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TRANSCRIPT
Document of
The World Bank
Report No: ICR0000317
IMPLEMENTATION COMPLETION AND RESULTS REPORT
(IDA-40520 MULT-56510)
ON A
CREDIT
IN THE AMOUNT OF SDR196.1 MILLION
(USD 300.0 MILLION EQUIVALENT)
&
GRANT
IN THE AMOUNT OF USD 387.98 MILLION
TO THE
PEOPLE’S REPUBLIC OF BANGLADESH
FOR A
HEALTH, NUTRITION AND POPULATION SECTOR PROGRAM
June 27, 2012
Human Development Sector
Bangladesh Country Management Unit
South Asia Region
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CURRENCY EQUIVALENTS
(Exchange Rate Effective)
December 31, 2011
Currency Unit =Bangladesh Taka (Tk)
Taka 84 = USD1
USD 0.0167 = Taka 1
FISCAL YEAR (July 1 – June 30)
ABBREVIATIONS AND ACRONYMS
AIDS
ANC
APIR
Acquired Immune Deficiency Syndrome
Antenatal Care
Annual Program Implementation Report
APR Annual Program Review
BDHS Bangladesh Demographic and Health Survey
BMMS
CES
CIDA
Bangladesh Maternal Mortality Survey
Coverage Evaluation Survey
Canadian International Development Agency
CPR Contraceptive Prevalence Rate
DCA
DFID
Development Credit Agreement
Department for International Development (United Kingdom)
DGFP Directorate General of Family Planning
DGHS Directorate General of Health Services
DP Development Partner
DSF Demand-side Financing
EC European Commission
EKN
ESD
Embassy of the Kingdom of the Netherlands
Essential Services Delivery
FM Financial Management
FMAU Financial Management and Audit Unit
FMR Financial Monitoring Reports
FY Fiscal Year
GDP Gross Domestic Product
GOB Government of Bangladesh
HEU Health Economics Unit
HIV Human Immuno-deficiency Virus
HNP Health, Nutrition and Population
HNPSP Health, Nutrition and Population Sector Program
HPSP Health and Population Sector Program
HSDP
HR
Health Sector Development Program
Human Resources
HCWM Health Care Waste Management
IDA International Development Association
IMED Implementation, Monitoring & Evaluation Division, Ministry of Planning
IO
IRR
ISR
Intermediate Outcome
Internal Rate of Return
Implementation Status and Results Report
JICA Japan International Cooperation Agency
KfW Kreditanstalt für Wiederaufbau (Germany)
LD Line Director
LLP Local Level Planning
M&E Monitoring and Evaluation
MDG
MDTF
Millennium Development Goal
Multi-Donor Trust Fund
MIS Management Information System
MMR Maternal Mortality Ratio
MOF Ministry of Finance
MOHFW Ministry of Health and Family Welfare
MOLGRDC Ministry of Local Government, Rural Development and Cooperatives
MSA
MTR
NCD
Management Support Agency
Mid Term Review
Non-Communicable Diseases
NGO
NNP
Non-Government Organization
National Nutrition Program
NPV Net Present Value
NTP National Tuberculosis Program
OP Operational Plan
PAD
PBF
PDO
PER
PFM
Project Appraisal Document
Performance Based Financing
Project Development Objective
Public Expenditure Review
Public Financial Management
PIP Program Implementation Plan
PMA
PSO
Performance Monitoring Agency
Program Support Office
RFW Results Framework
RVP
SBA
Regional Vice President
Skilled Birth Attendant
Sida Swedish International Development Cooperation Agency
SIP
SWAp
Strategic Investment Plan
Sector-wide Approach
TA Technical Assistance
TB Tuberculosis
THE Total Health Expenditure
TTL
UNFPA
UESD
WHO
Task Team Leader
United Nations Population Fund
Utilization of Essential Service Delivery
World Health Organization
Vice President: Isabel M. Guerrero
Country Director: Ellen A. Goldstein
Sector Manager: Julie McLaughlin
Project Team Leader: Bushra B. Alam
ICR Team Leader: Bushra B. Alam
ICR Primary Author: Finn Schleimann
BANGLADESH
HEALTH NUTRITION AND POPULATION SECTOR PROGRAM
CONTENTS
Data Sheet
A. Basic Information
B. Key Dates
C. Ratings Summary
D. Sector and Theme Codes
E. Bank Staff
F. Results Framework Analysis
G. Ratings of Project Performance in ISRs
H. Restructuring
I. Disbursement Graph
1. Project Context, Development Objectives and Design ............................................... 1
2. Key Factors Affecting Implementation and Outcomes .............................................. 6 3. Assessment of Outcomes .......................................................................................... 15 4. Assessment of Risk to Development Outcome ......................................................... 20
5. Assessment of Bank and Borrower Performance ..................................................... 20 6. Lessons Learned ....................................................................................................... 23
7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners .......... 24
Annex 1. Project Costs and Financing .......................................................................... 26 Annex 2. Outputs by Components ................................................................................ 27
Annex 3. Economic and Financial Analysis ................................................................. 30 Annex 4. Bank Lending and Implementation Support/Supervision Processes ............ 37 Annex 5. Beneficiary Survey Results ........................................................................... 39
Annex 6. Summary of Borrower's ICR and/or Comments on Draft ICR ..................... 40 Annex 7. Comments of Co-financiers and Other Partners/Stakeholders ...................... 49
Annex 8. List of Supporting Documents ...................................................................... 52 Annex 9. Results Framework of HNPSP ...................................................................... 54
A. Basic Information
Country: Bangladesh Project Name:
Bangladesh - Health
Nutrition and Population
Sector Program
Project ID: P074841 L/C/TF Number(s): IDA-40520,TF-56510
ICR Date: 06/26/2012 ICR Type: Core ICR
Lending Instrument: SIM Borrower: GOVERNMENT OF
BANGLADESH
Original Total
Commitment:
USD 300.00M (IDA Credit);
USD 450.00M (MDTF) Disbursed Amount:
USD 293.40 M (IDA
Credit)
USD 387.80M (MDTF)
Revised Amount: USD 300.00M (IDA Credit)
USD 387.90M (MDTF)
Environmental Category: B
Implementing Agencies:
Ministry of Health and Family Welfare
Cofinanciers and Other External Partners: Canadian International Development Agency (CIDA) Embassy of the Kingdom of the Netherlands (EKN)
European Commission (EC)
Kreditanstalt für Wiederaufbau (KFW) Germany
Swedish International Development Agency (Sida)
UK Department for International Development (DFID)
United Nations Population Fund (UNFPA)
B. Key Dates
Process Date Process Original Date Revised / Actual
Date(s)
Concept Review: 02/11/2004 Effectiveness: 06/14/2005
Appraisal: 11/17/2004 Restructuring(s):
10/22/2009
07/30/2010
03/02/2011
Approval: 04/28/2005 Mid-term Review: 04/01/2008 02/15/2008
Closing: 12/31/2010 12/31/2011
C. Ratings Summary
C.1 Performance Rating by ICR
Outcomes: Satisfactory
Risk to Development Outcome: Moderate
Bank Performance: Satisfactory
Borrower Performance: Satisfactory
C.2 Detailed Ratings of Bank and Borrower Performance (by ICR)
Bank Ratings Borrower Ratings
Quality at Entry: Moderately Satisfactory Government: Moderately Satisfactory
Quality of Supervision: Satisfactory Implementing
Agency/Agencies: Satisfactory
Overall Bank
Performance: Satisfactory
Overall Borrower
Performance: Satisfactory
C.3 Quality at Entry and Implementation Performance Indicators
Implementation
Performance Indicators
QAG Assessments (if
any) Rating
Potential Problem Project
at any time (Yes/No): Yes Quality at Entry (QEA): Moderately Satisfactory
Problem Project at any
time (Yes/No): Yes
Quality of Supervision
(QSA): Moderately Satisfactory
DO rating before
Closing/Inactive status:
Moderately
Satisfactory
D. Sector and Theme Codes
Original Actual
Sector Code (as % of total Bank financing)
Central government administration 36 36
General education sector 4 4
General public administration sector 9 9
Health 40 40
Other social services 11 11
Theme Code (as % of total Bank financing)
Child health 13 13
Health system performance 24 24
Nutrition and food security 25 25
Other communicable diseases 13 13
Population and reproductive health 25 25
E. Bank Staff
Positions At ICR At Approval
Vice President: Isabel M. Guerrero Praful C. Patel
Country Director: Ellen A. Goldstein Christine I. Wallich
Sector Manager: Julie McLaughlin Anabela Abreu
Project Team Leader: Bushra Binte Alam Cornelis P. Kostermans
ICR Team Leader: Bushra Binte Alam
ICR Primary Author: Finn Schleimann
F. Results Framework Analysis
Project Development Objectives (from Project Appraisal Document [PAD]) The project assisted the Government of Bangladesh (GOB) in the implementation of its
Strategic Investment Plan (SIP), 2003-2010, for the Health, Nutrition & Population
Support Program (HNPSP) with support from a large group of Development Partners
(DPs) through a Sector-wide Approach (SWAp). The main purpose of the SIP was to
increase the availability and utilization of user-centered, effective, efficient, equitable,
affordable and accessible quality services be it the Essential Services Package, improved
hospital services, nutritional services or other selected services. To achieve these
objectives, the program focused on three major reform areas: (i) Strengthening Public
Health Sector Management and Stewardship Capacity, through development of pro-poor
targeting measures as well as strengthening sector-wide governance mechanisms; (ii)
Health Sector Diversification, through the development of new delivery channels for
publicly and non-publicly financed services; and (iii) Stimulating Demand for essential
services by poor households through health advocacy and demand-side financing options.
Revised Project Development Objectives (PDO)
The PDO as described in the PAD was not changed. During the Mid-Term Review
(MTR), the Results Framework (RFW) was changed and the change was approved as part
of a Regional Vice President level restructuring in October 2009.
(a) PDO Indicator(s)
Indicator Baseline Value
Original Target
Values (from
approval
documents)
Formally
Revised
Target
Values
Actual Value
Achieved at
Completion or
Target Years
Indicator 1 :
Proportion of total Ministry of Health and Family Welfare (MOHFW) expenditure
allocated to the 25% poorest districts (increasing to 40%) – dropped during MTR.
Revised to: percentage of MOHFW expenditures at the upazila level and below (on
07-Oct-2009)1
Value
quantitative or
Qualitative)
25% (original indicator ) ;
45% (for the revised
indicator)
40 %
50% revised
on 07-Oct-
2009
47%
Date achieved 06/30/2005 06/30/2010 06/30/2011 06/30/2011
Comments
(incl. %
achievement)
40% achieved; source: Public Expenditure Review 2008/09 (published in July
2011).
Indicator 2 :
Utilization rate of Essential Services Delivery (ESD) of the two lowest income
quintiles increased – divided into two parts (a and b) during MTR.
Revised to (on 07-Oct-2009): Utilization rate of ESD of the two lowest income
quintiles: (a) Delivery attended by skilled personnel2
1 Not the original PAD indicator, as it was changed at restructuring.
2 Modified from the original PAD indicator.
Value
quantitative or
Qualitative)
55% (as per PAD);
baseline revised to 4.10%
(for the revised indicator)
during MTR
65% 10% set on 07-
Oct-2009 11.8%
Date achieved 12/01/2004 06/30/2010 06/30/2011 06/30/2011
Comments
(incl. %
achievement)
131% achieved; source: Utilization of Essential Service Delivery Survey (UESD)
2010.
Indicator 3 : Utilization rate of ESD of the two lowest income quintiles: (b) Antenatal coverage
(by medically trained provider)3
Value
quantitative or
Qualitative)
55% (as per PAD);
baseline revised to 32.5%
(for the revised indicator)
during MTR
65%
40% revised
on 07-Oct-
2009
40.3%
Date achieved 12/01/2004 06/30/2010 06/30/2011 06/30/2011
Comments
(incl. %
achievement)
104% achieved; source: UESD 2010.
(b) Intermediate Outcome Indicator(s)
Indicator Baseline Value
Original Target
Values (from
approval
documents)
Formally
Revised
Target Values
Actual Value
Achieved at
Completion or
Target Years
Indicator 1 : Proportion of births attended by skilled personnel (from 12% to 40 % by 2010)
Value
(quantitative
or Qualitative)
25% (as per PAD);
baseline revised to 15.5%
during MTR
40%
28% revised
on 07-Oct-
20094
26.5%
Date achieved 06/30/2004 06/30/2010 06/30/2011 11/30/2011
Comments
(incl. %
achievement)
88% achieved; source: Bangladesh Maternal Mortality Survey (BMMS) 2010
Preliminary Report.
Indicator 2 : Tuberculosis (TB) case detection rate (from 41% to 70% by 2010)
Value
(quantitative
or Qualitative)
41% (as per PAD);
baseline revised to 46%
during MTR
70%
72% revised
on 07-Oct-
2009
74%
Date achieved 06/30/2003 06/30/2010 06/30/2011 06/30/2011
Comments
(incl. %
achievement)
108% achieved; source: National TB Program (NTP) 2010 (as reported in
Directorate General of Health Services [DGHS] Health Bulletin 2011).
Indicator 3 :
% of children 1-5 receiving Vitamin A supplements during the last 6 months
Revised (on 07-Oct-2009) to: % of children age 9-59 months receiving vitamin A
supplements during the last 6 months5
3 Modified from the original PAD indicator.
4 Reduced from PAD (was 40%), but baseline also lower than what was assumed in PAD (originally 25%).
Value
(quantitative
or Qualitative)
81.80% 90% 90% 92%
Date achieved 06/30/2004 06/30/2010 06/30/2011 06/30/2011
Comments
(incl. %
achievement)
124% achieved; source: Coverage Evaluation Survey (CES) 2011.
Indicator 4 : Non-communicable disease (NCD) strategy developed and implemented as per
details in results framework
Value
(quantitative
or Qualitative)
Strategy not yet
developed.
Strategy
implemented
Strategy
developed;
NCD risk
behavior
survey, NCD
piloting, and
Injury piloting
activities are
incorporated
into the
operational
plan (OP)
Strategy developed
and updated; NCD
risk behavior survey
conducted; NCD
piloting and Injury
piloting activities are
incorporated in the
NCD Operational
Plan
Date achieved 12/01/2004 06/30/2010 06/30/2011 06/30/2011
Comments
(incl. %
achievement)
Fully achieved; source: Annual Program Implementation Report (APIR) 2010.
Indicator 5 : Proportion of contracts awarded within initial bid validity period (95% from 2006
onwards)
Value
(quantitative
or Qualitative)
N.A. 95% or more 90% or more6 80%
Date achieved 06/10/2005 06/30/2010 06/30/2011 06/30/2011
Comments
(incl. %
achievement)
89% achieved; source: APIR 2010.
Indicator 6 :
Demand-side financing (DSF) pilots on schedule as per details in results
framework
Revised to: % of women targeted by voucher scheme who deliver by skilled birth
attendants (at facility or at home)7
Value
(quantitative
or Qualitative)
N.A. (as per PAD);
7% (for the revised
indicator)
Piloted by 2006,
evaluated in
2007 and scaled up
in 2008
60% revised
on 07-Oct-
2009
64%
Date achieved 06/01/2005 06/30/2010 06/30/2011 06/30/2011
5 Slightly modified from the original PAD indicator
6 Changed from 95% to 90% at MTR
7 Modified from original PAD indicator
Comments
(incl. %
achievement)
108% achieved; source: Economic Evaluation of DSF Program for Maternal
Health in Bangladesh 2010
Indicator 7 : % of districts with disease surveillance reports8
Value
(quantitative
or Qualitative)
52%
N/A (as this
indicator was
added during MTR
(on 07-Oct-2009)
95% 95%
Date achieved 12/01/2004 06/30/2011 06/30/2011
Comments
(incl. %
achievement)
100% achieved; source: APIR 2010.
Indicator 8 : % of children (under 1 year) fully immunized9
Value
(quantitative
or Qualitative)
68.4%
n/a (as this
indicator was
added during MTR
(on 07-Oct-2009)
85% 80%
Date achieved 12/01/2004 06/30/2011 06/30/2011
Comments
(incl. %
achievement)
70% achieved; source: CES 2011.
Indicator 9 : TB cure rate10
Value
(quantitative
or Qualitative)
85%
n/a (as this
indicator was
added during MTR
(on 07-Oct-2009)
85% 92%
Date achieved 12/01/2004 06/30/2011 06/30/2011
Comments
(incl. %
achievement)
108% achieved; source: NTP 2010 (as reported in DGHS Health Bulletin 2011).
G. Ratings of Project Performance in ISRs
No. Date ISR
Archived DO IP
Actual Disbursements
(USD millions)
1 06/16/2005 Satisfactory (S) Satisfactory 0.00
2 12/15/2005 Moderately Satisfactory
(MS) Moderately Satisfactory 0.00
3 05/10/2006 Moderately Satisfactory Moderately Satisfactory 43.07
4 10/27/2006 Moderately Satisfactory Moderately Satisfactory 54.57
5 04/25/2007 Moderately Satisfactory Moderately Satisfactory 131.05
6 05/25/2007 Moderately Moderately 131.05
8 Added to the original PAD indicators 9 Added to the original PAD indicators
10 Added to the original PAD indicators
Unsatisfactory Unsatisfactory
7 11/20/2007 Moderately
Unsatisfactory
Moderately
Unsatisfactory 124.71
8 01/19/2008 Moderately
Unsatisfactory
Moderately
Unsatisfactory 124.71
9 05/13/2008 Moderately Satisfactory Moderately Satisfactory 124.71
10 12/05/2008 Moderately Satisfactory Moderately Satisfactory 124.71
11 06/16/2009 Moderately Satisfactory Moderately Satisfactory 144.59
12 11/18/2009 Moderately Satisfactory Moderately Satisfactory 226.05
13 06/22/2010 Moderately Satisfactory Moderately Satisfactory 235.95
14 01/15/2011 Satisfactory Satisfactory 287.66
15 04/02/2011 Satisfactory Satisfactory 287.78
16 11/30/2011 Satisfactory Moderately Satisfactory 293.59
H. Restructuring (if any)
Restructuring
Date(s)
Board
Approved
PDO
Change
ISR Ratings at
Restructuring
Amount
Disbursed at
Restructuring
in USD
millions
Reason for Restructuring & Key
Changes Made DO IP
10/22/2009 MS MS 171.95
This was an RVP level restructuring
to: (i) modify two PDO indicators
and to refine the intermediate
outcome indicators to improve
relevance and accuracy in
measurement; (ii) reduce the
resource envelope for program
parts/activities that have not been
implemented and/or are progressing
slowly, and to reallocate funds to
pro-poor activities; and (iii) extend
the Closing Date of the program by 1
year to December 2011.
07/30/2010 MS MS 235.98
Approved by the World Bank’s
Country Director to document a
change in the amount of the grant to:
1) include agreed additional
contributions from CIDA and
KfW; and 2) reduce DfID’s original
commitment of co-financing.
03/02/2011 S S 287.66
Approved by the World Bank’s
Country Director. Restructuring to
show (i) a reallocation of available
funds between the disbursement
categories, and (ii) increasing the
amount of the grant from USD 335
million to USD 387.9 million.
I. Disbursement Profile
$0
$100,000,000
$200,000,000
$300,000,000
$400,000,000
$500,000,000
$600,000,000
$700,000,000
FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012
Original amount Revised amount Cumulative expenditure
1
1. Project Context, Development Objectives and Design
1.1 Context at Appraisal
In spite of being regularly affected by natural disasters and being one of the poorest and
most densely populated countries in the world, Bangladesh sustained high rates of
economic growth with considerable improvements in social indicators over the two
decades preceding this project. As such, the country was well on the way to achieving
many of the Health Nutrition and Population (HNP) related Millennium Development
Goals (MDGs).
Notwithstanding the achievements gained in the past years, Bangladesh faced an
unfinished agenda of systemic problems, originally identified in the Health and
Population Sector Strategy of 1997. In 1998, the strategy was translated into a five-year
program, the Health and Population Sector Program (HPSP), which had marked a shift
from multiple individual project approach to a single health Sector Wide Approach
(SWAp). While key health outcomes had improved under HPSP, albeit at a faltering rate,
the GOB‘s agenda of systemic reform could not be completed.
At the appraisal of HNPSP, key issues faced by the sector included:
Health Inequalities. Despite improvements in health indicators, the gap in health
conditions between the rich and the poor remained high. There remained wide
inequity, with children in the poorest households being more than twice as likely to
be moderately malnourished, and four times as likely to be severely malnourished as
children from the richest households. There was a pressing need to better address the
health rights of poor people by targeting consumption subsidies and restructuring
allocation mechanisms based on population and poverty indices.
The Dynamics of Public and Non Public Health Service Provision. In Bangladesh,
total annual per capita spending on health averaged US$12, of which only US$ 4
came from the public sector and the bulk (65%)11
was funded from household out-of-
pocket sources. Up to a third of the public budget on health was provided by DPs
during 1998-2003. Almost half of the households used the non-public sector for
treatment compared to only 10% who used the public sector. The remaining used
traditional sources of care.
Quality Health Care. Most services were provided by the non-public sector, more
specifically by local unregistered, traditional practitioners, largely in a poorly
regulated environment. Developing feasible and acceptable strategies for regulating
and enforcing regulation of quality and volume was critical for health services and
pharmaceuticals.
11 Bangladesh National Health Accounts, 1999-2001. Health Economics Unit, MOHFW, 2003
2
The sector was plagued by serious governance issues such as staff absenteeism,
pilferage, extracting illegal payments from patients, and so forth.
The Changing Epidemiology. In addition to the increasing incidence of injuries,
accidents (drowning were the leading cause of mortality for the 1-5 year olds) and a
growing risk of spread of Human Immuno-deficiency Virus/ Acquired Immune
Deficiency Syndrome (HIV/AIDS), Hepatitis B and C, amongst non-communicable
diseases (NCD), cancer and cardio-vascular diseases were the leading causes of
morbidity and mortality.
The HNP needs of Marginalized Groups: Gender, disability, age, type of disease and
cultural differences were the basis for discrimination, access and utilization of HNP
services in Bangladesh. Poor women and children, especially those from tribal
populations were being poorly served by the existing system, as were people with
disabilities, the elderly, adolescents and HIV/AIDS patients.
Maintaining the status quo was not the solution for Bangladesh, and the Government
stated its intention to reform the HNP system through its Strategic Investment Plan (SIP),
and proposed to significantly increase the level of spending on HNP. This intention
confirmed GOB’s commitment to pro-poor health service provision and to address the
need to reappraise the essential core functions of the public sector.
Under the SIP, new areas of focus were proposed which included a comprehensive
approach to nutrition programming, introduction of demand side financing pilots,
enhanced stewardship role of the government, developing incentives for health workers,
and performance-based financing mechanisms. The SIP also laid out four broad policy
directions that would have an impact on reducing health inequalities: (a) shifting
resource allocations to poorer districts (or districts with poor health outcomes; (b)
targeting and demand side subsidies to explore alternative ways of reaching to the poor;
(c) diversification of service provision to improve the quality and coverage of HNP
services through public-private partnerships; and (d) intersectoral collaboration to create
linkages between the Ministry of Health and Family Welfare (MOHFW) and other
ministries and programs which would have direct impact on the health status of the poor.
The Health, Nutrition and Population Sector Program (HNPSP) was designed to address
the above mentioned challenges and built upon the lessons learnt from the first health
sector SWAp (HPSP). Under the new HNPSP (2005-2011), seven DPs (DfID, CIDA,
EU, Sida, KfW, The Netherlands and UNFPA) contributed financing jointly with the
International Development Association (IDA), and participated in joint implementation
support activities, keeping in line with the signed Partnership Arrangement. The DPs set-
up a multi-donor trust fund (MDTF) with the Bank to support the Government’s SWAp
which was disbursed as co-financing with the Bank project. The total cost of HNPSP was
US$4.3 billion (the “Program”), of which US$3.1 billion was GOB funding and US$1.2
billion in DP funding. Of the DP funding, US$687.98 million was pooled funds (the
“Project” which comprised of the MDTF of US$387.98 million and IDA credit of
US$300 million) and the remaining US$512 million was parallel funding. During the
3
implementation of the program, the Bank administered the MDTF on behalf of the
pooling partners and ensured fiduciary oversight of the funds spent. The MDTF included
two portions – one executed by GOB, the other by the Bank for supervision of MDTF
and undertaking analytical and advisory activities.
Overview of the sectors financing, budgeting and monitoring
Partner Measured by Proportion
financing
Budget
channel
Budget
mechanism
MOHFW
MOHFW -
other
MIS, Survey
and
administrative
records
US$160.40
million
Revenue &
Development
Through
specific
parallel
projects
MOHFW -
HNPSP
Broad RFW &
MIS, Survey
and
administrative
records
US$2,945.82
million
Revenue &
Development
38 OPs
Pooled
Fund
IDA “Project” RFW
(12) , Survey
and
administrative
records
US$300.00
million
Development
MDTF Broad RFW
(30) , Survey
and
administrative
records
US$387.98
million
Non-pool partners Misc. project
monitoring
US$512.00
million
Miscellaneous
project
accounts
Miscellaneous
project
budgets
Total US$ 4306.20
million
1.2 Original Project Development Objectives (PDO) and Key Indicators
The project was intended to assist the GOB in the implementation of its Strategic
Investment Plan (SIP) 2003-2010, for the HNPSP in cooperation with a large group of
DPs through a SWAp mechanism.
The PDO of the project, as stated in the Project Appraisal Document (PAD) and in the
Implementation Status and Results Reports (ISRs), was to “Increase the availability and
utilization of user centered, effective, efficient, equitable, affordable and accessible
quality HNP services”. The project was monitored using this PDO and was measured by
the indicators outlined in the PAD and later revised during project restructuring in 2009.
(See the ICR datasheet for details).
It should be noted that the objective of the project, as stated in the Development Credit
Agreement (DCA), differed from the description of the PDO in the PAD. The DCA
4
states that “The objective of the Project, which is an integral part of the HNPSP is, inter
alia to: (i) reduce infant, under-five child and maternal mortality and the proportion of
malnourished children; (ii) eliminate the gender disparity in child malnutrition and
mortality; (iii) ensure increased access to reproductive health services; (iv) lower total
fertility with a view towards achieving replacement level by 2010; (v) reduce the burden
of tuberculosis (TB), HIV/AIDS, malaria and other priority diseases; (vi) initiate a system
to control newer health threats and protect health risks by improving emergency services;
and (vii) improve the prevention and control of NCDs. These goals are consistent with
the overall objectives of the HNPSP, as presented in the PAD, and were monitored by the
overall HNPSP indicators, as presented in Annex 9 of this ICR.
1.3 Revised PDO (as approved by original approving authority) and Key Indicators,
and reasons/justification
During the restructuring of the project in 2009 at the Regional Vice President level, one
PDO indicator (Proportion of total MOHFW expenditure allocated to the 25% poorest
districts) was replaced by “Proportion of MOHFW expenditure at the Upazila level and
below”. This change better reflected MOHFW’s regular monitoring and was a more
realistic way of measuring the pro-poor resource allocation. Another PDO indicator
(Utilization rate of Essential Service Delivery [ESD] of the two lowest income quintiles)
was modified to better reflect improvements in two specific essential health services
related to maternal health (i.e. skilled assistance during delivery and antenatal care
(ANC) by medically trained provider), as follows: “Utilization rate of ESD of the two
lowest income quintiles: (a) Delivery attended by skilled personnel, and (b) ANC
coverage by medically trained provider”. In addition, during restructuring, two
intermediate outcome (IO) indicators were deleted and three IO indicators were added to
ensure better monitoring and better alignment with the project components and to better
measure the PDO. Likewise, during restructuring, the GOB’s Results Framework was
also changed to reduce the number of indicators from the original 62 to 30 indicators. See
Section below on Monitoring and Evaluation (M&E) for a detailed outline of these
changes.
1.4 Main Beneficiaries
The entire population of Bangladesh was to benefit from this project, with a special focus
on the vulnerable population groups, e.g. the poor, women, children and the elderly.
1.5 Original Components
The project had three components, which were closely interlinked. While the first
component focused on objectives for service delivery in the classical primary health care
domain and achieving the HNP MDG, the second was to develop policies and strategies
to the changing disease burden due to urbanization and aging of the population. The third
component was to address major policy reforms and strategies in order to achieve better
equity and efficiency in the HNP sector. Disaggregated component costs were not
specified.
Component 1: Accelerating achievement of HNP-related MDG and Poverty Reduction
Strategy Paper (PRSP) goals. The component was intended to support the delivery of a
5
package of essential services. The ESD would focus on (a) reduction of maternal
mortality; (b) reduction of neonatal mortality; (c) reduction in childhood morbidity and
mortality; (d) improvement in the nutritional status particularly of adolescent girls,
pregnant and lactating women and children; (e) reducing fertility to replacement level;
and (f) reducing the burden of TB and malaria and preventing and controlling HIV/AIDS.
Component 2: Meeting emerging HNP sector challenges. This component was intended
to support the development of policies and strategies for emerging challenges, with a
focus on: (a) reduction of injuries and implementing improvements in emergency
services; (b) prevention and control of major NCDs; (c) urban health service
development; and (d) improvement of the HNP response to disasters.
Component 3: Advancing HNP sector modernization. This component was intended to
address the following health, nutrition and population (HNP) reforms:
Public health sector management and stewardship capacity: Improving sector
management would focus on improving institutional and personal skills for (i) better
planning and monitoring; (ii) improved budget management through a medium term
budgetary framework (MTBF) process; (iii) reform management; (iv) improved aid
management; (v) development of proper contract documents and management of
contracts with private and non-government organization (NGO) providers; (vi)
information management; and (vii) development of alternative financing mechanisms.
Major targets were established and agreed upon in order to implement a step-wise
delegation of responsibility to promote decentralization and local level planning (LLP).
Health sector diversification: In order to diversify service provision, MOHFW would
build capabilities to become active service purchasers in partnership with NGOs and
private providers. The pattern of service provision would be adjusted over time by the
increasing use of contracts and commissions for NGOs to provide primary and secondary
care in areas where they had a comparative advantage, and for private providers to offer
secondary and tertiary services for poor people where they could do so cost-effectively
and at high quality.
Stimulating demand for HNP services: This was to be achieved through: (i) improving
the sector’s image and greater attention to effective communication, education and
information strategies for key health problems; and (ii) expansion of demand-side
financing. MOHFW initiated a pilot with technical support provided from the World
Health Organization (WHO), of a voucher scheme to enable poor pregnant women to
purchase maternal health services initially in 21 Upazilas and which was further
expanded to 53 Upazilas during the life of HNPSP. Further piloting of other demand-side
financing schemes, such as health insurance, were planned with the aim of scaling up
following independent evaluation.
1.6 Revised Components
N/A
6
1.7 Other significant changes
The HNPSP was restructured three times, as follows:
October 2009 (Regional Vice President Level):
One PDO indicator was revised to improve measurement, implying a less specific but
more realistic way of measuring pro-poor resource allocation, and in line with regular
MOHFW monitoring. Another PDO indicator was made more specific for improved
measurement. Also, the intermediate results indicator (for Component 2) indicating
an increase from 5% to 10% in share of govt. expenditure allocated to MOHFW was
removed as it was outside the authority of MOHFW. Lastly, other IO indicators were
modified to enable better measurement of the PDO (see Section 1.3).
Reduction of the resource envelope for those program activities that were lagging in
implementation under component 3 of the Project, mainly under the aim of
“diversification12
” because of lack of progress by GOB to contract out services
despite the presence of a large non-government and private entities in the health
sector.
The Closing Date was extended by one year to 2011 to ensure the full utilization of
remaining resources.
Overall, the restructuring was timely and contributed to the success of the program.
2010 (Country Director Level):
To accommodate changes in the grant amounts from donors (DfID, KfW and CIDA).
2011 (Country Director Level):
To accommodate an increase in grant amount and reallocation of funds between
categories.
Supplementing the restructuring there was an agreement at the Annual Program Review
(APR) 2009, that funding would be reallocated towards pro-poor activities (e.g. essential
drugs).
2. Key Factors Affecting Implementation and Outcomes
2.1 Project Preparation, Design and Quality at Entry
Project preparation: The preparation of the HNPSP was informed by a thorough
background analysis and building on GOB’s HNP Strategic Investment Plan (SIP, 2003-
2010) and was linked to the Poverty Reduction Strategy Paper (PRSP), with PDO and
component objectives very relevant to the priorities of the country. The preparation
12 In the PAD, diversification is described as increasing use of contracts and commissions for NGOs to
provide primary and secondary care in areas where they had a comparative advantage, and for private
providers to offer secondary and tertiary services for poor people where they could do so cost-effectively
and at high quality
7
specifically incorporated lessons learned from the previous support, the Health &
Population Sector Program (HPSP) such as (a) clearly identifying the role of DPs and the
Government with the GOB leading the program; (b) aligning technical assistance (TA)
with policy documents; (c) carefully considering the political economy of reform; and (d)
having demand-side strategies complement supply-side interventions.
The preparation involved all major stakeholders, including the 16 members of the DP
Consortium, civil society organizations (CSOs) and Bangladesh Medical Association
(BMA). The risk assessment correctly identified most of the major risks, although the
risk of “commitment for the proposed sectoral reforms” may have been rated too low.
The problem of low GOB financing of the health sector was identified in the PAD, and
the HNPSP, therefore, included a target of doubling MOHFW’s share of the GOB budget
(from 5 to 10%). This was a very ambitious target and the identified risk of “GOB
financing does not meet required spending level” was, therefore, appropriately classified
as Substantial.
Project design: The choice of the lending instrument, the Sector Investment and
Maintenance Loan (SIM), and the choice of the Sector-wide Approach (SWAp) was very
appropriate given the nature, size and scope of the support envisioned and requested by
GOB. A number of factors influenced the SWAp design that was developed, and the
decisions as to how Bank and trust fund (pooled) financing would be disbursed, i.e. on a
specific set of activities rather than supporting a time slice of the MOHFW program13
.
Also, expanding the scope of the project to cover all of MOHFW budget items was not
considered feasible as it would have significantly increased the burden for the Bank in
terms of providing fiduciary oversight given the capacity constraints of MOHFW.
HNPSP, therefore, was a “hybrid between a project and a sector-wide program”14
. While
this approach was justified by the specific circumstances prevailing at the time of
appraisal, the choice of a broader SWAp (i.e. financing a time slice of the MOHFW
program rather than financing a specific set of activities) may have been a more ideal
foundation for more far-reaching sector dialogue, both with respect to sector reforms,
ongoing resource allocations and priorities within the sector.
2.2 Implementation
General. HNPSP implementation really gathered momentum after the Mid-Term
Review (MTR) in early-2008, following rather slow progress in the first two years. This
was reflected in the downgrading of project ratings to Moderately Unsatisfactory in the
ISR in mid-2007 after it became clear that there were real impediments to
implementation which needed to be resolved. The delay in project start-up was due to
unresolved audit observations from the previous program (HPSP). Also, the slow
13 The project did not finance “all” the activities as identified in the PIP for a specific time period, e.g. the
project did not pay for staff salaries of MOHFW.
14 As stated in a paper co-authored by the TTL responsible for the PAD (Kostermans & Geli, undated)
8
implementation progress was due to the fact that sector programs such as HNPSP rely on
adequate government leadership, which was not sufficiently strong (according to 2006
and 2007 APRs, and the Implementation, Monitoring & Evaluation Division [IMED]
Evaluation), particularly during the first two years. Further, a critical TA body e.g. the
Program Support Office (PSO) which was supposed to serve as the Program
Implementation Unit, was not in place until the MTR in 2008. Indeed, in 2007, some
DPs were contemplating whether to continue financing of the program which prompted
the GOB and the DPs to jointly agree on six critical actions to be prioritized by the
Ministry. This created new momentum, including increased government leadership,
facilitated by the active engagement of the World Bank Country Office and British High
Commission. Subsequently, implementation picked up momentum and four out of the six
actions were achieved within a period of six months. Limited progress was achieved in
the other two of the six action areas (putting Management Support Agency [MSA] in
place and setting up a procurement tracking system in the Directorate General of Family
Planning [DGFP]) as noted by the half-year stock take in November 2007. The program
was restructured following the MTR (although formally recorded only in 2009) and by
early-2008, the project rating was upgraded to Moderately Satisfactory in the ISR and
then to Satisfactory in 2011. The Quality Assurance Review (QAG) in 2008 also rated
the project as Moderately Satisfactory. At the end of project implementation in June
2011 (while the project formally closed in December 2011), most of the key targets were
achieved as described in Section 3 and in the ICR Datasheet. The GOB and DPs put in a
concerted effort to achieve the program targets despite the challenge of the program’s
size and scope.
The program was guided by a series of high quality independent Annual Program
Reviews. The APR had two parts – assessment by an independent team which submitted
a full APR report, and then based on the report, the GOB and DPs jointly agreed on
Action Plans which were recorded in the Aide Memoire. Not all the recommendations
provided by the independent team were implementable due to various constraints in the
government systems and, therefore, were not included in the Action Plan. This APR
mechanism functioned well. The IMED Evaluation15
notes that “the APRs became the
main source of dynamism in performance evaluation and establishing the future course of
action for the year”.
The following were some of the key issues which affected implementation either in a
positive or negative way as well as some elements of the program which require a brief
description to set project implementation within a broader context. While many of the
issues described below were indeed major challenges, the overall implementation of the
program turned out to be much more successful than indicated by the sum of these
challenges. This is important to note, particularly given the large size of the program and
the inherent and historically difficult environment of working in Bangladesh.
15 Implementation Monitoring & Evaluation Division (IMED), Ministry of Planning: “End-Line Evaluation
of Health, Nutrition and Population Sector Program (HNPSP)”, Final Report Sep 2011.
9
Political context. Bangladesh witnessed frequent (2006, 2008 and 2009) changes of
government during the implementation period, leading to changes in national priorities as
well as transfer of staff in key positions. One of the major effects of these changes was
that the diversification process (i.e. outsourcing NGOs and private providers, as described
in section 1.5) could not be implemented as originally planned. Consequently, when the
program was restructured, the overall budget was reduced by the unspent funds in this
area. Another example of this was that the original commitment to the PSO, MSA and
Performance Monitoring Agency (PMA) was no longer there (discussed in details in the
section on “other institutional issues”). Furthermore, the frequent shift of Line Directors
(LDs) (often only in position for less than a year), responsible for the operational plans16
(OP), also emerged as a factor causing systemic inefficiencies. The attempt in the latter
half of HNPSP to keep LDs for the major OPs in place for 2-3 years was only partly
successful, as many LDs either retired or got promoted.
Decentralization. Although a decentralization policy was approved in 2009, the health
system in Bangladesh remained very centralized. It is widely agreed (PAD, MTR, APRs)
that in order to improve service delivery at the primary level, delegation of authority over
planning and budget at the upazila level had to be increased. Consequently, in terms of
improving service delivery, the lack of progress on decentralization was problematic. In
order to circumvent the slow progress of overall decentralization reform and to move
towards functional integration of health and family welfare, an Upazila Health System
(UHS) was suggested by the APR 2009, and also endorsed in the 2009 Aide Memoire to
be piloted and subsequently implemented in the follow-on sector program.
Budgeting & planning. The division of the health sector in a health and a family
planning directorate, a division that extends from the center to the lowest institutional
level of the service delivery system, (except the Community Clinics), impeded integrated
budgeting and planning of health services at all levels. At the central level, integrated
budgeting and planning was impeded because the development and revenue budgets were
planned in different units, resulting in an “absence of synchronization between the
revenue and development budgets of MOHFW” (IMED Evaluation). In addition, the
structure of the two budgets was different: the revenue budget was allocated to
facilities/institutions, while the development budget was allocated to programs. This
problem was and remains pervasive in the GOB system and is not specific to the
MoHFW. The Program Implementation Plan (PIP) of HNPSP identified a large number
of OPs (38) for implementation of the program. The difficulties of integration between
the silo-like OPs were identified as an important problem (MTR 2008), and IMED 2012
documented the inefficiencies that this led to, one example being constructed facilities
not utilized to full capacity due to lack of coordination between the procurement of
equipments and allocation of manpower.
16 Operational plan is defined as the primary implementation structure of the MOHFW’s Health SWAp.
There were 38 OPs distributed across the Directorate General of Health Services, Directorate General of
Family Planning and the MOHFW and other agencies. Each OP reflected a priority area of the MOHFW’s
Health SWAp and was led by a Line Director with a functional administrative structure including staff,
budget and infrastructure.
10
New institutions & TA (PSO, MSA & PMA): As part of the HNPSP, some new
institutions were planned: the PSO and the MSA were created in 2007 and 2008
respectively. However, their effectiveness could be challenged, as there was “a huge
disconnect between these agencies and the Ministry whom they were supposed to
support” (as noted in the 2009 APR). The PMA was never established, but its function
was integrated into the existing structures by hiring consultants. At the program design
stage, there was ownership of these new structures at the top level management of
MOHFW. With the change of government, the level of ownership also changed,
exemplified by MOHFW not fulfilling the legal covenant of PSO/MSA for several years.
Instead of showing flexibility, DPs insisted on having PSO/MSA/PMA despite the
MOHFW’s reluctance. MOHFW took so long (nearly two years) to evaluate the bidders’
proposals for PSO/MSA that good quality firms withdrew their proposal, and/or
shortlisted firms were no longer in a position to field the staff indicated in their proposals.
These delays also meant that firms that were awarded the contracts for PSO/MSA could
not send experts as originally proposed and, therefore, the quality of the TA suffered and
the TA institutions could not deliver as per expectations. This led the GOB to discontinue
the contracts for PSO and MSA in 2010.
NGO contracting. The diversification, particularly in terms of contracting of NGOs, did
not progress as originally planned. This was mainly due to the shift in GOB’s political
preference as the new Government did not want to contract out essential public health
service delivery, like nutrition, to the private sector. NGOs were contracted out for
nutrition, TB and HIV services as a part of the diversification agenda. However, lack of
capacity and planning at the implementer’s level were two other issues that impeded the
greater involvement of the non-government sector in the service delivery. For example,
the National Nutrition Program (NNP) under HNPSP was plagued by regular
interruptions in service delivery due to the government’s delays in contracting the NGOs
as service providers. Furthermore, the performance of some NGOs was questionable as
documented in periodic performance reviews of NNP.
Goods and Civil Works. The HNPSP financed capital investments, i.e. equipment and
civil works, as well as procurement of goods such as essential drugs and vaccines,
funding areas of major importance to the delivery of quality services. Capital investments
and procurement of commodities ended up constituting 71% of the pooled funding
expenditures (out of which 3% for civil works). These were major contributions to
improving service delivery.
Performance Based Financing (PBF). Twenty five percent of pooled funding was
allocated for PBF based on fulfillment of agreed upon specific indicators. The indicators
were agreed on with the government every year and the funds were provided when the
indicator target were achieved. This modality was initially not very successful in terms of
achieving the targets set, and in the first years the amount set aside for PBF was not
disbursed. One reason could have been that the incentives provided by the PBF may not
have been adequate, as the funds received for achieving the PBF target were not directly
allocated to the level which was responsible for achieving the target. Nevertheless, due to
the reallocation of the budget (in 2009), the GOB did not eventually lose any funding as a
11
consequence of noncompliance with the targets for obtaining the PBF associated funding.
The MTR gave a quite harsh assessment of PBF, calling it “an example of old fashioned
conditionality”, and “inconsistent with Paris Declaration principles”. While there is a
certain truth to this, particularly as the first tranche was associated with establishing the
PSO and MSA, there are also clear benefits in enhancing the focus on results by financial
incentives. During the last two years, the PBF targets were met and the mechanism was
well understood and it turned out to be useful as it enabled the MOHFW to use funds on
priority activities, thereby serving as a valuable source of flexible funding. Eventually,
the PBF did deliver results, and important lessons were learned regarding this new
modality in development assistance.
HNPSP Coordination. The HNP Coordination Committee and HNP Forum led by
MOHFW, including DPs, assessed project progress and discussed implementation and
policy issues. The DPs were organized in a HNP Consortium with a Chair, who spoke on
behalf of the DPs as much as possible. MOHFW held Coordination Meetings (Secretary
and the Director Generals of DGHS and DGFP) reviewing mainly the OPs, in principle
monthly, but in practice less frequently. Monitoring was highly centralized leaving little
discretion to lower level management (e.g. Divisional and Upazila).
In addition Task Groups were established - following the recommendation of the first
APR - to assist MOHFW in monitoring implementation progress of priority areas. The
regularity and effectiveness of meetings varied; but it seems this modality was functional.
The IMED Evaluation of HNPSP concluded that “neither of the fora17
engaged in
systematic policy review because there was little demand/need for policy discussions
from either the Ministry or the DPs”. It should be noted that broader policy dialogue may
not have been part of their terms of reference. Overall, the coordination provided good
guidance on a number of implementation issues, but less so on higher level policy issues.
2.3 Monitoring and Evaluation (M&E) Design, Implementation and Utilization
Design. The HNPSP was monitored using two sets of indicators – one for the full sector
program with 62 indicators (PAD Annex 3A, p.34-39), which was revised during the
MTR to a list of 30 indicators; and the other for the pooled fund, which was drawn from
the broader Results Framework and included 10 key project indicators. This subset of
indicators (PAD Annex 3A, p.33) was revised during the MTR and was used for
reporting in the Bank’s ISR.
The Development Credit Agreement (DCA) PDO was referred to in Annex 4 of the PAD
with a different set of 8 indicators (6 of which are of impact level indicators). Most but
not all of the DCA PDO indicators were also part of the broader sector Results
Framework (RF). An update of the status of indicators in the broader RF, including a
number of those listed in Annex 4 of the PAD, is provided in the ICR Annex 9.
17 i.e. HNP Coordination Committee and HNP Forum
12
As discussed earlier, one of the original PDO indicators “Proportion of total MOHFW
expenditure allocated to the 25% poorest districts” could not be monitored and, therefore
due to unavailability of data and up until the MTR the same level has been reported. This
indicator, therefore, was changed to “Percentage of MOHFW at the upazila level and
below” during the RVP level restructuring approved in October 2009. It was done in
consultation with MOHFW and DPs on the basis of available data reported in the Public
Expenditure Review (PER), conducted by the Health Economics Unit (HEU) of the
MOHFW with the support from Gesellschaft für Internationale Zusammenarbeit (GIZ).
However, the PER was not published as regularly as planned during 2009-2011, and data
relating to the revised PDO was available only up to fiscal year (FY) 2008/09 (the report
was published in 2011). Changes to other indicators have been discussed already in
Section 1.3 and 1.7 of the ICR. The ICR Datasheet reflects both original and revised
targets and includes comments for each indicator.
The HNPSP included establishing a Monitoring and Evaluation Unit (MEU) in MOHFW
and improving the overall Management Information System (MIS). Several means of
measuring output and outcome indicators (including inequality) were introduced. Most
important were the Bangladesh Demographic and Health Survey (BDHS) and the
Utilization of Essential Services Delivery (UESD) Survey. The sector program was to be
reviewed annually by an independent team of experts during APR.
Relying on periodic cross-sectional surveys like BDHS and UESD only enables to
monitor the RFW indicators with a lag of nearly two years, as the surveys use a 3 to 5
years’ recall period. For this reason, the indicator updates at the end of the program date
usually refer to a much earlier time than the completion date.
Implementation. The project indicators were regularly monitored as part of the APRs and
were reported in the aide memoires. The broader Results Framework indicators were
monitored (to the extent data were available) in the first three years. These were annexed
to the aide memoire, but following the revision of the list in 2008 during the MTR, they
were no longer part of the aide memoire, and evidence of their use for monitoring
HNPSP was not found. However, the Annual Program Implementation Report (APIR)
continued to update the revised RFW with 30 indicators.
There were a number of challenges with the use of the overall MIS for the sector,
including problems with coverage, data quality and fragmentation. Specifically, the
problems included bifurcation of routine data systems between the Directorate General of
Health Services (DGHS) and the DGFP; private sector providers, who provide a major
share of services not accounted for in the routine system; and heavy dependence on cross-
sectional surveys for regular monitoring of program activities. The Monitoring and
Evaluation Unit was established but not fully staffed and mainly run by Gesellschaft für
Internationale Zusammenarbeit (GIZ) staff and short-term consultants to deliver APIR,
and with unclear institutional home.
13
Utilization. The APRs pointed to a low level of use of data for decision making on all
levels. It was pointed out during the ICR review, however, that the APRs contributed
substantially to identifying and analyzing issues and improving sector dialogue.
2.4 Safeguard and Fiduciary Compliance
Safeguards. MOHFW complied with the Bank's safeguards requirements and policies. A
Health Care Waste Management (HCWM) Guideline was developed, and implementation
of the HCWM plan was rolled out involving a partnership with the Ministry of Local
Government as well as private organizations. The DGHS took the lead in implementing
the HCWM plan at the health facilities.
There were no adverse impacts of the project on the indigenous people who mostly reside
in Chittagong Hill Tracts. As part of the sector program, the United Nations Development
Program (UNDP) implemented a package of health services in the Chittagong Hill Tracts.
Limited progress, however, was made in implementation of the Tribal Health Plan. A
Tribal Health Plan Implementation Committee and a separate Task Force for
implementation of the Plan was set-up, but neither the Committee nor the Task Force met
regularly. A mapping exercise of service availability and an ethnographic study were
initiated but not completed.
At the design stage of HNPSP, it was not envisaged that the project would finance civil
works. Following the MTR, it was agreed that the project would finance some civil works
in pro-poor areas keeping in line with the Bank’s social safeguards and environmental
policies. An environment management plan (EMP) was prepared during appraisal of
HNPSP. The Bank worked with the Government to ensure that the civil works financed
out of the pooled funds met social safeguards and environmental policies of the Bank.
The final ISR rated overall safeguard compliance as Moderately Satisfactory.
Financial Management (FM). During program implementation, MOHFW made
considerable progress in Public Financial Management (PFM). The FM Assessment of
HNPSP indicated that the PFM system in MOHFW, like all other sectors in Bangladesh,
was not streamlined enough to manage public funds effectively.
A TA support provided by DFID to the Financial Management and Audit Unit (FMAU)
focused on regular and timely preparation of Financial Monitoring Reports (FMRs) and
did not include any component for FM systems strengthening which could have enabled
funds to be channeled through the GOB system.
The Medium Term Budgetary Framework (MTBF) was introduced in order to improve
the efficiency and effectiveness of public expenditure. MOHFW and the DPs reached an
agreement on single sector accounts and reporting (FMRs), auditing, M&E systems under
the Program. The quarterly FMRs were mostly submitted on time. MOHFW is the first
Ministry in Bangladesh that outsourced its internal audit function to ensure effective
periodic monitoring of financial and operational activities in the sector. Between fiscal
14
years (FY) 2006 and 2011, the World Bank identified 36 audit observations (worth USD
68.14 million) as material and substantive from the observations raised by the Foreign
Aided Projects Audit Directorate (FAPAD) auditors. Although MOHFW has resolved all
of them, the pace of resolving these issues was slow.
MOHFW organized regular Financial Management Task Group (FMTG) meetings that
gave an overview of progress on sectoral financial management, including performance
of preparation of FMRs, implementation of APR action plans, resolution of both internal
and external audit observations, capacity development and training of staff.
There were weaknesses during project implementation relating to the weak internal
control environment and high staff turnover. While, these challenges did not adversely
affect project implementation as necessary mitigation measures to improve the internal
control environment were planned at project preparation and some additional measures
were put in place during implementation which, however, did not aim at long term
capacity building. The mitigation measures included TA for preparing FMRs;
outsourcing internal audits; training of staff; developing action plan as well as arranging
tri-partite meetings to follow-up on audit observations.
The final ISR rating for FM was Moderately Satisfactory.
Procurement. Performance of three procuring entities Central Medical Stores Depot
(CMSD), DGFP, and Health Engineering Department (HED) was satisfactory even
though there were some delays in completing the procurement cycles. The other two
entities (NNP and National AIDS/STD Program (NASP) struggled with preparing quality
procurement documents and hence needed a lot of support. Modest progress was noted
in strengthening procurement capacity. On the positive side, computerized procurement
tracking systems were put in place in one procuring entity (under DGFP), and
procurement desk officers were provided with training throughout the project period.
However, challenges remained and these included high staff turn-over, lack of capacity in
dealing with complaints, and delays in conducting procurement audits.
Often, the Bank was accused of having very cumbersome and slow procedures. However,
the reasons for delays had a lot to do with issues of low quality documents prepared by
the procuring entities and weak capacity. Although some capacity building did take place,
no comprehensive support to improve MOHFW capacity in this area nor in the FM area
was included in HNPSP which is regrettable. Nevertheless, in spite of these limitations
and capacity constraints, MOHFW was able to ensure supplies of commodities as evident
from the fact that there were no stock outs of family planning commodities in the last two
years of HNPSP, for example. The final ISR rating for Procurement was Moderately
Satisfactory.
2.5 Post-completion Operation/Next Phase
With the one year extension of HNPSP (to end in 2011) and the reallocation of budget
included in the restructurings, a smooth transition to the next phase (Health Sector
15
Development Program – HSDP – approved by the Bank in May 2011) of support was
ensured. The HSDP comprises: Improving Health Programs (Component 1A) including
essential services (nutrition and NCDs); Improving Service Provision (Component 1B)
including the Upazila Health System, hospital management and urban health; and
Strengthening Health Systems (Component 2) including governance, planning &
management, human resources (HR), financing, Health Information System (HIS),
quality assurance (QA), drug administration & regulation, procurement and supply chain,
and construction & maintenance. Given this scope and focus of HSDP, no significant
transition issues are envisaged.
In terms of performance indicators to monitor the longer term impact, most if not all of
the 12 project indicators are regularly monitored in Bangladesh. In addition, the HSDP
contains a broader Results Framework that will also ensure continued monitoring of
relevant key sector indicators. The exception may be in the area of NCDs where
indicators for follow up are not described.
3. Assessment of Outcomes
3.1 Relevance of Objectives, Design and Implementation
Relevance of Objectives: The PDO as well as the underlying three component objectives
(Intermediate Results) were highly relevant in terms of health outcomes and systemic
issues identified at appraisal. The objectives and project design were also highly relevant
vis-à-vis the GOB’s strategies and the World Bank’s Country Assistance Strategy (CAS).
The objectives were very broad, which is expected given the size and scope of HNPSP.
The relevance of objectives is rated as High.
Relevance of Design: The design, in terms of a sector approach with GOB implementing
the HNPSP and TA largely integrated within MOHFW (e.g. no separate project
implementation unit), components, sub-components and implementation arrangements
were consistent with the stated objectives at outset. However, key actors in GOB outside
the MOHFW did not seem to be fully on board with a major assumption underpinning the
HNPSP, namely a doubling of the share of GOB budget going to MOHFW, and as a
consequence this specific indicator and target was eventually dropped, following the
MTR.
There were a number of constraints and relevant concerns that made a more limited
SWAp design (i.e. financing a specific set of activities rather than a time slice of the
MOHFW program) an appropriate solution. These are described in more detail under
Section 2.1.
The clear focus on service delivery was important and very appropriate. The underlying
systemic problems in the sector particularly relating to HR and decentralization issues
continued to impede the efficient delivery of services over the life of the project. While it
should be noted that many issues like HR, governance, public finance, decentralization,
urban health, etc. are beyond the health sector and can only be addressed by government
16
wide reforms, thereby falling outside the control of HNPSP, there is a question as to how
much this constraint should have been better anticipated in the project design stage.
The establishment of contracted out TA agencies/units, i.e., PSO, MSA and PMA,
created problems as described in section 2.2 and was abandoned during the later part of
HNPSP.
The use of a MDTF combined with IDA to form pooled fund for the sector was a very
efficient and practical way of aligning different DP funding for implementing the GOB’s
health SWAp.
In sum, the project design is deemed to be appropriate in the complex context of
Bangladesh, and hence the rating of design is Substantial.
Relevance of implementation: Implementation arrangements comprised several fora to
discuss issues, both between GOB and DPs as well as between DPs supported by an
efficient independent review mechanism. Changing circumstances were well reflected
both in a revised focus from year to year as well as in the restructurings. Also, the
changes made following the MTR reflected the revised priorities and ensured better
ability to track and evaluate the program. Other adjustments in budgets and allocations
were also very appropriate and timely. The relevance of implementation is rated
Substantial.
Overall rating of relevance is Substantial.
3.2 Achievement of Project Development Objectives
During the implementation of HNPSP, Bangladesh made impressive progress on most of
the health outcomes and the country is now on track to achieve MDGs 4 and 5. The
maternal mortality ratio (MMR) declined by 40% from 322 in 2001 to 194 maternal
deaths per 100,000 live births in 2010 and under five child mortality rates (U5MR)
declined by 26% from 88 per 1,000 live births in 2004 to 65 in 2010. Total fertility rate
(TFR) declined from 3.0 in 2004 to 2.5 children per woman in 2010 and the contraceptive
prevalence rate (CPR) for modern methods increased by 10% over 2004 and 2010 (from
47% to 54%).
Out of the three PDO indicators of the project RFW, one indicator “% of MOHFW
expenditure at the Upazila level and below” showed a positive trend although data is
available only up to FY 2008/09. The overall achievement of PDO and IO indicators is
satisfactory as reflected in the ICR Datasheet, particularly considering that some data for
results are referring to a point in time before the completion of HNPSP, and that many (7
of 12) indicators have exceeded the target (up to 131% achievement).
The main thrust of the PDO statement centered on availability, utilization and
accessibility of quality HNP services. Achievements relating to the availability and
utilization of services can be drawn from progress in the following indicators:
17
TB Case Detection Rate (97% of the target achieved)
% children (under 1yr) fully immunized (84% achieved)
% Children 1–5 receiving Vitamin A supplements in last 6 months (113% achieved)
Achievements relating to the accessibility of services can be drawn from progress in the
following indicators:
% of women targeted by voucher scheme delivered by skilled birth attendants (SBAs)
(at facility or home) (107% achieved)
MOHFW expenditure on medical and surgical requisites at districts and below (fully
achieved)
Utilization rate of ESD of the two lowest income quintiles in terms of
a) delivery attended by skilled personnel (130% achieved)
b) ANC coverage by medically trained provider (fully achieved)
The following table summarizes the achievements towards PDO and IO targets before
and after restructuring of HNPSP. Actual achievements in the overall program’s results
framework are provided in Annex 9.
Original PAD
indicators
(used to monitor
progress from
2005-2009)
Revised Project
Indicators18
(used to monitor
progress from
2009-2011)
Overall Program
Results
Framework19
PDO
(2) IO (8)
PDO
(3) IO (9) I/OI (7) OI (24)
Target surpassed (above
100%) – Highly Satisfactory 2 2 5 1 4
Target fully achieved (85%-
100%) – Satisfactory 3 4 10
Target substantially achieved
(70%-84%) – Moderately
Satisfactory
1 2 2
Target partially achieved
(50-69%) – Moderately
Unsatisfactory
2 2
Target not achieved (1-
49%)– Unsatisfactory 2
20 4 1 6
21
Overall achievement % 50% 65% 83% 94% 89% 78%
Note 1: PDO – Project Development Objective; IO – Intermediate outcome; I/OI – Impact/outcome
indicators; OI – Output indicators
Note 2: the Overall Achievement is calculated using a weighted average: a weight of 100 assigned to the
number of HSs, 90 to Ss, 80 to MSs, 60 to MUs, 50 to Us.
18 As per revisions made during October 2009 restructuring
19 As per revisions made in July 2008, see details in Annex 9
20 Update not available for both the indicators
21 Update not available for one indicator
18
It is important to note that the pooled funds contributed to a slice of the sector program
and, therefore, the success of the project relied on a number of factors, both within and
outside the pooled fund, including funding from other sources (e.g. GOB revenue and DP
earmarked funding). The specific causality in terms of achievement of targets is,
therefore, difficult to measure, due to the nature of such broad-based support. It must be
noted, however, that given the very large amount of the MOHFW’s revenue funding
allocated to salaries, with little flexibility in the short term, the contribution of the pooled
funding appears much more substantial in terms of the proportion of key inputs it
financed, e.g. drugs, and new initiatives. Therefore, it is fair to assume that the HNPSP
has contributed significantly to the very positive achievements in the sector. Furthermore,
it is more relevant to consider the HNPSP as a partnership between the GOB and the DPs
with HNPSP co-financing the Bangladesh HNP sector and to assess whether this
partnership achieved what it had set out to do in the sector as a whole. In other words,
rather than looking at the possible specific impact (attribution) of the pool funds (IDA
plus MDTF), consistent with the agreements made under International Health
Partnership22
and the Paris Declaration23
the issue is whether HNPSP supported an
overall successful program. On the basis of program achievements with respect to key
health sector indicators, as outlined above, it is clear that HNPSP was part of a largely
successful GOB effort albeit more could have been done in some key areas as discussed
earlier in the implementation section of the ICR.
In sum, on balance, the achievement of the Development Objectives is rated Satisfactory.
3.3 Efficiency
Revisiting the assumptions for the PAD’s cost efficiency analysis indicates that Net
Present Value (NPV) and Internal Rate of Return (IRR) presumably are quite good,
probably even better than expected (see Annex 3).
The primary health care interventions that have been the emphasis of the HNPSP are
generally considered very cost-effective, e.g. immunization, antenatal care, SBAs,
vitamin A supplementation, nutrition services, contraception and treatment of childhood
infections. The HNPSP’s poverty focus (see 3.5a) has also directed funding towards those
in most needs and with the highest disease burden.
One source of inefficiency was that there were 38 OPs, resulting in limited coordination,
overlaps and lack of synergy between the activities of the MoHFW, as has been well
documented by the IMED Evaluation as well as the Public Expenditure & Institutional
Review.
One issue pertaining to efficiency is the overall funding of the public sector. A public
sector funding level of US$ 4-5/capita/year (even with the addition of private and out-of-
pocket spending to total health expenditure of US$ 16/capita/year), is generally
considered grossly inadequate to deliver comprehensive basic services. Given the results
22 Details can be found at http://www.internationalhealthpartnership.net/en/
23 Details can be found at http://www.oecd.org/dataoecd/11/41/34428351.pdf
19
of the sector in terms of more vertical approaches, it seems that performance can be
increased even with such a low level of funding. Achieving what is generally accepted as
very good results in key areas such as maternal and child mortality with limited funding
can be considered effective24
. But the problem remains that it is likely that efficiency of
other more complex services, to which HNPSP can be assumed to contribute as well, is
quite low given the severe under-financing of the sector.
Achievement of efficiency is rated Substantial.
3.4 Justification of Overall Outcome Rating
Combining the ratings for project relevance of Objectives, Design and Implementation
(the combined rating is Substantial), the rating for achievement of Development
Objectives (Satisfactory), and the rating for Efficiency (Substantial), the Overall
Outcome Rating is: Satisfactory.
3.5 Overarching Themes, Other Outcomes and Impacts
(a) Poverty Impacts, Gender Aspects, and Social Development
HNPSP investments have been pro-poor as evident by the fact that the poor actually
increased their share of service utilization during HNPSP period (e.g. utilization of ANC
and SBAs increased for the lowest two quintiles). In addition, HNPSP focused on the
rural areas, nutrition services were expanded to poor Upazilas, and areas selected for civil
works were based on poverty and health indicators.
With a strong focus on maternal and child health (MCH) services, the female population
has benefitted (e.g. the MMR was reduced), contributing to better gender balance in
health service delivery.
(b) Institutional Change/Strengthening
Facilities to deliver basic and comprehensive emergency obstetric care (EmOC) services
including maternal and child welfare centers (MCWCs), were established under HNPSP.
Besides, some of the health facilities at the Upazila level that cater to the needs of poor
people were upgraded from 31 to 50 bed with the associated equipment, drugs and health
personnel. Progress is also noted in areas, such as the establishment of an M&E unit,
modest improvements in procurement and FM capacities, expanding hospital autonomy,
improved budget management, some improvements in HR management (was included in
PBF) but not substantial, and improved disaster preparedness. The HNPSP was more
focused on service delivery.
(c) Other Unintended Outcomes and Impacts (positive or negative)
None documented.
24 As also pointed out by the 2010 Bangladesh Public Expenditure & Institutional Review (Vol. II): “While
expenditures on health are low, high value is obtained from those expenditures compared to other countries
in the region”
20
3.6 Summary of Findings of Beneficiary Survey and/or Stakeholder Workshops
No beneficiary survey was done as part of the ICR. However, the IMED evaluation
contained a survey of service recipients, which among other findings showed that
majority of the beneficiaries were satisfied with the health services provided at the
government health facilities and around 80% of the beneficiaries reported that the
government health services have improved during HNPSP compared to pre-HNPSP
period. Focus group discussions at Upazila level were also conducted revealing a quite
positive impression of HNPSP.
4. Assessment of Risk to Development Outcome
The lack of management and stewardship capacity constitutes a risk to further
development of the sector, but the risk may be less in terms of maintaining the current
level of achievement. This risk is further mitigated by the follow-on operation, HSDP,
which comprises a health systems strengthening component.
The general under-financing of the sector constitutes a barrier to progress much beyond
what has already been achieved. However, given Bangladesh’s sustained good
performance in some areas, particularly in relation to vertical and less complex
interventions, sustaining the current level of achievement is assessed to be fairly likely.
Risk to Development Outcome is rated Moderate.
5. Assessment of Bank and Borrower Performance
5.1 Bank Performance
(a) Bank Performance in Ensuring Quality at Entry
The Bank team did a thorough job during project preparation, as evidenced, for example,
by the Concept Note Review, the Quality Enhancement Review (QER) Report and the
PAD. Many relevant issues were raised that seem to have improved the quality of the
project design and the final documentation. Lessons from implementing the previous
SWAp (HPSP, 1998 to 2003) were incorporated while designing HNPSP and risks at
appraisal were adequately assessed. The Bank, jointly with the Government, led the task
of bringing together the DPs and harmonizing and aligning their support as much as
possible in line with the Government’s program and priorities, thereby providing
substantial flexible financing for the GOB’s HNP SIP. The design of the project was
rather complex with three components and five disbursement categories. The PDO that
was chosen for the pooled fund was the same as the overall objective of the SIP, even
while the description of the PDO in the PAD and the legal agreement were different. This,
however, did not lead to a substantive difference in terms of evaluation because they both
broadly reflected the goals of the SIP. However, it must be noted that the two PDO
Indicators that were chosen focused too narrowly on the equity (or poverty-related)
aspects of the PDO, which was only one of several dimensions of HNP services
incorporated in the PDO. The two PDO Indicators also proved to be difficult to measure
in practice, which is why these were changed during the 2009 restructuring. The Results
21
Framework is presented in two parts in the PAD, one for the pooled fund and the other
for the full sector program; but no explicit descriptions are provided which is likely to be
a source of confusion for those not involved with the program. The PAD also contains
some inconsistencies in terms of the DP financing figures presented in the datasheet and
the annex. On balance, while major effort was made by the Bank team, more could have
been done to improve the project indicators and documentation, as well as measures to
address fiduciary capacity issues. This was also a finding by the Quality at Entry Review
which was carried out by the Bank’s Quality Assurance Group (QAG) which gave an
overall rating of Moderately Satisfactory for project preparation.
Rating: Moderately Satisfactory
(b) Quality of Supervision
General supervision of HNPSP was comprehensive and thorough, and addressed the
relevant issues including development impact, as well as fiduciary and safeguards aspects.
Particularly, the independent APRs contributed very constructively to identifying major
problems and suggesting appropriate solutions. As indicated earlier, program
implementation and, therefore, disbursements were slow in the first two years. In 2007,
six critical actions were prioritized by the Ministry, facilitated by the Bank team and the
British High Commission. Implementation picked up within a period of six months. At
the mid-term in 2008/2009, the Bank team proactively restructured the project and
program implementation gained further momentum. The quality of supervision remained
satisfactory in the last three years of the program. In retrospect, the Bank team could
have downgraded the ratings of the project slightly earlier than in 2007, after two years of
implementation. Instead, the Bank team worked hard to address the issues hoping that
there would be improvements earlier on. Once it became clear that more substantial
changes were needed, the Bank team was proactive in pursuing restructuring.
Bank Task Team Leaders (TTLs) turn-over was high, with four TTLs during the
implementation of HNPSP. Given the Bank’s role as managing not only the IDA
contribution but also the MDTF in a very large operation, it would have been better to
have the TTL resident in Bangladesh (which was the case with a number of the TTLs) to
be able to stay involved in implementation monitoring on a daily basis. However, it
should be noted that locally based Bank staff were very closely involved in project
monitoring and had very collaborative relationship with the implementing agency and the
DPs, and in the final year of the program implementation a national staff served as a TTL
of HNPSP. The Bank team regularly provided updates to the pool funders on various
aspects of the project including financials and implementation progress. The Bank
managed a heavy workload relating to reviewing annually 38 OPs, procurement and
financial management documents/reports, ensuring due diligence as well as providing
procurement training to the Government counterparts. Generally, the Bank’s
administration of the MDTF was of good quality and the required fiduciary oversight was
provided by the Bank team. The Bank team also provided implementation support to the
Government on a daily basis. Regular visits were undertaken at field facilities and
program areas to oversee NGO-implemented activities (particularly nutrition and HIV)
and civil works sites (for ensuring social safeguards and environmental guidelines). The
22
Bank team also played a critical role in updating and revising the results framework as
well as agreeing on and monitoring the Performance Based Financing (PBF) indicators.
Considering the successful management of the complex and crucial pooled funding
arrangement, the rating for supervision is Satisfactory.
(c) Justification of Rating for Overall Bank Performance
Rating: Satisfactory
5.2 Borrower Performance
(a) Government Performance Government ownership and commitment should be ensured given that the HNPSP
supported the GOB HNP sector SIP. During implementation, there was considerable
progress in the service delivery aspects but limited progress in some of the reform areas
particularly in advancing HNP sector modernization.
The political economy played a major role in setting priorities and strategies. Democratic
elections resulted in changes in government which naturally also resulted in changes to
some policy priorities. This should, however, not be seen as lack of commitment.
Considering that health sector remained a priority area for the Government and there has
been sustained commitment in the sector, the rating is: Moderately Satisfactory
(b) Implementing Agency or Agencies Performance MOHFW was implementing its SIP for HNPSP under severe constraints in terms of
capacity, the systems in place, and within a very constrained overall financing envelope
(US$ 4 per capita, around 6% of total GOB budget). In addition, the influence of many
different political and other interest-groups created a very complex environment for
implementing the HNPSP. These issues were known and the difficulties in successfully
implementing all planned initiatives should be seen against this background. As
previously noted, MOHFW leadership was not very strong in the first two years of
program implementation but improved significantly in the later part (see also Annex 6:
IMED Evaluation). All legal covenants were eventually complied with and substantial
progress in program implementation was achieved despite the above mentioned
constraints. Overall, MOHFW achieved very good results, as described in previous
sections, overcoming difficulties, many of which were beyond its control. Consequently,
the rating is: Satisfactory
(c) Justification of Rating for Overall Borrower Performance Combining the rates for government and implementing agency performance, and
considering that HNPSP’s focus was more on improving service delivery (MOHFW
responsibility) than advancing sector reform (to a large extend GOB responsibility) gives
a rating of: Satisfactory
23
6. Lessons Learned
Sector-wide programs like HNPSP, which includes funding from various sources
necessitates an effective dialogue between government and DPs on the sectoral plan,
budgets and priorities as these DP support complement the GOB financing. Given the
circumstances during the design phase of HNPSP, a SWAp was the most feasible
approach for aligning with GOB systems and having a single set of sector priorities.
However, with the view to the next project it is essential to build in measures to
overcome the issues that had prevented a more full-fledged SWAp whereby all of the
parallel projects would have been under the SWAp umbrella. Under the new sector
program, HSDP, the parallel projects have been reflected in OPs (which was not the
case under HNPSP).
Ensuring commitment and maintaining policy dialogue with key ministries beyond
the health ministry, e.g. Ministry of Finance (MOF) and ministries responsible for
decentralization and civil service reform is very important for achieving
improvements in health. It necessitates a very good partnership and a sensitive
approach to fully understand the complexities of government commitment, including
ensuring the commitment and incentives for the lower levels of government.
Understanding the political economy, not least for complex countries like Bangladesh,
is important. More flexibility from DPs to adapt to changing national priorities will
help resolve any disagreements that may arise while implementing the project.
Performance based funding is challenging, both in terms of identifying appropriate
indicators and targets, and also in terms of understanding whether the incentives it
provides can be expected to yield the desired results. The overall incentive structure
of the system, and not least the specific incentives of the unit responsible for
achieving the target, need to be thoroughly analyzed.
Establishing new entities within a government system, with rules and regulations
different from those of government, is very difficult. Such initiatives should not only
be discussed and agreed upon at the highest level of the Government but also with the
actual implementers to ensure buy-in from all levels of the Government and that
proposed reforms are feasible.
For large sector programs like HNPSP, which rely on Government’s FM system,
specific systems strengthening component would have mitigated some of the issues
emanating from weak fiduciary capacity.
The results framework should include indicators that are directly linked to the project,
are within the purview of the implementing agency and are measurable. If there are
multiple sets of indicators, as in the case of HNPSP, it should be clearly stated in the
PAD which set is used for monitoring what.
24
In order to ensure proper M&E of the sector-wide programs like HNPSP,
restructuring of RFW indicators should be made as early as possible (if required) with
the aim to monitor a final set of indicators on regular basis during the program
duration.
For critical RFW indicators, relying on other DP-driven projects/initiatives to collect
data is not advisable.
For large SWAps, and particularly in circumstances such as in Bangladesh, it would
be advisable that Task Team Managers are locally based in order to provide
maximum support to Government and to ensure coordination with other partners.
7. Comments on Issues Raised by Borrower/Implementing Agencies/Partners
(a) Borrower/implementing agencies
1. The draft ICR of HNPSP has well identified the successes and weaknesses of the
HNPSP. MOHFW is in agreement with the ICR rating as “Satisfactory”, and this is
in line with the End-line evaluation of HNPSP by IMED, Ministry of Planning.
2. For seven out of the twelve indicators, achievement was more than 100%, which
contributed to increase in availability and utilization of essential healthcare
services.
3. HNPSP implementation has brought in some efficiency gains, which have been
identified well in the ICR. These include on-time submission of FMRs,
outsourcing of internal audit functions (as the first Ministry in GOB), and pro-poor
investments. The MOHFW is aware of the weaknesses of HNPSP as identified in
the ICR, viz. weaknesses in fiduciary management capacity, under-spending of
allocated finds, etc., and the new health sector program has been designed to
address these issues.
4. Regarding ICR’s observations on delay in contracting a) PSO/MSA and b) NGOs
for nutrition services, there were valid reasons for the delay in contracting
PSO/MSA and questionable performance of a number of NGOs resulted in delay
in contracting NGOs to provide nutrition services.
(b) Cofinanciers
Comments made by KfW:
The report gives an interesting overview on the program implementation. We share the
same points of view in many respects. The report describes the project implementation
from the WB perspective. However, the donor arrangements and the cooperation between
all development partners (pooling and non-pooling funders) could have been analysed
more in detail. It seems that the revision of PDO indicators and outcome indicators in
2009 translates the lowering of the expectations concerning the program results. If this
had not been done, the assessment would have been not so good. Further details provided
in Annex 7.
25
Comments made by DfID:
The report provides a relatively balanced narration of the implementation environment,
strengths and constraints of the last SWAp. However, preparation of this report nearly a
year after the completion of HNPSP may limit its usefulness. Progress on indicators were
generated by the Government information systems. The lack of third party verification or
triangulation of data and results continues to be a concern deepened by the recognition of
overall ‘weak internal controls…’ and limited progress in M&E in the sector. The report
states that Bangladesh is on track to achieve MDGs 4 & 5 according to the BDHS and
BMMS results, but it remains unclear how much is attributable to the public sector
through the SWAP. This is in part because of the considerable private sector health
provision in Bangladesh, some of this by public providers themselves, goes largely
unmentioned.Further details provided in Annex 7.
Comments made by Sida:
Although there have been significant achievements in the health sector but the experience
of HNPSP shows that weakness remain. It is clear that coordination between DPs and the
Government, as well as among the DPs must be revitalized in order to increase alignment
and harmonization. Systemic problems include overly centralized health system, weak
governance structure and regulatory framework, inefficient allocation of public resources,
lack of regulation of the private sector, and a shortage of human resources for health.
Progress in the health sector reform is very low and need to be fully owned by GOB and
supported by adequate technical assistance. Further details provided in Annex 7.
Comments made by Embassy of the Kingdom of the Netherlands:
The ICR is fine and informative.
(c) Other partners and stakeholders
N/A
26
Annex 1. Project Costs and Financing25
(a) Project Costs by Category (in USD Million equivalent) for pooled funds
Category Appraisal Estimate
(USD millions)
Actual/Latest
Estimate (USD
millions)
Percentage of
Appraisal
Category 1 Goods ,works,
services and operating costs under
Part D of the project 187 58.48 31%
Category 2 Services of NGOs,
private sector and non public
provider 112 86.67 77%
Category 3 Goods other than
those included in Category 1 236 463.61 196%
Category 4 Works other than
those included in Category 1 127 23.56 19%
Category 5 (a) Services other than
those included in Category 1 37 7.1 19%
Category 5 (b) Training/Studies 60 43.62 73%
Total Financing Required 760 683.04 90%
(b) Financing plan (commitments by pooling partners and actual receipts)
Source of Funds Type of Co-
financing
Appraisal Estimate (USD millions)
Actual/Latest
Estimate (USD
millions)
Percentage
of
Appraisal
CANADA: Canadian International
Development Agency (CIDA) Pool 13 4.6 36%
UK: British Department for
International Development (DFID) Pool 189 110.46 59%
EC: European Commission Pool 130 105.53 81%
Germany: German Development
Cooperation through KfW Pool 0 48.83
International Development
Association (IDA) Pool 300.00 300 100%
NETHERLANDS: Min. of Foreign
Affairs / Min. of Dev. Coop. Pool 53 44.99 85%
SWEDEN: Swedish Intl. Dev.
Cooperation Agency (SIDA) Pool 75 67.63 91%
UN Fund for Population Activities Pool 1 1.00 100%
Total 760 683.04 90%
25 The appraisal estimates of costs, by category, have been taken from Annex 6 of PAD. The appraisal
estimates for the financing plan have been drawn from the designated section on Pool Funding as stipulated
in Annex 9 of PAD. Financing data, in the PAD datasheet, includes financing plan by the DPs for both
pool as well as other parallel financing and hence differ from the data presented above
27
Annex 2. Outputs by Components
1. Accelerating
achievement of
HNP-related MDG
and PRSP goals
Bangladesh has seen an accelerated reduction in infant and child
mortality rates (MDG4) as well as impressive decline in MMR
(MDG5) about 40% in 10 years. Accelerated progress is being
achieved with regards to MDGs 4, 5 and 6, owing to successful
public health interventions. However there has been limited
progress in MDG 1. This requires essential service delivery
targeted to the poor, particularly women in the areas of
reproductive health, ante and post natal care, delivery by SBAs,
nutrition counseling and micronutrient supplementation. Fertility
decline in Bangladesh has resumed after a decade-long plateau
and has reached 2.3. There has also been substantial progress in
increasing contraceptive prevalence which has increased from
47.3 percent in 2004 to 54.1 percent in 2010 for modern methods.
Between 2004 and 2010, impressive gains have been made in the
coverage of vertical programs: 82 percentage of children under 2
receive all basic vaccinations in 2010 up from 73.1 percent in
2004; 82.6 percentage of children 9-59 months given vitamin A
supplements in 2010; and, 82.7 percentage of children under 5
with symptoms of acute respiratory infection sought care from a
trained provider in 2010, up from 74.6 percentage in 2004. The
progress in vitamin A supplementation and full immunization
coverage have been equitable with less than 10% difference
between the poorest and the richest wealth quintiles.
The challenge is to increase utilization of essential health service
deliveries attended by skilled personnel. In 2010 it was 26
percentage compared to 15.7 in 2004; percentage of antenatal
coverage by medically trained provider was 56 percentage in 2010
compared to 50.5 percentage in 2004.
A number of public health interventions have shown good
progress, achieving or exceeding their targets. TB control, one of
the most successful public health partnership programs, has
already achieved 2010 targets of a 70% detection rate and an 85%
cure rate, the latter due to the 100% coverage of Directly
Observed Treatment-Short-course (DOTS) at the District level.
The National Malaria Control Program also achieved the 50%
reduction of malaria specific mortality target in 2008.
MOHFW has finalized a National Health Policy that sets out the
priorities of the Government and aligns it with the goals set out in
the Second National Strategy for Accelerated Poverty Reduction
(NSAPR II).
28
2. Meeting
emerging HNP
sector challenges
Over the last several years, Bangladesh has been witnessing
several natural calamities, new and emerging diseases and an
increasing incidence of NCDs. Among the many aspects covered
under this component, avian influenza and emergency
preparedness are areas that have clearly progressed well. The
country seems well prepared for emergencies relating to natural
disasters. There are standard operating procedures in place for
mass casualty management and disaster mitigation for field level
health personnel. The program has well-functioning teams to
respond during emergencies. Although these systems are in place,
the quality of any response may be hampered by the often fairly
low level of institutional capacity and service quality in the health
sector.
For prevention and control of major NCDs, some limited progress
has been made. Under reduction of injuries and implementing
improvements in emergency services, four one-stop crisis centers
to address violence against women, were established during the
project period in four divisional Medical College Hospitals.
Further, the manual that guides management of violence was
updated in 2007 and training initiated for health service personnel.
There are, however, limitations regarding appropriately trained
personnel which constrain the availability of some services.
Limited progress has been made in the area of urban health
services development. The Ministry of Local Government, Rural
Development and Cooperatives (MOLGRDC) has contracted out
NGOs to implement services in the urban areas while MOHFW
provides the required commodities such as contraceptives and TB
drugs. Besides, MOLGRDC in coordination with the MOHFW is
in the final stage of development of a strategy for Urban Health
Services.
MOHFW has made important strides in developing policies and
strategies for emerging challenges. These include development
and endorsement of: The National Health Policy; b) Strategic Plan
for Surveillance and Prevention of NCDs 2011-2016; and c)
National Cancer Control Strategy and Plan of Action 2009-2015.
3. Advancing
HNP sector
modernization
The demand-side financing (DSF) pilot, a maternal health voucher
scheme for pregnant women, in 33 upazilas under this component
has been successful in increasing skilled delivery and substantially
increasing safe motherhood practices in the pilot areas. Major
policy decisions/agreements on decentralization and hospital
autonomy were not reached due to the changing political situation.
Building on the concept of LLP, district-specific work plan were
prepared and implemented by making resources available to
29
increase permanent and long-term contraceptive use in lagging
divisions of Chittagong and Sylhet.
There has been limited progress in implementation of this
component. This may be due in part to the setting of over
ambitious expectations that did not sufficiently take into account
political economy considerations.
Health sector diversification aimed at harnessing national
capacity for provision of HNP services by setting up mechanisms
for greater involvement of non-public providers. Progress in this
component was aimed to the expansion of the NNP area based
community nutrition program to 63 new upazilas and transfer of
management of HIV/AIDS NGO contracting from UNICEF to
the Management Support Agency(MSA).
Some additional achievements:
A regulatory framework for pharmaceuticals was established
MOHFW have also initiated a process to develop National
Health Care Financing Strategy.
The proportion of districts with Disease Surveillance Reports
increased substantially.
30
Annex 3. Economic and Financial Analysis
Annex 3A: General sector considerations
Total health expenditure (THE): According to the third round of the Bangladesh
National Health Accounts 1997-2007 (BNHA 1997-2007) per capita THE was US$ 16 in
2007 (Purchasing Power Parity US$ 46). The public sector accounted for one fourth of
the per capita health spending that remained under 1% of Gross Domestic Product (GDP)
throughout the period.
The total health expenditure (THE) as a percentage of GDP was 3% in 2003 which rose
to 3.4 percent in 200726
, showing a slow but steady increase over time (Figure A3.1). Per
capita health expenditure increased at a higher rate than per capita GDP. Rising THE is
explained by rise in households out-of pocket payment at the time of service delivery.
Figure A3.1 Public health spending and Households spending on health as a share of
GDP
Source: Bangladesh National Health Accounts 1997-2007
Government health expenditure: The HNPSP RFW set a target to increase MOHFW
budget to 10% of total national/government budget by 2010. During the implementation
of the Project, the share of health budget has remained under 7% (Table A3.1) except in
2007/08. In case of revised MOHFW budget the share crossed 7% only in 2006-07.
However, a closer examination of the MOHFW budget and expenditure reveals that it is
not lack of commitment or under financing rather under spending is an issue which
leads to fluctuation in allocation to MOHFW (PER 2007/08 and 2008/09, HEU,
26 Latest NHA data available is from 2007
2.7% 2.7% 2.7% 2.8%
2.9% 3.0% 3.0%
3.1% 3.2%
3.3% 3.4%
1.5% 1.6% 1.6% 1.6%
1.7% 1.8% 1.8% 1.8%
2.0% 2.1%
2.2%
1.0% 0.9% 0.9% 0.9% 0.9% 0.9%
0.8% 0.9%
0.8% 0.9% 0.9%
0.0%
1.0%
2.0%
3.0%
4.0%
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
THE HH spending Public health spending
31
MOHFW, 2011, Page 5). Under spending of budget is not unique to MOHFW, it is a
government wide problem (PER 2006/07, HEU, MOHFW, 2010, page 3).
Table A3.1. Share of MOHFW in national budget, revised budget and expenditure
Year Budget Revised
Budget
Actual
Expenditure
2003-04 5.8% 6.9% 6.3%
2004-05 6.7% 5.7% 5.3%
2005-06 6.7% 6.9% 5.1%
2006-07 6.9% 7.4% 6.9%
2007-08 7.0% 6.7% 6.5%
2008-09 6.4% 6.8% 6.7%
2009-10 6.3% 6.6% 5.7%
2010-11 6.6% 6.5% 5.7%
2011-12 6.0% NA NA
Source: Monthly Fiscal Reports of various years, MOF Website
Composition of expenditure: The composition of expenditure is analyzed in terms of
two broad categories: i) capital versus recurrent expenditures; and ii) salary versus non-
salary recurrent expenditure.
Capital expenditure remained around 20% during the project period but reached the peak
in 2005/06 (Table A3.2) As shown in the table, the share of MOHFW spending for
capital expenditure has been fluctuating.
Table A3.2. Capital and recurrent share of MOHFW spending (%)
Fiscal year Recurrent Capital
2003/04 80% 20%
2004/05 83% 17%
2005/06 77% 23%
2006/07 83% 17%
2007/08 80% 20%
2008/09 79% 21%
Source: PER 2003/04-2005/06 and PER 2007/08-2008/09, HEU, MOHFW
The share of non-pay recurrent expenditure to the total MOHFW expenditure has been
steadily declining since 2005/06 (Table A3.3).
Table A3.3 Share of non-salary recurrent expenditure in MOHFW spending (%)
Fiscal year Non-salary
recurrent
2003/04 44%
32
Fiscal year Non-salary
recurrent
2004/05 48%
2005/06 45%
2006/07 42%
2007/08 41%
2008/09 39%
Source: PER 2003/04-2005/06 and PER 2007/08-2008/09, HEU, MOHFW
It is to be noted that major share of total MOHFW spending is meant for salaries.
Therefore, it is important to examine how HNPSP money was spent. The following table
shows that 68% of HNPSP pooled fund was spent on goods and equipment which
includes contraceptives, drugs and medicines and medical equipment.
Table A3.4 Composition of HNPSP spending (IDA+ MDTF) (USD, %)
Category Amount in
USD
Percent
Performance Based Financing 58,486,671 9%
Services - NGO, Private 86,678,793 13%
Goods & Equipment 463,069,542 68%
Civil Works (Construction) 23,566,010 3%
Consultancy 7,123,649 1%
Training/Studies 43,628,288 6%
Total 682,552,953 100%
Source: FMRs and Bank System
Absorptive capacity. There is a chronic under spending of MOHFW development
budget. During 2003/04-2005/06 (covered by the Contingency Plan between HPSP and
HNPSP) unspent portion of the development budget halved from 28% to 14% (Table
A3.5). However, since 2005/06 it has been fluctuating. The Program aimed to resolve the
constraints that led to under-spending of the allocated budget. Several steps were taken to
expedite fund release.
Table A3.5 Unspent MOHFW revised development budget (%)
Fiscal year Unspent (%)
2003/04 27.6%
2004/05 17.2%
2005/06 13.6%
2006/07 25.2%
2007/08 17.1%
2008/09 26%
33
Source: PER 2007/08-2008/09, HEU, MOHFW
Annex 3B: HNPSP
HNPSP Expenditure by quarter
During the first two years of HNPSP, expenditure was low due to slow implementation of
program activities as discussed earlier while towards the end expenditure increased with
accelerated implementation of the program. Table (A3.6) shows disbursement pattern
throughout the program period by quarter. In almost every year, expenditure increased in
the last quarter while in the first two quarters, expenditures tended to be low. This may be
due to the fact that there were delays in release of funds to the cost centers.
Table A3.6: Share of Pooled fund expenditure by quarter
Year Q1 Q2 Q3 Q4
2005 - - - 100%
2006 11% 12% 0% 78%
2007 - 49% 7% 44%
2008 74% 8% 17% 0%
2009 40% 5% 0% 55%
2010 0% 19% 0% 81%
2011 0% 48% 49% 3%
Source: FMRs and Bank system
Economic rationale at Appraisal
A formal cost-benefit analysis was included in the PAD. Such analysis is known to be
difficult and is prone to methodological problems including uncertain assumptions.
Another way at looking at this issue is more qualitative as described below.
During the preparation of HNPSP, it was suggested that the program will allocate
increased resources to the poorest Upazilas. During implementation, this indicator was
revised to increase resource allocation to all Upazilas as there were difficulties in
measuring this indicator. The program also focused on reaching the poor and underserved
and investing in known cost effective interventions (e.g. immunization, behavior change
communication on nutrition and NCDs).
The HNPSP also set out to address governance issues that could have reduced wastage
and improved efficiency. Many of these identified at Appraisal had to do with financial
management, yet increasing GOB capacity in FM system strengthening was not included
in the HNPSP.
Furthermore, with a very high level of out of pocket (OOP) expenditure combined with
the market failures in the health sector, improving government stewardship of the sector,
34
as intended, was economically sound. The planned pilots on Demand Side Financing had
the potential of increasing utilization of cost-effective services, which was delivered on.
Implementation implication for efficiency
Most of the economic rationale was maintained throughout HNPSP. And overall the
HNPSP fared well in terms of achieving its goals, including increasing service uptake by
the poor, and sustaining a high proportion of funding spent at the Upazila level (>50%). It
also maintained a focus on poverty and equity, for example when it was decided to fund
civil works these were prioritized towards poor/underserved areas.
Other areas related to efficiency were less successful: diversification was achieved to a
minimal degree. Capacities in financial management and procurement were weak and
during the program implementation capacities were built on procurement and preparation
of timely FMRs. The structure of the HNPSP with its many silo like OPs where
investments often were not sufficiently coordinated caused a number of inefficiencies (as
e.g. documented by the IMED Evaluation).
Financial analysis
The overall HNPSP (pooled funding, i.e. IDA and MDTF) performed well with a much
larger disbursement from the MDTF than originally envisaged, see disbursement profile
below.
$0
$100,000,000
$200,000,000
$300,000,000
$400,000,000
$500,000,000
$600,000,000
$700,000,000
FY 2005 FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012
Original amount Revised amount Cumulative expenditure
35
Sustainability
Funding in the sector was US$ 4-5/capita/year to deliver comprehensive basic services.
Given the results of the sector in terms of more vertical approaches, the performance
could have been improved more with higher levels of funding. Given that the pooled fund
financed a fairly big share of MOHFW revised development budget (56%), sustainability
in the short term would have suffered, if a similar program had not followed HNPSP. In
the longer term GOB should easily be able to sustain a very basic primary health care
focused health system, given the economic growth of 6% and the fact that with the low
proportion of GOB funding going to the health sector, GOB could increase the proportion
it allocates for health if this was considered a political priority.
Cost-Benefit Analysis
The PAD calculated an NPV of US$ 610 million (5 year) and US$ 2,975 million (10
year) and an Internal Rate of Return (IRR) of 21% and 51% for 5 and 10 year horizons.
These calculations are based on the assumptions listed in the table below.
NPV/IRR Assumptions with present value.
Assumption Base/value Year Result Year Achievement
Malnutrition in children
under five years of age
reduced by 14% (MDG)
66% 1990 39% 2010
(FSNSP)27
More than
achieved
Malaria reduced by
30% (MDG)
0.0053
malaria
death rate
per 1000
2003 0.0034 2010 (Health
Bulletin )
Achieved
32% increase in number
of TB cases treated
84%
93%
2010
(NTP)28
HNPSP target
of 95% cure
rate probably
not quite
achieved (93%
in 2010, a year
before HNPSP
finish )
Proportion of people
seeking medical
treatment
89% 2000,
HIES
91% 2010 (HIES) Increased,
which would
only improve
cost-efficiency
Healthcare visits to
public facilities as % of
total
13% 2003,
CIET
Not
Available
Can be
assumed to be
unchanged or
increased
Average days of illness 2 days Not
available
Assumed
unchanged
27Food Security and Nutrition Surveillance Program, BRAC University
28 National Tuberculosis Program (NTP) Annual report
36
Assumption Base/value Year Result Year Achievement
For chronic
disease: 80
months
2000,
HIES
81.4 months 2010 ,(HIES)
Cost of an Essential
Service Package
US$ 34 200129,
WHO
Estimate
remains the
same
Proportion of people
receiving treatment in
public hospitals
6.6% 2000,
HIES
9.3% 2010 , HIES Increased,
which will
only improve
HNPSP cost-
efficiency
Proportion of service
users who attends
government hospitals
2% 2003,
CIET
Not
Available
No CIET
survey
available
after 2003
Given the
above
indicator, this
can be
assumed
unchanged or
increased
GDP per capita growth
rate
3.3% 1990-
2004
avrg.
6.7% 2011 BD
Economic
Review
Higher than
estimated,
which would
influence NPV
and IRR
positively
% of users who receive
inpatient treatment in
public hospitals and
who would be at risk if
they had not received
treatment
5% Not
Available
No reason to
change
assumption
Health sector spending 30would increase in line
with projected expenses
stated in the SIP 2005-
10
Estimated
at 10%
nominal
and 5% real
per year
SIP 14.2%
nominal and
7.6% real per
year
BNHA1997
-2007
Better than
expected,
would
influence cost-
efficiency of
HNPSP
positively
Discount rate 10% Unchanged
assumption
Most of the assumptions have been fulfilled, and furthermore the PAD Sensitivity
Analysis shows a respectable NPV and IRR of US$ 1,288 million and 27% respectively
at a 50% reduction in benefits, it can, therefore, be concluded that overall ,HNPSP has
been a very worthwhile investment.
29 Macroeconomics and Health: Investing in Health for Economic Development, WHO, 2001
30 This refers to Total Health Spending (THE)
37
Annex 4. Bank Lending and Implementation Support/Supervision Processes Task Team Members:
Supervision/ICR
Name Title Unit Responsibility/
Specialty
Md. Mahtab Alam Program Assistant SACBD Administrative
support
Anisuzzaman Chowdhury Consultant SASHD Operations
Shahadat Hossain Chowdhury Program Assistant SACBD Administrative
support
Rafael A. Cortez Sr. Economist (Health) LCSHH Health Economics
Agnes Couffinhal Economist SASHD Health Economics
Md. Raziq Hossain Operations Officer SASHD Operations
Farzana Ishrat Nutrition Specialist SASHD Nutrition
Preeti Kudesia Senior Public Health Specialist SASHD Public Health
Iffat Mahmud Operations Analyst SASHD Operations
Dinesh M. Nair Sr. Health Specialist SASHD Team Lead
Sandra Rosenhouse Sr. Population & Health Specialist. SASHD Public Health
Harvinder Singh Suri Consultant SARPS Procurement
Yolanda Tayler Lead Procurement Specialist SARPS Procurement
Bina Valaydon Health Specialist AFTH1 Public Health
Elfreda Vincent Program Assistant SASHD Administrative
support
Alejandro Welch Information Assistant SASHD Administrative
support
Suraiya Zannath Sr Financial Management Specialist SARFM Financial
Management
Kees Kostermans Lead Public Health Specialist SASHN Team Lead
Albertus Voetberg Lead Health Specialist SASHN Public Health
Sameh El-Saharty Senior Health Policy Specialist SASHN Team Lead
Bushra Binte Alam Senior Health Specialist SASHN Team Lead
Nkosinathi Mbuya Senior Nutrition Specialist SASHN Nutrition
Aparnaa Somanathan Senior Economist EASHH Health Economics
Ramesh Govindaraj Senior Health Specialist SASHN Pharmaceuticals
Tania Dmytraczenko Senior Economist LCSHH Health Economics
Michael Engelgau Senior Public Health Specialist SASHN Non-communicable
diseases
Ruma Tavorath Senior Environmental Specialist SASDI Environment
Teen Kari Barua Consultant SASHN Social safeguards
Marghoob bin Hussein Senior Procurement Specialist SARPS Procurement
Karar Zunaid Ahsan Research Analyst SASHN M&E
Hasib Ehsan Chowdhury Program Assistant SARFM Operations
Nasreen Begum Team Assistant SASHN Administrative
support
Mariam Claeson Program Coordinator SASHN HIV/AIDS
38
Tatyana Klimova Senior Resource Management
Officer SARRM Trust Funds
Maria Gracheva Senior Operations Officer SASHN Operations
Nilufar Ahmad Senior Gender Specialist SDN Social issues
Shirin Jahangir Consultant Social issues
Tahmina Begum Consultant Heath Economics
(b) Staff Time and Cost
Stage of Project Cycle Staff Time and Cost
No. of staff weeks USD Thousands
Lending
FY02 14.45 50.48
FY03 15.05 52.72
FY04 30.53 117.16
FY05 56.89 199.05
FY06 0 0.00
FY07 0 0.00
FY08 0 0.00
FY09 0 0.00
FY10 0 0.00
FY11 0 0.00
FY12 0 0.00
Total: 116.92 419.41
Supervision/ICR
FY02 0.00 0.00
FY03 0.00 0.00
FY04 0.00 0.00
FY05 0.00 0.00
FY06 17.6 48.12
FY07 149.4 359.43
FY08 198.68 645.36
FY09 237.38 834.33
FY10 254.05 774.58
FY11 173.87 216.15
FY12 139.39 324.03
Total: 1,170.37 3,202.00
39
Annex 5. Beneficiary Survey Results
No beneficiary survey was done as part of the ICR. However, the IMED evaluation
(IMED evaluation, pp. 139-145) contained a survey of service recipients at the facility
level and Focus Group Discussions (FGD) at upazila level, a summary of which is
provided below.
Main findings from the interviews with service recipients:
A total of 490 exit clients and beneficiaries of the catchment areas of District Hospitals,
Maternal and Child Welfare Centers (MCWC), Upazila Health Complexes (UHC) and
Union Health & Family Welfare Centers (UH&FWC) were randomly selected for
interview in order to assess the utilization of health and family planning services
provided by the respective health facilities. Among the patients interviewed, 87%
indicated that they have visited the health centers in the last six months, and the main
services sought in the health facilities were treatment for common disease, various
illnesses affecting children, emergency health care, complications during delivery and
side effects of family planning methods. 89% of the patients reported that they were
provided service by MBBS doctors at the facility and the rest by para-professionals or
Family Welfare Visitors (FWV).
The mean waiting time of the patients was 31 minutes and 49% of the patient reported
that privacy was maintained during examination. 90% of the patients reported the service
providers’ behavior as satisfactory/fairly satisfactory, while 3% reported service
providers’ behavior as very unsatisfactory. Majority of the patients suggested that in
order to improve the health services in the public facilities, it is important to ensure
supply of essential medicine, regular availability of the physicians at the facilities,
placement of MBBS doctors, and availability of equipments. Around 80% of the patients
indicated that the services provided from the government health facilities has improved
over time.
Main findings from focus group discussions (FGD) at upazila level:
Seven FGD meetings were conducted at the upazila level. The groups comprised of male
and female patients in selected health facility, Chairperson as well as members of the
Upazila Parishad (i.e. local government body), private physicians, teachers, community
youth leaders, and farmers. All the groups opined that HNPSP was implemented well,
which resulted in marked improvement in a) quality of health services through UHC, b)
availability of doctors, nurses and equipments, and c) supply of essential drugs to the
patients especially to the women, children and the poor.
The groups also identified that there should be more attempts to take the health services
to the door-steps of the poor people and the health workers should be equipped with all
required facilities. Adequate supervision should also be ensured.
40
Annex 6. Summary of Borrower's ICR and/or Comments on Draft ICR
As outlined in the Executive Summary & Chapter 5: “Strengths and Weaknesses of
HNPSP” from IMED Evaluation.
Summary of IMED Evaluation:
1. The Report presents the End-line Evaluation of HNPSP as per the terms of reference
(TOR) prepared by the Evaluation Sector of IMED. HNPSP is the second sector-wide
program of the MOHFW and continued from 2003 to 2011. The implementation of
the Program involved three separate governments: (1) from 2003 to end-2006, (2)
from 2007 to end-2008, and (3) from 2009 to June 2011. Implementation picked up
from 2007 after the APR diagnosed HNPSP as a patient needing intensive care under
the threat of becoming terminally sick. This prompted even the-then Chief Adviser's
Office (of the care-taker government) to establish monthly monitoring of the Program.
The MTR of HNPSP was done in 2008 followed by revision of the PIP and that of all
the 38 OPs for the remaining period. In view of the expenditure patterns, it was
decided to extend the HNPSP for an additional year i.e. upto June 2011, (sec. 1.1).
2. In line with its terms of reference, the End-line Evaluation attempts to assess how far
HNPSP has been able to achieve its declared goals and targets, to identify its
strength and weaknesses and to offer recommendations for 'more pragmatic and
effective implementation of the Program' (sec 1.4).
3. Both quantitative and qualitative data have been used in preparing the Report. Annual
Performance Review (APR) reports and a considerable number of periodic national
surveys and occasional reports provided the secondary material which has been
supplemented by the findings of a quantitative survey, focus group discussions (FGD)
and intensive qualitative interviews with the stakeholders. The findings of the field
survey and interviews are placed at Part III of the Report (sec. 1.5). These are in
broad agreement with, and supportive of, the findings of the national level surveys
and affirm quite high level of user's satisfaction with HNPSP services.
4. Part II of the Report contains studies on a number of OPs prepared by 4 Consultants
covering some of the major OPs dealing with (a) services delivery and with (b) the
services delivery support systems. The service delivery OPs include 3 from DGFP:
Clinical Contraception Service Delivery Program, Family Planning Field Services
Delivery Program and the OP on Maternal, Child and Reproductive Health Services
Delivery Program. 2 OPs from DGHS have been covered: OPs on Essential Services
Delivery and Improved Hospital Services Management. In addition 1 OP on Nutrition
has been included, so that 6 OPs related to service delivery have been covered.
The following OPs on Service Delivery Support System have been covered by the
Consultants: 3 OPs on human resource management along with the investments on
capacity development, spread over a large number of OPs and 3 OPs on PFM and 2
41
on Procurement (Chapter 9). These Reports are also accompanied by an Executive
Summary.
5. The Report presents an assessment of the major impact indicators (Ch.4 and Annex-
D) which shows considerable improvements in health outcomes both for the
achievement of MDG and PRS goals: reduction of maternal and child mortality,
reduction of malnutrition and total fertility rate (TFR), improvements in: CPR, Vit-A
supplementation, women receiving ANC & PNC, delivery at health facility,
assistance by medically trained provider during delivery and the nutritional status of
women and children etc. TB case detection and cure rate was higher than targeted,
while HIV/AIDS had remained low in coverage. The poor performed better thereby
reducing the gap with those in the highest quintile, though the remaining gap is still
very substantial.
6. It is however not possible to apportion these improvements to health sector
interventions or specifically to HNPSP alone. A number of socio-economic factors
seem to have influenced the outcome (sec 1.3). Moreover, the HNPSP represented
only a part of the resources being invested in the health sector: it did not include the
non-public sector; neither did it include all the resources of the MOHFW. In fact, it
did not even include all the development budget interventions of the Ministry: e.g. 11
development projects in Annual Development Program (ADP) (2010-2011) including
the project on Revitalization of the Community Clinics were outside its purview. In
view of its limited boundary, it will be unrealistic to assign the national health
outcomes to effects of HNPSP. However there is an international recognition that
Bangladesh must have been doing something right to achieve the improvements in
health status.
7. The Report has specifically focused on the structure of implementation and co-
ordination in HNPSP (sec. 3.1), with coverage of its monitoring mechanism (sec. 3.2).
The planning, processing and approval of OP, the role of the LD and the various
monitoring mechanisms like APR, APIR, Stakeholders Consultation, the monthly co-
ordination meetings etc. have been highlighted with notes on lessons learnt and
suggestions (section 3.2.4).
8. Strength and weaknesses of HNPSP-both structural and operational-have been
identified (Ch. 5) with recommendations linked to the weaknesses (Chapter 6). The
four Reports on the OPs at Part II also include analysis of weakness and strength with
recommendations for those OPs.
Strengths and Weaknesses of HNPSP (As in IMED Evaluation)
HNPSP is the second program of MOHFW using a SWAp, as mentioned in section 1.1 of
the introductory chapter of this Report. Some of its strengths and weaknesses can be
traced to its inheritance. These appear to fall into 2 broad categories: structural and
operational. Below are some of them, which are not exhaustive but may be representative.
42
1. Strength of HNPSP:
a) Structural- In spite of reservations about certain operational aspects of the
Program, the planners and policy formulators of MOHFW recognize the usefulness
of the SWAp, however limited and constrained it is in coverage of health services
delivery in the sector. They emphasize on the fact that the SWAp allowed them to
concentrate on specified objectives, develop programs to match those objectives, fix
targets for achieving improvements and marshal needed financial resources to
support the various activities for achieving the targets. Moreover, this helped
MOHFW to be in the driving seat while allowing the DPs a broader role in the total
process of planning and implementation of the Program. The SWAp had bestowed
upon MOHFW the responsibility of taking a holistic view of the health sector and
had raised expectations about the Ministry's stewardship role for both the public and
non-public sectors through setting service standards, accreditation and quality
control etc. This had led to increased awareness and ownership of the Program by
MOHFW.
b) Operational-
1. At the operational level, HNPSP provided flexibility to adjust to new
challenges, e.g. the Avian flu or the health risks posed by cyclone Aila etc. and to
develop fully funded program activities to meet those emergencies. Moreover,
Inter-OP fund adjustments could be made based on annual review / assessments to
improve utilization, even though it was felt that there was scope for improving
upon the flexibility in HNPSP operation.
2. HNPSP practiced a 'soft' SWAp which allowed it to mix sector and project
resources to overcome or side-step constraints of accessing 'pooled' funds as
needed. This was used as an option by MOHFW to avoid or to reduce shortfall in
procurement planning, or to address needs which the established processes were
failing to respond to, or to pilot new interventions / approaches.
3. Major health indicators like maternal mortality, child and infant mortality,
population growth rate, CPR (Table 4.1), immunization rate, TB case detection
and cure rate or even the sero-surveillance rate for HIV/AIDS etc. showed
remarkable performance during the program period. See Annex- D for the
achievement of benchmark indicators. Impressive improvements in health
outcomes have been consistently reported by variety of surveys, reports and
studies. It is however common knowledge that a host of conducive socio-
economic factors influenced the positive health outcomes (see section 1.3) and it
would be difficult to apportion the responsibility to only the health interventions.
Yet there is an increasing awareness in international circles that Bangladesh and
MOHFW must have been doing something right to take forward and sustain the
positive trends. There is no better evidence than these to affirm the success of the
policy and programs being followed by MOHFW.
4. During the long HNPSP period, the performance of service delivery- both
MNCH and public health- improved, after initial slow take-off. Utilization of
43
facilities at District and levels below increased without increase in financial
investment, indicating achievement of efficiency gains. Access of the poor to
utilization of public services also improved steadily, even though it remained
considerably lower than that of the highest quintile.
5. Fiduciary risk management consistently improved over time within the
constraints of MOHFW's financial management structure.
2. Weakness and Constraints of HNPSP
Some of the constraints and weaknesses of HNPSP followed from its structure-the way
in which the Program was designed or its activities were structured, while quite a
substantial number of the weaknesses appear to be of operational nature- the way in
which the program and the activities were implemented.
2.1 Structural weakness and constraints
1. The Program design of HNPSP was both complex and rigid. The 4 major
components described at section 2.2 indicate the vastness of its scope and ambition.
The beginning of a policy shift from MOHFW being a 'provider' of health services
to a 'purchaser' was skillfully built into the Program, with provision of institutional
support in the form of 3 private sector agencies assisting MOHFW to take the
necessary steps. The burden of these 'reforms' weighed heavily on the scarce
managerial resources of MOHFW, made more challenging by the political
transitions which took place in end-2006 and again in early 2009. The MTR in 2008
recognized this design-aspect as a major draw-back of HNPSP and suggested re-
designing the Program with emphasis on the service delivery system and a
strengthened support system (to include HR, procurement, M&E and financial
management etc.) The suggestion was not acted upon and the constraints posed by
the mentioned aspects of the Program's design remained to the end.
2. Procurement and funds release posed serious points of contention and
misunderstanding between MOHFW implementers and the fund manager, the
World Bank, throughout the HNPSP period. The dissatisfaction often reached the
planners and policy formulators in MOHFW and this became quite voluble when
the new government took charge in 2009. Delays in procurement processing and in
logistic supply as well as the fund's release conditionalities (involving 3 categories
of payments, the annual conditionalities around release of performance based
financing and the quarterly fund release system through reconciled FMRs etc.)
adversely affected the progress of implementation of the Program. Limited steps
could be taken by MOHFW and the World Bank to reduce the difficulties but both
were hobbled by their built-in institutional inadequacies.
The procedural rigidities connected with delays in procurement and funds release
could be traced mainly to the type of loan which Bangladesh (ERD) negotiated with
the World Bank- an investment loan which reflected perception of higher level of
44
fiduciary risk, as opposed to say, policy lending. PFM system of Bangladesh is the
responsibility of the MOF and the issues connected with perception of fiduciary
risks are beyond the scope of MOHFW. The fact, however, remains that HNPSP
was implemented within the rigidities imposed by the investment loan and suffered
procedural delays and considerable management challenges in smooth
implementation of the Program.
3. The structural divide between the Revenue and Development aspects of budget in
the governmental financial system had serious implications for planning and
implementation of HNPSP. For example, shortage of needed (health) human
resource due to difficulties in creation of posts or in filling up vacancies- both of
which are functions of Revenue budget created shortfall in service delivery as a
constant feature of HNPSP. Systems were not set up to trigger the creation of posts
or the filling of vacancies in the revenue set-up of the Ministry to tie-up with the
creation or upgrading of additional physical facilities (for hospital or medical
training etc.) through HNPSP OPs. This explains existence of newly built physical
facilities failing to provide the planned services due to acute shortage of needed
manpower e.g. doctors, nurses or technicians with specific skills. Development
expenditure through OPs was thus robbed of creating improved service impact due
to absence of synchronization between the Revenue and Development budgets of
MOHFW.
4. Additional structural rigidity was introduced by the way in which each of the 38 OP
was designed as separate units independent of each other. This led to misuse and
misallocation of resources as has been pointed out in sub-sections 3.1.1 and 3.1.2.
Thus, for example, investments through OP on physical facilities were made
without providing those with supply of equipments through OP on Improved
Hospital Management Services. This was made worse by the absence of
coordinated steps for supply of needed human resource on the Revenue side. MTR
2008 and APR 2009 drew attention to the constraints created by the structure of
stand-alone OPs and their 'tunnel' visions.
5. The uncompromising bifurcation of services between the two Directorates-of
Health and Family Planning-from the centre to the lowest service delivery points at
the field level - led to duplication and avoidable wastage of financial and human
resources. Both the MTR 2008 and APR 2009 commented on the negative effects
of the bifurcated services and urged upon improved co-ordination in the absence of
any realistic possibility of providing integrated services. Unfortunately, those who
were MOHFW policy formulators during the planning of HNPSP supported and
contributed to the bifurcation of the services. It is a negative legacy with which
subsequent health programs will also have to grapple with.
2.2 Operational Weakness and Constraints
The operational weakness and constraints could be traced mainly to the ways in which
OPs were planned, processed and implemented, the management’s performance: in
45
procurement, placement and retention of HR, supervision and monitoring of
implementation, MOHFW's stewardship role, quality of service, and governance etc.
1) OPs - planning, processing and implementation:
a. OP Planning: OPs were the main instruments for the content and
implementation of HNPSP. Unfortunately, these were centrally planned,
without any input from or interaction with the field-level implementers. The
top-down planning was accompanied by top-down implementation, without
being responsive to the needs or suggestions originating from the actual
implementers of the programme-activities. There was no scope for learning
from experience. This approach, for example, used a traditional facility-based
resource allocation formula which failed to take into account the specific area-
based needs or the needs of poverty stricken areas. Studies were made with
suggestion to develop more rational resource allocation formula, e.g. based on
population and poverty, but these remained as academic exercise only. Similar
was the fate of studies undertaken with HNPSP funds for the
operationalisation of district plans or LLP, which failed even to generate a
small-scale pilot.
b. OP Processing: The OPs were hastily prepared, processed and approved
(Sections 3.1.1-3.1.3), each OP as self-sufficient stand-alone unit unconnected
with each other. The ill-effects of such an approach have been pointed out in
Section 3.1 and commented upon especially in MTR 2008 and APR 2009.
2) LD - most important manager:
The LD was a key manager of HNPSP. He also provided the basic input for
planning and revising the OP. However, he didn’t have the training, exposure or
institutional support needed to effectively play his role as planner or manager of
implementation. Not even the dozen LDs, each of whom handled over 50 crore
taka worth of programmes under their OPs, had any specialised support for fund
management, disbursement, accounting or reporting. They were not given even a
preliminary orientation to the scope or contents of HNPSP or what constituted a
SWAp. To complicate matters, there were quick turn-over of LDs often: there
were stark examples of 5 LDs within a year for an OP! The choice of a LD was
not based on merit but on seniority, where only an officer of the level of a
Director in the Directorates was given the responsibility. As a result, quite often,
officers became LDs at the fag end of their career when learning new things or
being enterprising or imaginative would be very exceptional. The quality of
leadership from the most important manager of implementation of HNPSP, i.e.
LD, suffered due to deficiency in management support system as well as due to
poorly prepared individual leadership. The same holds true of the LDs in the
Ministry as well.
3) Management Performance:
46
The management's performance in procurement, placement and retention of HR,
monitoring and supervision of implementation in the field, ensuring quality of
service and good governance etc. left scope for considerable improvement.
a. Procurement: Deficiency in procurement planning, processing and tracking
was reasons for complaints and frustrations of most LDs and implementers,
especially against centralised procurement. More unfortunate and counter-
productive was the fact that there were many instances where procured
equipments or drugs were allocated to places or institutions which had no use
for them either because they did not need those or because the required
technical staff/resources for their operation were not made available. A survey
of procured equipments by the World Bank found considerable wastage of
HNPSP resources due to uncoordinated central procurement. (Bangladesh
Equipment Survey, 2008, WB)
b. Placement and Retention of HR: Given the fact that there is overall shortage
of health service providers in the public sector- doctors, nurses and
technicians, there is a pressing need to make judicious and equitable use of
this critical input for ensuring promised service delivery. In spite of the
widespread recognition of this need, the MOHFW management failed to
evolve a system for national placement and retention of service providers. The
rural and hard-to-reach areas continued to remain at the receiving end, while
the absence of appropriate skill-mix deprived the people of services for which
investments had been made e.g. emergency obstetric care services. MOHFW
made attempts from time to time to address the problem, but these were
neither consistent nor driven by legal or ideological compulsion.
c. Monitoring and Supervision of Implementation: Like planning, monitoring of
implementation in HNPSP was concentrated at the Centre, with little
opportunity or responsibility to the other tiers of MOHFW structure like the
Division, District or Upazila managers. MIS data originating from the ward
level (by the Health Assistant/ Family Welfare Assistant) travelled upward all
the way to the Directorate HQ (of DGHS and DGFP) where these got
aggregated, but the field implementers had little scope to utilise them in
programme monitoring. Neither were these used at the monthly co-ordination
and review meetings held at the level of Secretary MOHFW or of the DGs at
the 2 Directorates. At the field level, there were no systemic requirements for
regular and periodic supervision. As a result, no Supervision Manual or
guideline was developed. Monitoring was restricted to one-way reporting
from the field to higher levels, with little systematic feedback from those
levels or from the LD or the DGs. The Ministry's M&E Cell had little role to
play in analysing the MIS data, the field reports or the monthly IMED reports
sent by the Planning Wing of MOHFW. Neither did IMED prepare or discuss
Monitoring Report on HNPSP with MOHFW. Monitoring and Supervision
remained a neglected activity in HNPSP.
47
d. Quality of Service and Good Governance: Quality of service and good
governance suffered partly due to absence of an established regime of field-
level monitoring and supervision. It was also partly a result of absence of
quality-culture. The OP on quality assurance did develop Quality Manuals in
the form of Standard Operating Procedures for different health facilities and
conducted training workshops to orient and train the service providers at some
districts and upazilas. However, these were not implemented and put into
practice. While the top managers did not possibly feel it important and urgent
enough for introduction, there was no community pressure or demand from
the public representatives associated with the Management Committees of
those facilities. The community's voice had little institutional role in HNPSP
for improving service quality or poor governance e.g. absenteeism, informed
payments, non-receipt of available service or mistreatment, etc.
4) MOHFW's stewardship role:
MOHFW is not merely the public service provider but also the regulator for all
service providers: public, private, NGOs etc. The private sector's role has been
gradually expanding in providing medical education (for doctors, nurses,
technicians, etc.), hospital and clinical services and in drug production etc. So has
been the NGO's role in piloting new technology, new medicine, new service
delivery methods and targeting the disadvantaged people or hard-to-reach areas
etc. The quick expansion of the non-public sector has raised issues about
standards and quality and the need for the Government to ensure that the public
receives an assured and dependable service. MOHFW exercises its role as
regulator through enactment of laws and through institutions specifically created
to administer those laws e.g. BMDC, BNC and SMF for registration of doctors,
nurses and paramedics respectively. The expanding non-public sector is making
demands on the capacity and resources of the regulators, for which they are not
adequately equipped and resourced. Accreditation and standard-setting are crucial
for ensuring quality for the private and the public sector as well. MOHFW had
failed to take major steps during HNPSP period to convince that it took its
stewardship role of the health sector as seriously as needed.
5) Response to New Challenges:
Increasing and rapid urbanisation together with improving income are posing
serious health challenges in the form of the NCDs like hypertension, diabetes, etc.
while drawing attention to inadequate public service provisions for the expanding
number of urban dwellers. HNPSP identified both as important areas of concern
but failed to take adequate steps to address these. The OP on NCD was inadequate
in leadership, programmes and implementation while MOHFW failed to take
meaningful steps to establish an urban health strategy or engage the Ministry of
Local Government for joint initiatives in addressing the challenges of urban
health.
6) Absence of Strong Leadership of HNPSP:
48
The SWAp expects strong leadership from the Government while the DPs provide
support- both financial and technical for the successful implementation of the
sector programme. The Annual Programme Reviews lamented the absence of
ownership of HNPSP by the senior leaders of MOHFW particularly during the
APRs of 2006 and 2007. Things improved since then but no follow-up action was
taken by MOHFW on recommendations by the APRs for branding HNPSP or
developing a communication strategy for its recognition by the service providers
and recipients. Instead of the MOHFW leadership, the APRs became the main
source of dynamism in performance evaluation and establishing the future course
of action for the year. Similarly, the Task Groups for different functions (see sub-
section 3.2.3.3) failed to yield optimum service in the absence of adequately
prepared government leadership.
MOHFW felt diffident in taking up and resolving problems HNPSP was facing
regarding release of funds, procurement processing, sudden personnel changes,
uncertain reporting by parallel funders and similar other issues involving other
Ministries of the Government (like M/O Finance, M/O Establishment, etc.) and
those involving the World Bank or the DPs. The need of SWAP for different
dispensation separate from a project was not systematically made at inter-
ministerial levels by MOHFW.
49
Annex 7. Comments of Co-financiers and Other Partners/Stakeholders
KfW (reproduced verbatim):
General remarks:
The draft report gives an interesting overview on the program implementation.
We share the same points of view in many respects. However, we have a few
remarks on the draft.
The report concludes that most implementation activities focused on the delivery
of medical services and that there were not many activities in favour of health
systems reform or for health policy development. Apparently, there was a lack of
real policy dialogue among others also between donor and MoHFW. In the
“lessons learnt” the importance of political dialogue and system reforms are again
emphasized. However, in the document we miss an analysis on the hindering
factors and how they could be overcome.
There are a number of institutional reform areas in the health sector in Bangladesh.
Health services could gain a lot of efficiency if the institutional problems would
be overcome. In the draft report, you find some indications of some of them but
the report does not go very far when discussing those very critical issues of
institutional modernization.
The draft report describes the project implementation from the WB perspective.
However, the donor arrangements and the cooperation between all development
partners (pooling and non-pooling funders) could have been analysed more in
detail.
It seems that the revision of PDO indicators and outcome indicators in 2009
translates the lowering of the expectations concerning the program results. If one
had not done this, the assessment would have been not so good.
On page 9 of the draft, the revenue and development budgets are described.
However, the risks involved with that budget presentation is not clearly spelt out
including the untimely release of the revenue budget information. We consider the
timely presentation also of the revenue budget as an essential element of
transparency. If we want to assess the performance of MoHFW, we need to know
whether they have been able to mobilize their own resources in time. If those
budgets are structured in, different ways both are spent by the MoHFW.
As for the procurement issue (page 14), a few problems are pointed out
concerning the tender documents. We also want to know whether the procurement
entities have prepared needs assessments and whether those needs assessment
were checked.
Specific remarks:
The list of abbreviations is incomplete. I could not find the following
abbreviations: CSO, DO, MSA, MS, and SIM.
On page 8 they talk about six critical actions taken by the GOB and DPs. Those
actions are not disclosed in that text section. I suggest indicating them.
Annex 1, table b: Please write for Germany: “Germany: German Development
Cooperation through KfW”
50
DfID (reproduced verbatim):
The report provides a relatively balanced narration of the implementation
environment, strengths and constraints of the last SWAp. However as an internal
World Bank assessment of progress and received nearly a year after the
completion of the last sector programme in June 2011, this may have limited
practical usefulness.
What is striking in the report is that significant statistical progress seems to have
taken place in all of the key indicators during the last sector programme yet the
data comes largely from Government’s own systems. For example, progress on
indicators like “percentage of Districts with disease surveillance systems”, “TB
cure rates” are generated by the Government information systems while public
expenditure reviews are done by the Health Economics Unit of the MoHFW itself.
The lack of third party verification or triangulation of data and results
continues to be a concern deepened by the recognition of overall ‘weak internal
controls…’ and limited progress in M&E in the sector.
A second concern is that 71% of pooled funds were expended on capital
investment, yet there is no system for performance or operational audits (only
financial audits are conducted).
Although there were (and continue to be) Annual Performance Reviews that
include independent reviewers, the report states: “not all recommendations
provided by the independent team (APR) were implemented due to various
constraints in the Government system….”. However the constraints were not
explained.
Finally, the report states that Bangladesh is on track to achieve MDGs 4 & 5
according to the BDHS and BMMS results, but it remains unclear how much is
attributable to the public sector through the SWAP. This is in part because of the
considerable private sector health provision in Bangladesh, some of this by public
providers themselves, goes largely unmentioned.
Sida (reproduced verbatim):
Although there have been significant achievements in the health sector but the
experience of the second health sector programme, HNPSP, shows that
weaknesses remain.
The result framework shows many of the targets are not achieved or achieved
partially despite of changing initially set targets. Disparities between poor and
not-so-poor have increased at the sub-regional level, and inequity in access to
quality social services remains a challenge.
Gradual decline of health budget is another area of concern. MOHFW’s total
budget is a proxy for the total HNPSP budget and it reflects government’s priority
and political will. This budget is increasing in nominal terms, more than 10
percent per year since 2008/2009. But inflation is 10.5 percent that indicates real
increases are less impressive.
Systemic problems include overly centralized health system, weak governance
structure and regulatory framework, inefficient allocation of public resources,
lack of regulation of the private sector, and a shortage of human resources for
health. Progress in the health sector reform is very low and need to be fully owned
51
by GOB and supported by adequate technical assistance. Policy dialogue needs to
be more inclusive.
The funding modality of HNPSP took a cautious approach to fiduciary risks. It is
in principle similar to the financing mechanisms used in very difficult
environments and provides a relatively high degree of assurance that donor funds
will be properly and effectively used. However, the modality risks achieving less
significant improvements in Bangladesh’s PFM systems, imposing higher
transaction costs on GoB and reducing sustainability compared with a more
aligned support. Sweden and like-minded donors will encourage GoB system
improvement during the programme and if possible greater alignment.
The experience of the previous sector programme makes it clear that donor
government coordination and coordination among donors must be revitalized, in
particular to increase alignment and harmonization. A significant share of support
to the health sector is provided through parallel mechanisms, not necessarily
consistent with the sector programme, on budget, or even on plan. Sida considers
this an area of improvement. Global health and GAVI funds were outside the
sector policy dialogue, although they are on budget. Civil society is not truly
involved in sector coordination mechanisms.
Embassy of the Kingdom of the Netherlands ((reproduced verbatim) :
The ICR looks fine and informative
EKN is not mentioned in the list of Abbreviations and Acronyms
52
Annex 8. List of Supporting Documents
The following are the main documents used for the ICR:
Begum T & T Dmytraczenko: Public Expenditure and Institutional Review of HNP
Sector, March 2008.
Chowdhury ME et al: Determinants of reduction in maternal mortality in Matlab,
Bangladesh: a 30 year cohort study, The Lancet 2007
Scanteam: Options for Aid modalities for the Health sector pool fund mechanism, Final
Draft Report, Scanteam Feb. 2011
HLSP: “Performance Monitoring Frameworks in the Health Sector. Country Notes:
Bangladesh”. Undated, HLSP Institute.
HNPSP: Bangladesh Health, Nutrition and Population Sector Program, Annual Program
Review 2006, IRT April 2006
HNPSP Annual Program Review 2006: Aide Memoire, April 2006
HNPSP Annual Program Review 2007, Report by the Independent Review Team (IRT)
(vol. I & II), April 2007
HNPSP Annual Program Review 2007: Aide Memoire, April 2007
HNPSP: Bangladesh Health, Nutrition and Population Sector Program, Mid Year Stock-
take, November 5-18 2007
HNPSP Mid-term Review, Report by the Independent Review Team (vol. I & II), April
2008
HNPSP Mid-term Review 2008: Aide Memoire, April 2008
HNPSP Annual Program Review, Report by the Independent Review Team (vol. I & II),
May 2009
HNPSP Annual Program Review: Aide Memoire, May 2009
HNPSP: Aide Memoire: 2010 Light Touch Annual Program Review of HNPSP, July
2010
MoP: End-Line Evaluation of Health, Nutrition and Population Sector Programme
(HNPSP), by Implementation Monitoring & Evaluation Division (IMED), Ministry
of Planning, September 2011
53
Kostermans K & P Geli: The Sector Wide approach in Action: The Example of
Bangladesh Health, Nutrition & Population Sector; SASHD, World Bank - undated
MoHFW: Bangladesh National Health Accounts 1997-2007, Health Economics Unit,
Ministry of Health and Family Welfare, December 2010
MoF: Monthly Fiscal Reports of various years, Ministry of Finance Website
MoHFW: Public Expenditure Review of the health sector 2003/04-2005/06, Health
Economics Unit, Ministry of Health and Family Welfare, October 2007
MoHFW: “Annual Program Implementation Report (APIR) 2009; M&E Unit. MoHFW
April 2009
MoHFW: Public Expenditure Review of the health sector 2007/08-2008/09, Health
Economics Unit, Ministry of Health and Family Welfare, October 2011
MoHFW: Health Bulletin 2011, Directorate General of Health Services, Ministry of
Health and Family Welfare, March 2011
NIPORT: Utilization of Essential Services Delivery (UESD) Survey 2010, National
Institute of Population Research and Training, Ministry of Health and Family
Welfare, August 2011
NIPORT: Bangladesh Maternal Mortality Survey 2010 (preliminary report), NIPORT
and MEASURE Evaluation, February 2011
Vaillancourt D: Do Sector Wide Approaches Achieve Results? Emerging Evidence and
Lessons from Six Countries; World Bank IEG Working Paper 2009
World Bank: Project Appraisal Document for Health, Population and Nutrition Sector
Program (HNPSP), Report No: 31144-BD, March 2005
World Bank: HNPSP Implementation Status and Results (ISR), seq no. 16, November
2011
World Bank: Country Assistance Strategy, 2006-2009
World Bank: Country Assistance Strategy, 2011-2014
World Bank: Implementation Completion and Results Report: Guidelines; OPCS, World
Bank August 2006 – updated 10/05/2011.
World Bank: Bangladesh Public Expenditure & Institutional Review Vol I & II, June
2010
54
Annex 9. Results Framework of HNPSP (overall program indicators)
Results Framework of HNPSP (2003-2010), REVISED on July 2008
Indicators
Status Target Achievement
Using Benchmark as baseline.
Benchmark
with
reference
period
2004 2010 2010
COMPONENT I: ACCELERATING ACHIEVEMENT OF MDG/PRS OUTCOMES
a) Impact / Outcome Indicators
Infant Mortality Rate (IMR) 94 (1990)
65
BDHS 2004
45
BMMS 2010 37* 86%
Neonatal Mortality Rate (NMR)
52
BDHS 1993-
94
41
BDHS 2004
32
BMMS 2010 30* 91%
Under Five Mortality Rate (U5MR) 151 (1990)
88
BDHS 2004
56
BMMS 2010 52* 96%
Maternal Mortality Ratio (MMR) 574 (1990) 320
BMMS 2001
194
BMMS 2010 240* 113%
% U5 underweight (6-59 months) 67 (1990) 47.5
BDHS 2004
38.6
FSNSP 2010 34* 86%
% U5 stunted (24-59 months) 54.6
BDHS 1996 43.0
BDHS 2004
35.5
FSNSP 2010 30* 78%
Total Fertility Rate (TFR)
3.4
BDHS 1993-
94
3.0
BDHS 2004
2.5
BMMS 2010 2.2 75%
b) Output Indicators
TB Case Detection Rate 41.0
NTP 2003 46
NTP 2004
74.0
NTP 2010 75 97%
TB Cure Rate 83.7
NTP 2003
85
NTP 2004
92.0
NTP 2010 95 73%
% children (under 1yr) fully immunized 52.8
CES 1999/00
73
CES 2003
80.0
CES 2011 85 84%
Percentage of newborn protected at birth
against tetanus
83
CES 1995
86
CES 2003
91.3
UESD 2010 95% 69%
% Children 1–5 receiving Vita-A
supplements in last 6 months
73.3
BDHS
1999/00
81.8
BDHS 2004
92.2
CES 2011 >90% 114%
Utilization rate of ESD of the two Lowest
Income Quintiles
a) % of Births
attended by skilled
personnel (by wealth
quintiles)
Total 12.1
(1999/00)
13.4
BDHS 2004
26.5
BMMS 2011 50%
Lowest
Quintiles 3.5 (1999/00) 3.3
BDHS 2004
11.8
UESD 2010 10% 128%
b) % ANC by
medically trained
providers (by wealth
quintiles)
Total 33.3
(1999/00)
48.7
BDHS 2004
56.0
UESD 2010 75%
Lowest
Quintiles 19.4
(1999/00) 24.9
BDHS 2004
40.3
UESD 2010 40% 104%
Contraceptive Prevalence Rate – CPR
(modern methods)
43.4
(1999/00) 47.3
BDHS 2004
54.1
UESD 2010 72 (any)
60 (modern) 64% (modern)
% eligible couple/women on Long Lasting
Birth control methods 8.9 (1999/00)
7.2
BDHS 2004
7.4
UESD 2010 9.3 Negative (10% if compared to
2004)
55
Indicators
Status Target Achievement
Using Benchmark as baseline.
Benchmark
with
reference
period
2004 2010 2010
COMPONENT II: MEETING HNP SECTOR CHALLENGES
Tobacco usage among
men and women aged
15+ (%)
Smoking
tobacco NA
20.9 (2004)
WHO(SEAR
O) 2007
23.0
GATS 2009 15%
Not achieved
Smokeless
tobacco NA
19.7 (2004)
WHO(SEAR
O) 2007
27.2
GATS 2009 15%
NCD strategy developed and implemented
as per details in RFW Nil
Strategy not
developed
Strategy
developed and
updated; NCD
risk behavior
survey
conducted;
NCD piloting
and Injury
piloting
activities are
incorporated
into
Operational
Plan
Implemented
& indicators
identified
Achieved
Share of total government expenditure
allocated to MOHFW expenditure 6.5% (2004) 6.5%
6.7 (2007/8)
APIR 2009 10% 6%
COMPONENT III: HNP SECTOR MODERNIZATION
Budget management
Proportion of total MOHFW expenditure
allocated to the 25% poorest districts NA NA
15% (2006-
07)
APIR 2009
40% Not achieved
MOHFW expenditure on medical and
surgical requisites at districts and below NA 9%
67%
(FY06/07)
APIR 2009
- Achieved (although no target)
% of MOHFW expenditure at upazila and
below NA 51%
47%
PER 2008/09 >50%
40% (see section F under key
data sheet)
% serious audit objections (part a of audit
report) settled within the last 12 months NA NA
100%
FMAU (2011) 100% 100%
Diversifying service provisions
HNP services commissioned to non-public
providers by MOHFW NA NA NA - N/A
Decentralized planning
Pilot on management autonomy in 6
district hospitals and 14 UHCs Nil Nil
6 districts
(Strat Plan
2011)
6 district
hospitals & 14
UHC
100%
Pilot LLP at 6 districts and its Upazilas
and FY 2009 budget to reflect these pilots Nil Nil
Not done
(IMED 2011)
6 districts &
Upazila below 100%
Demand side financing
% of women targeted by voucher scheme
delivered by SBA (at facility or home) NA NA
64%
(DSF Eval.
2010)
60% 107% (no baseline)
56
Indicators
Status Target Achievement
Using Benchmark as baseline.
Benchmark
with
reference
period
2004 2010 2010
Aid management
# of DPs reporting their planned
expenditure on HNP sector (annually) NA NA NA 100% Achieved
# of DPs reporting their actual expenditure
on HNP sector (quarterly) NA NA NA 100% Achieved
Procurement
% of contracts awarded within initial bid
validity period:
For NCB b) For ICB
93%
(2005/06)
APIR 2009
93%
(2005/06)
APIR 2009
80%
APIR 2010 90% Not achieved (declined)
Monitoring and evaluation
MIS (Health &
FP) delivering
management
information to
agreed
specifications
Coverage of disease
profile by
upazila/district
facilities
NA NA 98%
APIR 2010 100% 95% (no baseline)
% Districts with
Disease Surveillance
Reports
NA 52% (2006) 95%
APIR 2010 100% 89% (using 2004 as baseline)
* Calculated in line with MDG 2015 targets