised on how to continue the care of the child at home (60). Another study found that ‘the most powerful predictor for client satisfaction with government health services was the provider’s behaviour towards the patient, particularly

respect and politeness. This aspect was much more important than the provider’s technical competence (characterized by elements such as explaining the nature of the problem, physical examination, and giving advice). The second most powerful predictor for being satisfied was the respect for privacy, followed by short waiting times.’(61) As noted in Chart 6 above, the private sector (including dual practice within government facilities) provides the majority of health services. Private services are largely unregulated by government authorities.

4.1.5 Human resources

Like many low income countries, Bangladesh has a shortage of trained health workers. Latest WHO statistics show that Bangladesh has an average of 3.6 physicians per 10,000 population, compared to an average 2.4 per 10,000 for low income countries globally. But Bangladesh also has only 2.2 nurses and midwives per 10,000 population, less than half the global average for low income countries (59). Other estimates suggest that the total health workforce in Bangladesh is substantially smaller than in other countries at 58 per 10,000 population (57). Whatever the actual figure, workforce density is well below WHO’s recommended 22.8/10,000 required to achieve relatively high coverage for essential health interventions in countries most in need (62). Bangladesh has a large demand for midwives – there were an estimated 1415 obstetric and newborn complications per day in 2010 – yet has a shortfall 9360 midwives if the country is to achieve 95% skilled birth attendance by 2015 (63). Like many countries, the workforce challenge in Bangladesh is not just about shortfalls in numbers of workers. Of equal importance is their distribution (rural/urban, primary versus tertiary facilities) and the quality of their performance. An additional challenge is to ensure that the health workforce is well trained and equipped to

meet the new demands facing Bangladesh including the rise of NCDs and the roll out of UHC. Notwithstanding these problems, it is acknowledged that there is a pervasive network of publicly-funded health personnel from both the DGHS and DGFP systems, all the way down to community level. Along with the NGOs, these are responsible for implementation of Bangladesh’s highly successful, evidence-based preventive health programmes in RMNCH (64). It remains to be seen if these highly dedicated community health workers, who have been effective in reducing fertility and basic childhood illnesses, will have the skills and competence to manage or refer newborn complications, an increasingly important need as under-five deaths continue to fall.

4.1.6 Procurement and logistics. Procurement and logistics are a potentially large source of waste, inefficiency, and corruption in many developing countries. WHO estimates that between 20 – 40 % of health expenditure is wasted globally due to waste, corruption, and inefficiency (65). This includes poor procurement choices of items that absorb large parts of the budget including pharmaceuticals. Mis-procurement can often be a major cause of financial delays and well-designed plans being abandoned. Yet implementation of plans, including procurement, is often neglected by managers and decision makers (11). Lack of funding for maintenance of equipment is a common source of waste and inefficiency. Counterfeit and sub-standard drugs is an increasing problem in South Asia and South East Asia (66) with Bangladesh particularly at risk due to imports of counterfeit drugs from India (67). On the other hand, Bangladesh procures the majority of vaccines used in its immunisation program, and the government-run distribution and logistics systems associated with these, drugs for tuberculosis control and other basic health services are well regarded (64).16 http://www.heu.gov.bd/index.php/health-care-financing/resource-allocation-formula.html


4.2 Appraisal of health sector performance in relation to RMNCH

Despite poverty and low income, Bangladesh has achieved international recognition for its remarkable progress in several key health related outcomes. For example, Bangladesh is one of a select group of countries included in the high profile “Good Health At Low Cost” study published in the Lancet. As that study notes, Bangladesh “now has the longest life expectancy, the lowest total fertility rate, and the lowest infant and under-5 mortality rates in south Asia, despite spending less on health care than several neighbouring countries”(68). In 2010 the United Nations presented Bangladesh its MDG Award for reducing child mortality. In 2013 the UN awarded Bangladesh a similar award for being one of the first countries to halve the incidence of hunger. Bangladesh was included as a special case study for its reductions in fertility in the first edition of the high profile Millions Saved: Proven Successes In Global Health(69). Bangladesh is also included in the forthcoming third edition of that book in recognition of Bangladesh’s implementation of Integrated Management of Childhood Illness (IMCI). Bangladesh has achieved a remarkable reduction in under-five mortality and is “on track” to reduce the maternal mortality ratio by three quarters, and the infant mortality rate by two thirds, between 1990 and 2015 (24).

What explains these dramatic RMNCH improvements in a low income country, with low expenditure on health, and high poverty?

Widespread application of evidence-based interventions is one explanation for Bangladesh’s success in RMNCH. Adams et al. (27) argue that “large scale health interventions with known effects on mortality and morbidity is the first and most obvious explanation for disproportionate gains in health by the most disadvantaged children” in Bangladesh. More specifically, these include rapid scale up of immunisation coverage; use of ORS and vitamin A supplementation, along with the “scale, speed and selectivity” of application of those and similar key interventions. Other researchers note the widespread coverage of essential generic drugs and application of applied research in areas such as ORS and Integrated Management of Childhood Illnesses (IMCI) (68). Widespread availability of antibiotics, albeit unregulated, may have reduced child pneumonia deaths. Chowdhury et al, in noting the paradox of dramatic improvements in health outcomes alongside persistent problems of under-nutrition and other health challenges, concludes: “Exceptional performance might be attributed to a pluralistic health system that has many stakeholders pursuing women-centred, gender-equity-oriented, highly focused health programmes in family planning, immunisation, oral rehydration therapy, maternal and child health, tuberculosis, vitamin A supplementation, and other

Box 2: The distinctive scale and role of NGOs in BangladeshSource: El Arifeen et al (2013)

‘Successive governments in Bangladesh have maintained a supportive policy environment with very few constraints and regulations for NGOs to operate, thus lending support to their expansion.

As of July 2013, 2252 NGOs were registered by the government’s NGO Affairs Bureau. Other sources document the existence of more than 23 000 NGOs, of which more than 4000 work in the health, population, and nutrition sector.

Foreign funding to NGOs increased from US$180 million annually in the early 1990s, to $380 million during 2003–04.34 The number of NGO projects in Bangladesh has grown concomitantly, from less than 500 in 1990 to more than 18 000 in 2011.

A 2003 World Bank survey showed that provision of health services was the second most common area of service activity after microcredit, with nearly 60% of NGOs providing health-care-related services.’

activities, through the work of widely deployed community health workers reaching all households”(54).

But technical interventions are only part of the explanation: the relationship between the state, community, and civil society is also an important factor. Bangladesh offers a unique example of active collaboration (or mutual tolerance) between government and civil society. Government has certainly demonstrated political commitment to and action on key social sector reforms that improve RMNCH outcomes. Balabanova et al note, for example: A “high-level political commitment to health dates back to independence. This commitment has endured despite major political changes, including transition from military to civilian rule, and has been facilitated by institutional continuity of civil servants and by partnerships between government and the non-governmental sector—an extender of government exemplified by BRAC” (68).

Bangladesh also has a particularly strong record of community mobilization and pro-poor development programs by NGOs (Box 2). Bangladesh has more NGOs per capita than any other developing country (27). Grameen Bank, BRAC and other NGOs have supported microcredit programs to over 33 million poor Bangladeshi women, and have now expanded into broader banking, education and retail services. Part of this growth of NGOs reflects the important role that community mobilisation played during and after the War of Liberation. Part of the growth of NGOs also reflects the desire by political and social activists not to be ‘captured’ by what they see as traditional party politics (70). There is a complicated relationship with the state, with NGOs sometimes filling the service delivery gap left by the state and jostling for influence and recognition (70-73). NGOs have often been financially supported by development partners who see them as potentially more effective, efficient, equitable and less prone to corruption than government. On the other hand, there are many examples of collaboration between government and NGOs in the implementation of public health services in Bangladesh (64, 74, 75).

NGOs are also very active in health related services. This is partly because NGO evaluations found that poor health (and limited education) were factors preventing very poor women from benefiting from micro-credit programs, necessitating further complementary interventions to improve their health(76). BRAC now reaches up to 110 million people in Bangladesh through 64,000 village health workers (68). These interventions have also changed the way stakeholders think about public health interventions. The widespread coverage of ORS – at one stage the largest program of its kind in the world – through community mobilisation helped overturn the prevailing assumption that illiterate village women would be unable to use it properly (56, 57).

Government-supported inter-sectoral influences were also important. Reductions in maternal mortality are due to a determined and sustained outreach campaign providing “doorstop delivery” of family planning services to virtually every village and household in Bangladesh by young, educated women (56, 57). This was an important cultural adaptation in what was then a particularly conservative society where women were often not encouraged to move in public outside the village by themselves. The provision of services through outreach, gains in child survival and rising cost of raising large families have also combined to reduce fertility (76). Investments in female education also helped. A purposeful program of government subsidies increased girls’ participation in secondary education from less than one in five students in the early 1970s to virtual parity in the early 2000’s (76). Strengthening disaster resilience and disaster management capacity was also helpful in reducing mortality and morbidity, including amongst vulnerable women and children (56, 57, 77).

Moreover, routine programmes and services, including those implemented by NGOs, rely on government-supported personnel, information and logistics, supply and distribution systems. These underwrite several successful vertical activities undertaken mainly through Bangladesh government agencies, such as those focusing on tuberculosis, vaccination and diarrhoeal disease control. Although supported by donors and technical partners, each depends on government-supported health systems components. There is a strong logistics, supply and distribution mechanisms for vaccines/drugs. The bifurcated Government systems (DGHS and DGFP) train and recruit health and family welfare workers all the way down to the lowest level of health system, achieving wide coverage and with improved supervision after technical support

provided UNICEF and WHO. There has also been rapid growth of the health management information system (HMIS) and e-health in recent years (in line with the Prime Minister’s initiative “Digital Bangladesh Vision 2021”), involving rapidly digitized and modernized technology so as to improve routine data collection, use and reporting (including service statistics, personnel, financial and logistics systems) (64). Tuberculosis treatment has long been a collaborative effort between government and community-based agencies (74). While each of these systems components remain in need of further input, they do provide the foundation for the substantive outputs achieved.

Rising incomes, social developments and geography have also contributed to RMNCH outcomes. As shown in Chart 7, there is a clear association between rising real (adjusted for inflation) incomes and under-five and infant mortality rates. While correlation is not causation, rising real incomes do improve living standards and access to essential services. Overseas remittances are an important source of increased income, although they may not reduce inequity as the poorest may not benefit. According to the Central Bank of Bangladesh, remittances totalled $14.2 billion in 2013/14, the equivalent of $93 per person per year. This is much more than the $4.20 per person per year government has been spending on health care until recently. A quadrupling of female participation in the formal workforce since the early 1980s, especially in the garment industry, is also a source of rapid social change and increased income for women and their households. A largely homogenous, dense population (reducing the cost and challenges of delivering services) also contributes to good RMNCH outcomes (27, 68). Family planning program costs were estimated at $100-150 million per year during the 1970’s, or a low $13-18 per birth averted (69).

Source: World Development Indicators (2014)

Development partners are also part of the explanation of good RMNCH outcomes. Overseas development assistance for all sectors peaked at 29.5% of central government expenditure in 2003, declining to an estimated 11.7% in 2013. External resources financed 70% of overall health related investments in the 1970s, but less than 10% in 2005 (43). For several development partners, NGOs are increasingly the preferred conduit for donor assistance rather than government (54). United Nations agencies play a significant role in the donor community, and have more direct lines of communication with government on technical and policy issues than many NGOs.

Despite progress, Bangladesh still faces important RMNCH challenges. Rates of maternal antenatal care use, skilled birth attendance, and facility-based deliveries are lower than are those for neighbouring countries (54). Under-nutrition still remains a serious challenge: 41% of under five are stunted, 16% are wasted and 24% of reproductive age women are underweight, increasing the chance of generational stunting and poor economic outcomes (78). While under-nutrition is concentrated among the poor, 21% of children in the wealthiest quintile were also underweight, and around 30% of children born to mothers with a secondary education were malnourished(54). UNICEF’s representative to Bangladesh makes the important point that “Bangladesh has made significant progress by curbing the under-five mortality rate

…. However, nine neonates still die every hour, which is 76,000 neonatal deaths every year. The neonatal mortality rate has not decreased substantially for the past 10 years. Mortality among children in the poorest households and those in hard-to-reach areas is at least 50% higher than those in the wealthiest areas” (58). Despite progress, family planning services have yet to reduce fertility to the Government’s desired level. Furthermore, Bangladesh also has one of the highest rates of child marriages: 65% of women (aged 20 to 24) were married before they turned 18 and 60% became mothers by 19 years of age. The Bangladesh Demographic and Health Survey shows that 85% of births occur in the home and only 24% of children receive appropriate care within 24 hours of birth.

Bangladesh also now faces ongoing public health challenges, including a ‘double burden’ of communicable and non-communicable diseases. Bangladesh ranks sixth in global incidence of tuberculosis . Cases of multidrug resistant TB are being increasingly reported (79). Malaria is also highly endemic in certain areas. However, as seen in Chart 8 below, Bangladesh is also facing a rapid rise of non-communicable diseases (NCDs). This will impose large long term additional costs on household and government health budgets, along with new and different technical and human resource demands on the health system.

Chart 8: Rising importance of NCDs in BangladeshChart 7: Rising real incomes and child and infant mortality rates


200

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0

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1000

0

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1993

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IMR andU5MR per 1000 live

births

GNI per capita PPP in constant

$ I (2011)

IMR per 1000

U5MR per 1000

GNI per catita PPP caonstant 2011

1986

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1988

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1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

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2005

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2009

100%

80%

60%

40%

20%

0%

Unknown/missing

Maternal and neonatal Communicable Miscellaneous

Injuries Noncommunicable

Source: Koehlmoos TP, et. al 2011 (64)

Related to NCDs, tobacco use is the single biggest risk for death and disability in Bangladesh, increasing the health and financial burden on governments and households, and increasing poverty. The latest Global Burden of Disease estimates finds that tobacco use is the leading risk factor for the burden of disease in Bangladesh, followed by household pollution and dietary risks (80). There are over 1.2 million cases of tobacco-related illnesses, and around 9% of all deaths (57,000 deaths) each year in Bangladesh (81). The WHO estimates that the use of tobacco costs Bangladesh approximately Tk. 26.1 billion ($ 380 million) annually. Tobacco use also increases inequity and poverty. As WHO noted in an earlier report:

“In Bangladesh, households with an income of less than $24 a month smoke twice as much as those on much higher incomes. The average amount spent on tobacco by the poorest 10 million male smokers could buy an additional 1400 calories of rice per day, or significant amounts of protein for each family. If these men quit, and put 70% of their saved income into food, this would provide enough calories to save 10.5 million Bangladeshi children from malnutrition.” (WHO 2004)

The political situation also creates challenges for the health sector. As noted previously, governments in Bangladesh have historically been politically committed to RMNCH. However, as noted by one analysis: “Chronically weak governance, including the failure to enforce legal frameworks around minimum age at marriage, dowry, and child rights, represents a major obstacle to women’s and children’s health”(76). Moreover, manipulation of funding for public health programs for political purposes without follow up occurs.

Finally, public funding for the health sector is clearly a major bottleneck. As noted previously, the priority given to health in political statements is not reflected in the national budget. The 4.1% allocation of the current government budget to health is much less than the 10% target laid down in the HNPSDP Results Framework, and the 7% allocated in 2008-09 (49). Furthermore, only 1.3% of total health spending went to public health programs in 2007 (52). Senior officials interviewed for this study could not explain the relatively low share going to health, but speculated that the dramatic reductions in fertility and under-five mortality implied that fewer resources were needed. By contrast, most senior public officials asserted that “health is a top priority” for Government.


5. Analysis and Recommendations

The above analysis makes it possible to formulate an overall perspective on the political economy of health and RMNCH in Bangladesh. In turn, this enables the development of recommendations for DFAT and other development partners seeking guidance on their engagement with government and other stakeholders in Bangladesh’s health sector.

5.1 Analysis

In general, health and RMNCH enjoy a high level of bipartisan political commitment in Bangladesh, but this does not translate into government prioritisation or the allocation of substantive resources. Government financing for health is low in both absolute and relative terms compared to other comparable countries, overall needs, and the priority given to other sectors. Government officials insist that RMNCH is an important priority but this is not reflected in budget allocations. There is no clear or simple explanation for this obvious disconnect between stated priorities and budget realities. One possible explanation is that Government is aware that Bangladesh has done remarkably well in improving certain key RMNCH outcomes at low levels of expenditure, and so does not feel compelled to increase budget allocations. The strong role of NGOs, often supported by overseas development partners, supports this perspective. The high level of private overseas remittances – averaging around $93 per person per year and able to be spent on health or other discretionary items – may also help to explain why Government does not feel compelled to increase public expenditure on health. Indeed, it could be argued that government is abandoning health to NGOs and the private sector. This augurs poorly for the implementation of UHC in Bangladesh, if it is to entail a high level of government financial input and related governance and stewardship of the sector.

Unlike other countries in much of Asia, Bangladesh is not decentralising government planning or decision making in the health sector. This reflects several political economy factors. The most important is that Government and senior bureaucrats within the MoH perceive benefits in maintaining tight political control – and the opportunities for patronage – in Dhaka. It can also be argued that unlike many other countries in Asia, Bangladesh does not have large ethnic or geographical separatist movements, a political economy factor driving decentralisation of visible government services such as health in many parts of Asia. It could also be argued that the strong NGO and community based approaches so evident in Bangladesh serve as a de facto form of decentralisation given that NGOs can be very responsive to local needs. By contrast, the World Bank-supported decentralised planning in the Ministry of Local Government suggests that local level priority-setting and budgeting can be implemented successfully in this country.

The lack of an official role for local governments in planning of health services and the low budgets allocated to sub-national health authorities has potentially important equity implications. For example, rapid urbanisation and the growth of slums requires the creation of new services and related infrastructure (e.g. for provision of safe water and sanitation) but there is no mechanism for encouraging and enabling local governments to create them.

Rigid, fragmented, input-based approaches to planning and resource allocation limit the capacity of government to reallocate resources to where they will have the greatest impact. As noted, there are basically two disconnected budget streams operating in the health sector, with very limited flexibility to reallocate resources between them; the 32 Operational Plans; and even within programs. The inability to reallocate resources to where there is the greatest need, or potential impact, undermines the effectiveness and efficiency of government expenditure. Although the newly established Health Economics Unit is generating high quality and policy relevant analysis, there is a surprising lack of policy attention to efficiency or value for money in the formulating and implementation of government budgets.

On the other hand, Bangladesh has clearly benefited from the remarkable and successful degree of NGO participation in community health. The difficulty, then, for international partners and domestic stakeholders, is to develop solutions for the current and future challenges facing health and RMNCH that retain the ultimate authority and approval of government and improve the health systems elements that are currently weak. It will also be important to address more complex technical issues that will inevitably arise with more advanced and complex cases of NCDs, including cancer and dialysis treatment of diabetes. However, it is not a given that NGOs have either the regulatory ability to work on health systems issues or the needed additional technical capacity – and potentially expensive equipment - to provide inpatient maternity services and newborn care, cross-sectoral interventions to reduce under-nutrition, outpatient and eventually facility-based management of NCDs and health financing solutions to implement UHC. These higher-level, more complex issues and solutions will most likely either require a dramatic increase in publicly funded and managed health services or the formal recognition of a role for the private sector, with implications for financing and again, mechanisms to achieve UHC. United Nations agencies including UNICEF can expect to play an increasing role in the development of solutions for UHC in Bangladesh.

A likely influence on the future political economy of RMNCH in Bangladesh is the rise of NCDs, particularly those caused by tobacco. Because NCDs are increasing in


prevalence, and their cost of treatment is often chronic and expensive, there is a real risk that NCDs will divert already limited public funding for unfinished priorities in RMNCH and under-nutrition. While it may be possible for NGOs to move into community diagnosis and basic management of NCDs, it is unlikely that they will be able to treat more complex later stages of these chronic illnesses at community level such as cancer treatment or dialysis for kidney failure. Moreover, their own limited funding may force them to make decisions on what elements of community health they prioritise. Under current health financing arrangements in Bangladesh, this raises the risk of higher out of pocket expenditures. Expensive treatment of NCDs may displace spending on community or facility-based RMNCH and under-nutrition. The introduction of a well-funded and well-designed UHC program with a focus on affordable but effective treatments – especially with a focus on primary and secondary prevention - may help to mitigate the worst effects of the NCD challenge, but possibly at the expense of further progress in RMNCH. A major focus on reducing tobacco consumption – the biggest single risk factor for death and disability in Bangladesh – is a key policy priority. Raising taxes on tobacco is a proven means of reducing tobacco consumption while simultaneously generating additional revenue for Government. The Philippines has used increased tobacco taxes to help fund the scale up of UHC.

Government’s aim of achieving UHC by 2032 is a strategic opportunity for the health sector and RMNCH in particular. Making further progress in RMNCH, including reducing newborn deaths, and addressing NCDs, are likely to involve more technically complex interventions. There is also a need to strengthen the management of health systems if Bangladesh is to reduce inequity in access and outcomes of health, improve the quality and accountability of service providers in the public and private sectors and reduce household financial distress from health expenditure. Well-designed UHC programs can help to achieve that. But Government will need to increase its financial commitment to the health sector either directly through more public financing, or indirectly through the engagement of, but better governance, stewardship and regulation of the private sector, including NGOs. There are many possible permutations and combinations in this regard and the development partners should continue to support Government of Bangladesh make choices based on evidence. Clearly the UHC target will require a strategy with milestones and indicators and a clear plan for raising the necessary revenues ways that are fair and efficient. To the extent that UHC does extend coverage to the whole population, it starts to “become the health system” as a whole, as distinct from a series of vertical disease or uncoordinated community interventions, each with their own plan and distinct funding stream, as applies now. International and larger domestic development partners, including the larger national NGOs, are a major influence on the political economy of health and RMNCH in Bangladesh. They provide important support

for the Government’s development budget. Development partners – including UNICEF – also have convening power given their technical expertise and brand name. This can be the essential catalyst for bringing together key government and/or civil society stakeholders which would otherwise not be engaged in policy development. The SWAP provides an appropriate context for this, although the obvious question of development partner and NGO displacement of government funding for the health sector looms large. At present, the evidence of this influence is not great, but as explained earlier this may change as government needs rise with attempts to reach UHC and raise the technical standard and quality of public health services.

5.2 Recommendations

The preceding analysis enables some suggestions for development partners working in Bangladesh.

First, given the current political economy of health and RMNCH within government, it seems that substantive gains are unlikely to occur from working solely in the public sector. Some development partners will therefore conclude it is probably more effective to work with the strong NGO sector in Bangladesh. On the other hand, larger NGOs, bilateral and multilateral partners will rightly conclude that government policy and programs are too important to bypass and will continue to attempt to engage with government. But development partners working in Bangladesh need to be aware of the limitations in both the public and private spheres. An effective and acceptable combination may involve strengthening government processes and systems (as UNICEF has been attempting with its investment case work) and the quality and use of locally owned data sources; engagement of the population and civil society in health program planning and performance appraisal; and using NGOs as implementing partners at community level. As government is expected to respond to the voice of an increasingly educated and wired population, there are aspects of the mixed system in Bangladesh that may provide lessons for other developing nations.

The movement to UHC will affect the whole health system: all development partners should therefore actively engage in the policy development and implementation of UHC. Bangladesh’s stated commitment to scale up UHC to all its citizens provides all development partners with an opportunity to engage in the design of a nation-wide program that is ‘owned’ by Government. International development partners and the larger domestic NGOs should engage in policy dialogue and advocacy on health financing, resource allocation, health governance, stewardship and regulation. As UHC is progressively rolled out there will be good opportunities to support impact evaluations on what works, for whom, at what cost and under what circumstances. Moreover, studies on the cost of prevention and treatment of key health burdens at different levels of the health system will inform the evidence-base

for formulating UHC policy and implementation strategies. UNICEF itself should continue to move ‘upstream’ in terms of broader policy engagement, and away from activities that are viewed locally as stand-alone projects. Interviews identified a view that the investment case approach was seen as such a “one off” project and had little buy-in from Government.

Capturing and analysing the cost of interventions is an important part of policy dialogue and influencing priorities. For example, UNICEF has an $18 million program in Bangladesh through which it directly or indirectly supports several health-related programs. UNICEF invests considerable resources in assessing the technical outputs and health outcomes of those activities. However, it is not clear that UNICEF is capturing and analysing the cost of implementing those programs. Do unit costs of interventions decrease because of economies of scale, or do unit costs increase because harder to reach populations are targeted? Notwithstanding higher costs for remote populations, is the approach even more cost-effective than alternatives because disease burdens are higher in remoter areas? Such cost information is not yet routinely captured and analysed. Yet cost data, and what happens to costs as programs expand, is normally of vital interest to Ministries of Finance and budget planners in terms of what programs they will fund or not. More could and should be done to collect and analyse cost data of programs UNICEF supports.

A common observation in the development sector is that the inputs of larger partners who might have the most impact are too short, as the more significant and sustainable outputs take time to occur. It is not just developing country institutions that are subject to political pressures and institutional incentives. Development partners are increasingly been told to demonstrate (early) results. While

understandable, this can lead to perverse and unintended consequences. Former USAID Administrator Andrew Natsios writes “those development programs that are most precisely and easily measured are the least transformational, and those programs that are most transformational are the least measurable” (82). This is relevant to Bangladesh. Low cost interventions that are simple and measurable, such as supplementary feeding receive attention, and therefore funding, but do not address the foundations of Bangladesh’s nutrition problem. Funding of ‘soft’ components (recruitment, human resources, management systems) that may yield more effective and sustainable outcomes receive less attention and budgets. Development assistance in Bangladesh will not yield rapid results; development partners should use their technical expertise and bureaucratic political capital to explain to their own stakeholders the risks of short-termism and ‘announcables’, and commit to long term support.

Finally, ‘evidence’ is only as good as the presentation. One experienced researcher with strong academic credentials observed that technically oriented domestic and international agencies still tend to assume that submitting robust evidence is the end, not the beginning, of their responsibility. Interviews in Bangladesh confirmed that technically strong agencies in particular tended not to ‘capture the imagination’ of politicians and decision makers, sometimes believing that simplified presentations undermined their credibility and / or independence. Some failed to understand that politicians in Bangladesh may feel intimidated by relatively straightforward presentations of technical data. Technical agencies must be astute in presenting messages accurately but in plain language, and to take into account the political economy of health and RMNCH, as identified in this report.

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6. Conclusion

To conclude, Bangladesh has made remarkable achievements, including in RMNCH, through a relatively unique mix of government-supported health systems elements and programmes and public health personnel stationed down to community level, supported by a very active NGO sector. Public and private/non-government agencies have collaboratively and successfully implemented a set of globally recommended preventive and public health interventions. Significant new challenges are emerging as the health program targets issues whose

resolution demands more complex approaches including the prevention and management of NCDs, reduction of under-nutrition, reduction of newborn and maternal mortality and roll out of UHC. Development partners can play an important, albeit catalytic, role in helping Bangladesh position itself to respond in ways that are effective, efficient, equitable, affordable, and sustainable in financial, social and political terms. But they must take into account the relatively weak political and economic foundation that exists.

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Annex one: definitions of political economy

There is no single, agreed definition of the term “political economy”. The OECD concisely says that: “Political economy analysis is concerned with the interaction of political and economic processes in a society: the distribution of power and wealth between different groups and individuals, and the processes that create, sustain and transform these relationships over time.”(17) Bueuran says “In its modern form, political economy studies refer to the study of the relations between political and economic processes which involve several factors such as incentives, relationships, and the distribution of power between various interest groups in society, all of whom have an impact on development outcomes”(83).

DFID has a more expansive description, which highlights how political economy analysis can improve development effectiveness:

Political economy analysis is a powerful tool for improving the effectiveness of aid. Bridging the traditional concerns of politics and economics, it focuses on how power and resources are distributed and contested in different contexts, and the implications for development outcomes. It gets beneath the formal structures to reveal the underlying interests, incentives and institutions that enable or frustrate change. Such insights are important if we

are to advance challenging agendas around governance, economic growth and service delivery, which experience has shown do not lend themselves to technical solutions alone…. It can also contribute to better results by identifying where the main opportunities and barriers for policy reform exist and how donors can use their programming and influencing tools to promote positive change. This understanding is particularly relevant in fragile and conflict-affected environments where the challenge of building peaceful states and societies is fundamentally political.(17)

The World Bank (18) says:

What is political economy? Political economy (PE) is the study of both politics and economics, and specifically the interactions between them. It focuses on power and resources, how they are distributed and contested in different country and sector contexts, and the resulting implications for development outcomes. PE analysis involves more than a review of institutional and governance arrangements: it also considers the underlying interests, incentives, rents/rent distribution, historical legacies, prior experiences with reforms, social trends, and how all of these factors effect or impede change

Annex two: approach and methodology

The following is an extract on initial thinking about methodology and approaches written by Dr Midori Sato. The full text is available on request.

There are numerous analytical tools and approaches that could be used to examine governance and political economy of priority setting, planning and budgeting in the social sectors of developing countries. According to DFID’s “how to note” on political economy analysis17, these tools are broadly divided into three types: 1) Macro-level country analysis (understanding how political and economic systems of a country enable or hold back overall development, and to identify strategic entry points for programming in a country); 2) Analysis focused on particular sectors (understanding the interests, incentives and institutions operating within a particular sector, to inform the design of a sector programme)18; and 3) Problem-focused analysis (understanding and resolving a specific problem that may be encountered in a particular donor programme)19.

For example, the analytical process proposed by DFID/ODI (Figure 1) broadly follows these three stages (including the above two levels of analysis at both country-level and sector/intra-sector-level) and supports DFID’s “Drivers of Change”20.

Another option is a problem-driven framework for political economy analysis (Figure 2)21 which was informed by a review by Wild et al., (2012),22 on governance and political factors affecting weak service delivery in three social sectors (education, health and water and sanitation) in multiple countries.

Mcloughlin (2012) maps technical characteristics of service provision in particular sectors and sub-sectors and identifies the political and governance implications of these characteristics for provision.

These papers facilitate our understanding by providing an analytical toolbox to give shape to the complex web of incentive structures that affect sector performance. The problem-driven analysis framework (Figure 2) presents a way of thinking about governance and political economy and the interaction between the three sets of variables/factors and corresponding steps to analyse those variables: (i) Identifying the problem, opportunity or vulnerability to be addressed, (ii) Mapping out the institutional and governance arrangements and weaknesses, and (iii) Drilling down to the political economy drivers, both to identify obstacles to successful and progressive change and to understand where a ‘drive’ for positive change could emerge from and likelihood is of stakeholder support for various change options.

The second and third layers are differentiated in order to emphasize that institutional and governance dimensions as well as stakeholders and their interests, motivations, power and behavior will be explicitly considered in the second layer. The framework is useful in framing the concrete, problem-focused analysis and for structuring the inquiry process, yet it has limitation, such as difficulty in understanding linkages between wider country-level dynamics and specific problem analyzed within specific sector (Fritz et al., 2009).

17 DFID. (2009) Political economy analysis: how to note. London: United Kingdom Department for International Development. 18 Moncrieffe J, Luttrell C. (2005) An analytical framework for understanding the political economy of sectors and policy areas. London: Overseas Development Institute. 19 Fritz V, Kaiser K, Levy B.(2009) Problem-driven governance and political economy framework: good practice framework. Washington DC: The World Bank 20 A conceptual model that seeks to explain how pro-poor change arises as a result of the interaction between structures, institutions and agents; useful to identify drivers for change, but less useful for understanding how political systems operate in practice. 21 Harris D. Applied political economy analysis: a problem-driven framework. London: Overseas Development Institute, 2013. 22 Wild, L., Chambers, V., King, M. and Harris, D. (2012) Common Constraints and Incentive Problems in Service Delivery. Working Paper 351. London: ODI.


Figure 1: Stages in political economy analysis (taken from Moncrieffe and Luttrell, 2005)

STAGE 1

STAGE 2

STAGE 2A

STAGE 3A STAGE 3B STAGE 3C

STAGE 2B

STAGE 3

STAGE 2C

BASIC COUNTRY ANALYSIS

UNDERSTANDING ORGANISATIONS, INSTITUTIONS AND ACTOR

OPERATIONAL IMPLICATIONS

DEFINING THE SECTOR

DEFINING OBJECTIVES

ANDEXPECTATIONS

DETERMININGENTRY POINTS

IDENTIFYINGMODE OFSUPPORT

INTRO-SECTOR ANALYSIS

RELATIONSHIPBETWEEN PLAYERS

HISTOROCAL / FOUNDATIONAL COUNTRY ANALYSIS

*HISTORY *CHANGE PROCESSES *STRUCTURAL FEATURES *POWER *IDEOLOGIES

• DETERMINING SECTOR BOUNDARIES• MAPPING THE PLAYERS IN THE SECTOR

• ROLE & RESPONSIBILITIES• ORGANISATIONAL STRUCTURE• MANAGEMENT & LEADERSHIP• FINANCING & SPENDING• INCENTIVES & MOTIVATION• CAPACITY

• NATURE OR THE RELATIONSHIP BETWEEN PLAYERS• HOW PLAYER INFLUENCE THE POLICY PROCESS • POLICY FORMULATION, NEGOTIATION & IMPLEMENTATION

• RESPONSIVENESS & CHANNELS OF ACCOUNTABILITY

Figure 2: Problem-driven framework for applied political economy analysis (taken from Harris, D. 2013)

23 Swedish International Development Agency. (2006) Power Analysis – Experience and Challenges 24 Clingendael Institute for the Netherlands Ministry of Foreign Affairs. (2007) Framework for Strategic Governance and Corruption Analysis (SGACA): Designing strategic responses towards good governance

Other tools and approaches that can also be applied for political economy analysis include: “Power Analysis”23 by SIDA (Swedish), which focuses on the nature of power relations, distribution of power, and incentives for pro-poor reforms; “Strategic Governance and Corruption Analysis (SGACA)”24 developed by the Netherlands’ Ministry of Foreign Affairs, which is very similar to “Drivers of Change”, but with a more tightly structured process and heavily relying on secondary sources of data conducted within a short timeframe; other tools include, but are not limited to “Politics of Development” by DFID and “Addressing Governance in Sector Operations” by the European Commission (EC).

All of the tools and approaches described above have strengths and weaknesses. Considering that there is great variety between, and within, the four assessment countries (Bangladesh, Indonesia, the Philippines and Nepal), it might be difficult to apply any one analytical framework coherently and comprehensively across all four.

Problem-driven framework for applied political economy analysis

Reflection Problem identification

Reflection What can be done?

Key question: What is the specific ‘problem’ to be addressed?If there is more than one problem, can they be clearly distinguished (e.g. operational and developmental)?

Identification of:1. Poor outcomes to which PE issues appear to contribute (for example, persistently poor development outcomes, repeated failure to adopt sector reforms);2. Theory of change underpinning previous interventions (if any) and their effectiveness.

2a: Structural Diagnosis: Context and Institutions 2b: Agency Diagnosis: Power, Incentives and behaviour

Key question: What are the systemic features in place that are relevant to the problem?

Key question: What combination of perceived incentives influences the behaviour that leads to this problem?

Analysis of:

1. Relevant structural features, including demography, geography (e.g. natural resource endowment), geopolitics, culture and social structure, historical legacies, climate change and technological progress.2. The ‘rules of the game’: Relevant institutions, including formal laws and regulations and informal social political and cultural norms, that shape power relations and, ultimately, economic and political outcomes.

Analysis of:

1. The motivations (financial, political, personal, ideational, etc.) of relevant individuals and organisations that shape their behaviour in ways relevant to the problem and potential reform.2. The types of relationships and balance of power between those actors.3. Relevant analytical concepts that provide some insight into actors’ incentives and decision logics: including credible commitment problems, collective action problems, information asymmetries, principal agent relationships, heuristics and blases, etc.

Key question:

1. What is a plausible pathway of change?2. What actions can be proposed that support that pathway of change?

Assessment of the range of potentially viable entry points, if any, for external actors seeking to facilitate this change. If viable entry points exist:1. Selection of appropriate inventions and modalities2. Timing, tailoring and sequencing of selected intervention

Analysis of:

1. Potential Change processes; and2. The realism of proposed change processes given the constraints and opportunities identified in the analysis

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Annex three: Inception report for Bangladesh

Key Political Economy Challenges identified in this note:

1) Even though, in absolute terms, the budget allocation to the social sectors (i.e. health, education, social welfare, and youth) has increased over time, the social sector budget as a percentage of GDP has been stagnant the past decade. The health sector clearly receives low priority both overall and even in the social sector budget, suggesting absence of fiscal commitment to health by the government, and an over-reliance on a rapidly growing private-for-profit market. 2) The current resource allocation and budgetary system (based on historical incrementalism rather than needs- based) are not well-aligned to address national and sub-district RMNCH priorities. 3) Inefficiency in use of health sector resources (duplication of programmes and insufficient coordination across DGHS & DGFP) with absence of strong regulatory functions in both public and private sector.

The Political Environment: Bangladesh has a multiparty parliamentary democracy with two major political parties, and a largely ceremonial presidential head of state. Parliamentary elections are scheduled to be held every 5 years. After enduring decades of political turmoil, some stability was seen with the Awami League (AL) party winning overwhelmingly in the elections of late 2008 over the Bangladesh Nationalist Party (BNP). The oath of Prime Minister was again taken in 2014 by the AL’s Sheikh Hasina, daughter of Sheikh Mujibur Rahman, nationalist leader and first president of Bangladesh, after the major opposition parties boycotted the general election. In addition to the political violence and disorder experienced before, during and after elections, the country continues to confront extensive corruption, (bottom of the Transparency International tables for more than a few years in a row), widespread poverty, popular agitation and civil disobedience is a pluralistic and free print media in addition to the state-owned and controlled broadcast media environment, which is undergoing changes with the advent of several privately owned television channels under a government licensing system.

Geographic and Demographic: Bangladesh is the most densely populated country in the world with a population of over 150 million. Administratively, the nation divided into 7 divisions, 64 districts, and 496 sub-districts (upazilas) and further divided into unions and lastly wards, the lowest administrative level. Despite the challenges of widespread poverty (146th of 187 countries in terms of

the Human Development Index)(1), urbanization25, political instability and regular natural disasters, considerable progress has been made towards achieving the MDG targets in maternal, infant and under-five mortality over the past decade, although the neonatal mortality rate shows a slowing decrease in recent years. Maternal mortality declined remarkably to 170 per 100,000 in 2013(2), attributed mainly to the success in fertility reduction, gains in female literacy and increased age at first childbearing. Other influencing factors include; 1) scaling up locally tested and evidence-based community approaches by the large voluntary NGO sector; 2) testing and application of innovative technologies through research; 3) focusing on pro-poor and gender-equity sensitive development programmes such as microfinance and education; and 4) strengthening disaster resilience and disaster management capacity(3,4,5). However, disparities and inequities still exist. For example, wide disparities were observed for four antenatal care (ANC) visits in the 20 UNDAF26 districts, between 9 and 77 percent overall, even more so between rich and poor, between urban and rural, by mothers’ education and across divisions. It was found that ANC coverage was higher in districts receiving support from UNICEF (in six districts) and other implementing partners, suggesting potential correlation between additional external funding to RMNCH and equity in utilization coverage at the district/sub-district levels.(6,7,8) Other areas where more progress is needed are low birth weight, malnutrition, injuries and drowning among children.(9)

Macroeconomic and fiscal context: Bangladesh has experienced steady economic growth, averaging more than 6% increase in GDP per year in the last three years, despite political instability, poor infrastructure, corruption, insufficient power supplies, and slow implementation of economic reforms. However, early projection of GDP growth for FY 2014 carried out by international institutions (i.e. WB, ADB) suggests an anticipated slow-down in growth to 5.5-5.8% as a consequence of the political unrest in the first half of the year. Despite its ambition to move towards middle-income status, Bangladesh faces critical challenges to sustainable economic development such as developing infrastructure, boosting investment, improving the business climate, enhancing the efficiency of the finance sector and the capital market, reducing corruption, developing skills and addressing climate change impacts. An estimated 31.5% of the population still lived below the poverty line in 2010. Fiscal trend analysis indicates Bangladesh lags behind in various indicators. For instance, overall government expenditure (expenditure-GDP ratio) has stabilized at around 16%, revenue-to-GDP ratio is one of the lowest in the world at around 10.8% (2006-2008), and gross debt as percent of GDP has been on a continuous upward track to about 50% (FY 2006). However, budget deficit shows a sustainable trend as it never rose over 5% of GDP in the past decade (10).

Sector-wise resource distribution (Figure 1) suggests that the health sector receives one of the lowest priorities in the government budget. While education and social 25 Urban population increased from 8.8% in 1974 to 27% in 2011 (2.5% growth) and expected to rise up to 50% in the next 20-30 years;

about 35% of the population in six metropolitan cities live in urban slums, which accounts for about 5.7 million (NIPORT 2006; NIPORT et al., 2013) 26 United Nations Development Assistance Framework 2012-2016. 20 districts were prioritized on the basis of poor performance across the following MDG-based parameters.

security/welfare receive relatively high priority (11.3% in education and technology, 5.1% in social security and welfare), pensions (3.0%), and health (4.1%) received less, in 2013-14 fiscal year. On the other hand, public administration (10.6%), transport and communication (9.0%), rural development and local government (6.6%), fuel and energy subsidies (6.9%), defense (5.6%) and energy and power (5.1%) all receive higher shares of the budget (Figure 1). Trends of public expenditure by major sectors (revenue and development) are increasing steadily in the past decade, yet the rate of increases is much higher for agriculture, public administration, education and social safety especially after 2005-2006. However, it is also important to note that the share of the education sector both as percentage of GDP is also decreasing. This suggests a distressing decrease in fiscal commitment even in key social sectors despite the steady increase seen in the country’s GDP.

Health Financing: Bangladesh has made rapid progress in primary health care despite weak health financing often characterized by: inequity in financing and utilisation with high levels of out-of-pocket expenditures (64 % of THE27); inadequate funding for the health system with the lowest per capita health expenditure by government in the South Asian Association for Regional Cooperation (SAARC) region at US$ 27 and THE 3.7 % of GDP; inefficient use of resources with absence of a proper resource allocation formula, shortage and inappropriate allocation of skilled health workers, vacant posts (44%) in public

27 WHO National Health Account shows 63%. Accessed June 29, 2014 at http://apps.who.int/nha/database/Country_Profile/Index/en


health facilities, lack of provider autonomy, no purchaser-provider split, duplication of programmes and insufficient coordination, and poor quality health facilities(12, 13, 14, 15). Despite a national budget increase in absolute terms, the MoHFW share decreased from 6.2% to 4.3% over the last 4 years and THE as a percentage of GDP reached only 3.4%. In absolute terms, the MoHFW budget increased by 36% over the past 4 years, yet as a percentage of GDP decreased gradually from just over a percent (1.01%) in FY2009-10 to 0.91% in FY2012-13, placing the GoB as the second lowest health sector spender (after Pakistan) among its South Asian neighbors. This suggests that the increase in THE is coming from household spending. Development aid to the health sector from both multilateral agencies and DAC countries followed an upward trend, reaching about US$ 9 billion and US$ 13 billion, respectively, in 2010 (16). UNICEF’s indicative contribution to the Health, Population and Nutrition Sector Development Programme (HNPSDP) (2011-2016) was the largest among the multilateral donors (8% of total Development Partners (DPs) contribution with a majority budgeted for RMNCH and Nutrition) and the fourth largest after the IDA of the World Bank, USAID, and DFID. The contribution from the DPs is estimated to be US$ 1.8 billion, close to two thirds (61%) of the total development budget (17, 18), with the remainder coming from government revenue. According to the Programme Implementation Plan of the HNPSDP, the budget for RMNCH-related activities (combining the budgets of the Operational Plans (OPs) for both the Directorate General of Health Services (DGHS) and Directorate General of Family Planning (DGFP)) is the second highest (17.6%) after the OP for Physical Facilities Development (22%), yet analysis of actual allocation of funds to maternal health in FY 2009/2010 suggests low level of actual allocation (only 2.5% of MoHFW budget and 0.15% of the total government budget), although increased slightly from 2007/2008 fiscal year (2.3% of MoHFW budget and 0.15% of national budget).(19) These trends (low spending by the government on health, low spending on private insurance (0.2%) of the THE, high level of OOP by households) suggest a rising influence of the private for-profit sector (expanding by about 15%), including NGO sector funded through external donor aid or its own resources in the case of BRAC28, and its expanding role in filling the gap left by the government(10). In 2004, Demand Side Financing (DSF) was designed to improve access to MNH services in 33 sub-districts and implemented till 2010. Based on both positive (utilisation increase) and negative (administrative and implementation-related) lessons learnt from the scheme, the government plans to establish a pooled fund that finances a social health protection scheme

focusing on specific target groups and conditions using results-based financing such as DSF, performance based zfinancing, and conditional cash transfers (10, 20).

Stewardship and Governance: Overall, weak governance, feeble legal frameworks and insufficient institutional capacity of regulatory functionaries in the sector and outside the health sector, e.g. weak legal framework around child marriage negatively affecting women and children(21) have weakened the stewardship role of the government. Thus, reviewing, updating and revitalizing the mandate and structure of the parastatal and professional associations,29 such as the Bangladesh Medical Association (BMA), Bangladesh Medical Research Council (BMRC), Bangladesh Medical and Dental Council (BMDC), is a key strategic priority in order to strengthen government’s stewardship and governance roles. In this light, MoHFW plans to extend its regulatory functions to the NGO and the private sectors in terms of quality and pricing (i.e. introducing fixed fee schedule of services for both public and private, introducing social health insurance scheme).

Health Policy, Decentralization, Upazilla Health System (UHS), LLP: The right to health care was enshrined in the Constitution of Bangladesh (1972), followed enactment of key policies influencing RMNCH programming i.e. Population Policy (1976), Drug Policy (1982), the Sector Wide Approach (SWAP), 1998, currently, the third SWAp (HPNSDP 2011-2016) is being implemented), and the Unification Reform (1998). The remarkable success in reducing total fertility rate (TFR) from 6.3 births per women in 1975 to 3.4 in 1994, only in 19 years (BDHS 2007) in Bangladesh was largely driven by a strong family planning sector infrastructure and large scale NGO service delivery mechanisms at the community level. DGFP was established in 1974 as a separate family planning wing as a result of high-level political commitment and positioning of family planning as a priority issue at the founding of the nation. Since then, the government built upazilla health service delivery system and trained tremendous number of family planning workers (Family Welfare Volunteers and Family Welfare Assistants (FWAs)) over the years. Unification reform in 1998 failed since it generated a power struggle and mistrust between the divisions.(22)

Article 11 of the Bangladesh Constitution sets the states that “The Republic shall be a democracy in which effective participation by the people through their elected representatives in administration at all levels shall be ensured.” Since independence in 1971, decentralization reforms have been attempted several

28 Bangladesh Rural Advancement Committee, currently, BRAC does not represent an acronym. 29 Other important councils with licensing functions are:, Bangladesh Nursing Council (BNC), Bangladesh Pharmacy Council (BPC) and State Medical Faculty (SMF). Other parastatal organizations / associations with regulatory functions in specific fields are: Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh College of Physicians and Surgeons (BCPS), Bangladesh National Nutrition Council (BNNC), Bangladesh Homeopathy Board and Bangladesh Unani and Ayurvedi Board for alternate medical care, in teaching and medical education.

times, but management and control continues by the central government administrative structures(23). The MoHFW envisions management of service delivery with proper participation of the community and delegation of financial and administrative power and autonomy to the upazilla (sub-district) level through establishment of Upazilla Health System (UHS). The UHS will be linked with the government policy through Local Level Planning (LLP) and is expected to introduce alternative financing models to meet the financing gaps and improve fiduciary arrangements. Similarly, hospital autonomy is also a current reform agenda of the sector programme with an aim to delegate maximum financial and administrative authority to the tertiary level specialized hospitals first and gradually to medical college hospitals. UNICEF disbursed funds for MNCH and immunization to eight UNDAF districts based on LLP, yet evidence of effects utilization of services by the target population is unknown.

Health System Structure: Top level officials in government such as the Minister, the Director Generals of Health Services (DGHS) and Family Planning (DGFP), and the Health Secretary make all final decisions. The health system is hierarchically structured with the ward level health facility at the bottom, i.e. Community Clinics, followed by the Union Health and Family Welfare Center (DGFP), which provide primary health care services through an Essential Service Package. At next layer, the Upazila Health Complex (housing both DGFP and DGHS units) provides inpatient, outpatient care, RMNCH services and disease control. The District Hospital (DHGS) and Mother and Child Welfare Centers (DGFP) are the top layer of the health care pyramid at district level. Finally, the medical colleges and post-graduate institutes offer a wide range of specialty services.

Planning, Budgeting, Resource Allocation: There is a disconnect between the development and non-development budgets whereby the revenue budget process takes a bottom-up approach, determined by size (# of beds, staffs) and the previous years’ budget, not by need. By contrast, the development budget is top down and programme-based with Line Directors (DGHS/DGFP) developing OP budgets which are compiled by the Planning Wing (PW, MOHFW). The major challenges are a complete lack of comprehensive planning and resource tracking and cost centers at the field level not at all participating in budget preparations, nor reflecting needs, thus causing under/over allocation. Lack of health finance and financial management capacity at both the central and district levels remain major issues (24).

Service Delivery: RMNCH service delivery confronts the obstacle of too many OPs and parallel structures that dilute and duplicate program priorities, offering bifurcated services with limited coordination among the line directors (LD), program managers and focal points. MoHFW proposes functional integration of MNCH services at district and sub-district levels to accelerate scale up and reduce inefficiency described earlier; however, this has not yet happened. Furthermore, local procurement, local hiring human resources is currently restricted by the quite centralized environment and rigid control of funds (25).Prepared by Midori Sato (July 9, 2014)

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