Health, Nutrition and Population Strategic Investment Plan (HNPSIP) 2016 – 2021

Section 1: Introduction 4 1.1 Better Health for a Prosperous Society 4 1.2 Scope of the 4th Sector programme 4 1.3 The Policy Context 4 1.4 Population and Demographic Transition 6 1.5 The State of the Nation’s health 7 1.6 Governance and Stewardship of the health sector 11 1.7 Strengthening health systems 12 1.8 Financing the health sector 15 1.9 Health, nutrition and population services 16

Section 2: A Progressive and Inclusive Agenda for the 4th Sector Programme (HNPSIP 2016-20) 23 2.1 Vision, Mission and Goal 24 2.2 Guiding Principles 24 2.3 Strategic Directions 24 2.4 Cross-cutting issues 26 2.5 Partnerships for health 27

Section 3: Strategic Priorities for the 4th Sector Programme 29 3.1 Component 1: Governance and Stewardship 29 3.2 Component 2: Health systems strengthening 32 3.3 Component 3: Provision of quality health services 36

Section 4: An Essential Health Service Package – The first milestone on the road to Universal Health Coverage 40

Section 5: HNPSIP Implementation and Performance Management 43 5.1 Organisation and management 43 5.2 The HNPSIP Documentation 45

Section 6: Indicative Budget for the 4th Sector Programme 47 6.1 Government Expenditure Trends in the HNP Sector 47 6.2 HNPSIP Expenditure Structure and Budget Implementation 49 6.3 Resource Envelope for the 4th sector programme 50 ii Annexes Annex 1 Essential Services Package 52 Annex 2 4th Sector Programme Results Framework 60 Figures Figure 1: Fertility trend and future scenario 6 Figure 2: Regional variation in TFR 6 Figure 3: Demographic composition (changing age structure) 7 Figure 4: Bangladesh on-track for MDG 5 8 Figure 5: Leading Causes of Mortality and Morbidity in Bangladesh, 2010 Estimates 8 Figure 6: Causes of female death (15-49 year olds) 9 Figure 7: 4th Sector Programme documentation 46 Figure 8: MOHFW Expenditure: Non-Development and Development 47 Tables Table 1: Low Scenario Resource Envelope (in Crore Taka) 49 Table 2: Moderate Scenario Resource Envelope (in Crore Taka) 50 Table 3: Optimistic Scenario Resource Envelope (in Crore Taka) 51 Table 4: Resource Envelope for the 4th Sector Programme 51 iii PREFACE The health, nutrition and population (HNP) Strategic Investment Plan (SIP) has identified the key investment areas required to accelerate the pace of development in the HNP sector in Bangladesh in line with the Sustainable Development Goals (SDG) and targets, and the 7th Five Year Plan (2016- 20) strategies of the Government of Bangladesh. The goal is to ensure that quality HNP services are delivered and key services are provided more effectively, with focus on equity. The longer- term aim is to move towards achieving universal health coverage (UHC) as targeted in SDGs. This SIP is the culmination of a process, led by Ministry of Health and Family Welfare (MOHFW) that began in 2015 with extensive consultations with the sector’s stakeholders including development partner (DP) representatives. A set of analytical studies and assessments including surveys were undertaken to identify gaps and continuing challenges. These findings also provided essential inputs to address new priorities and challenges relating to demographic and epidemiological transitions; expanding private investments in health service and medical education; increasing out of pocket expenditure; and a social environment of rising public expectations. The SIP sets out an analysis of the sector’s performance and the prime issues that are needed to be addressed. The SIP has been prepared by MOHFW with the intention to define an overall strategic framework to guide investments in the HNP sector. Guiding principles of the SIP are to address new and continuing challenges through (a) emphasizing service quality, (b) improving efficiency in resource use and reducing wastage; and (c) focusing on equity. Moreover, learning experiences during the last five years of implementation of HPNSDP had also contributed to generate information and understanding for the development of this SIP with a view to improving access, utilisation, poverty targeting and service quality. The SIP has also developed results framework (RFW) indicators for assessing progress against three components, namely (i) strengthening governance and stewardship, (ii) strengthening HNP systems, and (iii) improving service quality. The SIP highlights essential service package (ESP) and improved financial coordination as tools for achieving efficiency and equity. An important proposition underlying this SIP is that MOHFW has strategic stewardship and management roles that extend beyond the services it finances or provides directly. As a result, this SIP is sector-wide in scope, covering services related to health, family welfare and nutrition in both rural and urban areas and at primary, secondary and tertiary levels, whether provided by Government, private or NGO providers. MOHFW is to exercise its constitutional mandate to contribute more effectively to public priorities in the HNP sector. The hallmark of success will be that all Bangladeshi women and men have access to health services that extend life and improve its quality. The SIP sets out what the sector’s medium term priorities and strategies are and why. Its purpose is to create the basis for preparation of the Programme Implementation Plan (PIP) and future Operational Plans for the 4th Sector Programme for five years covering financial years from 2016/17 to 2020/21. I hope that while the PIP and the OPs are developed for the new sector Program in line with the agreement around SIP objectives and strategies, the Development Partners will also find SIP as a useful document for participation in financing the new Program. I congratulate all belonging to the GOB and DPs who contributed to the demanding process of developing the SIP. I expect, on behalf of the Government of Bangladesh, that our joint endeavour of “Better Health for a Prosperous Society” will be fruitful. iv ACRONYMS AND ABBREVIATIONS ADP Annual Development Programme AIDS Acute Immune Deficiency Syndrome MA4H Measurement and Accountability for AMC Alternative Medicine Care Results in Health ANC Ante Natal Care MAD Minimum Adequate Diet BCC Behaviour Change Communication MCU Maternal and Child Under-nutrition BDHS Bangladesh Demographic & Health Survey MCWC Maternal and Child Welfare Center BENAP Bangladesh Every Newborn Action Plan MDGs Millennium Development Goals BNNC Bangladesh National Nutrition Council MMR Maternal Mortality Ratio CGA Controller General of Accounts MNCH Maternal, Neonatal and Child Health CMSD Central Medical Store Depot M&E Monitoring and Evaluation CSBA Community Skilled Birth Attendants MOCHTA Ministry of Chittagong Hill Tracts Affairs CC Community Clinic MOF Ministry of Finance C-EmOC Comprehensive Emergency Obstetric Care MOHFW Ministry of Health and Family Welfare CHCP Community Health Care Provider MOPA Ministry of Public Administration CHT Chittagong Hill Tracts MPIR Mid -Term Programme Implementation Report CPR Contraceptive Prevalence Rate MR Menstrual Regulation CVD Cardiovascular Diseases MSR Medical and Surgical Requisites DALY Disability Adjusted Life Years MTR Mid-Term Review DBM Disease Burden of Malnutrition MTBF Mid Term Budgetary Framework DGDA Directorate General of Drug Administration NCD Non-Communicable Diseases DGFP Directorate General of Family Planning NEMEMW National Electro-Medical Equipment DGHS Directorate General of Health Services Maintenance Workshop DH District Hospitals NES Nursing Education and Service DP Development Partner NMR Neonatal Mortality Rate DPA Direct Project Aid NPAN National Plan of Action on Nutrition DRS District Reserve Stores NSSS National Social Security Strategy DSF Demand Side Financing NTD Neglected Tropical Disease ESP Essential Service Package NIPORT National Institute of Population EU European Union Research & Training FAPAD Foreign Aided Project Audit Directorate OCA Organisational Capacity Assessment FDI Foreign Direct Investment OOP Out of Pocket FY Financial Year OP Operational Plan FYP Five Year Plan PHC Primary Health Care FWA Family Welfare Assistant PIP Programme Implementation Plan FWV Family Welfare Visitor PMMU Program Management & Monitoring Unit FMAU Financial Management and Audit Unit PW Planning Wing GATS Global Adult Tobacco Survey PLMC Procurement & Logistics Management Cell GDP Gross Domestic Product PNC Post Natal Care GNSPU Gender, NGO and Stakeholder PPP Public Private Partnership Participation Unit PSE Pre-service Education GOB Government of Bangladesh PWD Public Works Department HA Health Assistant R&D Research & Development HBB Helping Babies Breathe RFW Results Framework HED Health Engineering Department RPA Reimbursable Project Aid HEU Health Economics Unit SBA Skilled Birth Attendant HFS Health Financing Strategy SCANU Special Care Newborn Unit HIS Health Information System SDGs Sustainable Development Goals HNP Health, Nutrition and Population SSK Shasthyo Shuroskha Karmasuchi HNPSIP Health, Nutrition and Population STG Strategic Thematic Group Strategic Investment Plan SOP Standard Operating Procedure HPNSDP Health, Population and Nutrition Sector SWAp Sector Wide Approach Development Programme TB Tuberculosis HRH Human Resources for Health TFR Total Fertility Rate HRM Human Resource Management THE Total Health Expenditure iBAS Integrated Budget and Accounting System TMIS Training Management Information System IMR Infant Mortality Rate TOE Table of Equipment IST In-service Training U5MR Under Five Mortality Rate IUFR Interim Unaudited Financial Reports UHC Universal Health Coverage LAPM Long Acting and Permanent Methods UH&FWC Union Health & Family Welfare Center LARC Long Acting Reversible Contraceptive WASH Water, Sanitation and Hygiene LD Line Director WB World Bank WHO World Health Organization v EXECUTIVE SUMMARY The Fourth Five-year Health Sector Programme as outlined in this Health, Nutrition and Population Sector Strategic Investment Plan (HNPSIP) 2016-21, calls for a substantive change in the way the sector is organised and managed. It recognises the need to expand existing services to currently underserved groups, including adolescents, the poor and those in urban and hard to reach areas. It recognises the need to continue to work on stabilising population growth through education and family planning services. It also recognises the demographic and epidemiological transitions taking place that require government and its partners to address emerging health challenges and to work more closely with other sectors whose actions have a direct bearing on health and health outcomes. This plan is underpinned by the commitment of government to safeguard and improve the health of all the population and establish more equitable access to health services. It recognises the important international initiatives and the need for alignment with national commitments, such as the Sustainable Development Goals (SDGs), for achieving these. As such the plan is consistent with the emerging priorities articulated in the SDGs, particularly those are relevant to health and well- being, while building on the gains already made towards achieving the Millennium Development Goals (MDGs). It aligns with the broader national policy framework as set out in the 7th Five-year plan and national policies on health, nutrition, population and social protection. The 4th Sector Programme starts at a time of transition from the MDGs to the newly agreed SDGs. While this reinvigorates the national and international dialogue and support for development it has particular risks and challenges for the health sector. The MDGs had a major focus on health sector specific goals whilst the SDGs encompass a much broader agenda for change. Some of the new SDGs are strongly related to the determinants of health (such as SDG 2 on nutrition and SDG 6 on WASH) as well as there being a health specific SDG (Goal 3). This opens up new opportunities for the Ministry of Health and Family Welfare (MOHFW) and its partners and in response the 4th Sector Programme calls for more action on the underlying causes of ill-health and the need to tackle issues of lifestyle and the environment as well as providing high quality curative care services. The MOHFW cannot do this alone since this needs to build a broad coalition of government, private sector and communities. Over the period of the MDGs Bangladesh has made remarkable progress in improving health outcomes as demonstrated by the reduction in maternal mortality (MDG 5) and child mortality (MDG 4). This sets the stage from where Bangladesh can now ambitiously look forward towards attaining the Sustainable Development Goals through ensuring universal health coverage, meaning – an end to inequity in health care. There is now good consensus on the future direction and focus for the health sector. The HNPSIP aims to both consolidate and sustain the achievements gained so far, and strive for more progress on health outcomes through further improvement in access to services, strengthening of core systems and ensuring continuous quality improvement. Expanding and strengthening the country’s comprehensive Maternal, Neonatal, Child and Adolescent health care approach (MNC&AH), including sexual and reproductive health services, is therefore being maintained as a priority and a crucial part of the government’s efforts to incrementally reduce morbidity and mortality and to ensure the well-being of the population (STG MNCH, 1 2015) 1. At the same time, the country has to prepare for addressing demographic and epidemiologic transition that will shape the need of the population during this sector programme and the subsequent ones. The focus of SDG 3 is to reach universal health coverage, and this calls for strengthening public health care services in order to increase utilization of quality primary health care by the poor and those living in geographically challenged areas. In order to effect the changes outlined in the HNPSIP the MOHFW has set out an agenda to move towards a stronger governance and stewardship role that will be needed to ensure that all health sector stakeholders including the expanding for-profit private sector adhere to policies, procedures and quality standards. More emphasis will be given to regulation and building transparency and accountability across the sector. This will in turn require substantive changes in the way the MOHFW is set up, a programme to develop capacity in governance, leadership and management areas across government departments and agencies, and a new partnership-based relationship with the private sector. In particular more emphasis will be needed on ensuring that the required skills in public health are available as are strategies for building community ownership and participation. The HNPSIP advocates for a comprehensive and well managed district and sub-district arrangements built around an effective functional integration of health services. This will be underpinned by sound management and planning, coordination and accountability and the need for a progressive roll-out of an essential health services package for all. These call for a renewed emphasis on providing good quality services to the most marginalised and those in hard to reach places. This will require innovative approaches, a motivated and skilled workforce and close collaboration with the private sector. Improvements in quality, equity and efficiency across the health service are a prerequisite to attaining Universal Health Coverage (UHC). The sector programme recognises the importance of heading off the severe consequences of the rapid rise in Non-Communicable Diseases (NCDs) through a shift in emphasis towards public health and a creative lifestyle change programme and coordinated multi-sectoral action to improve nutrition, environmental conditions through work on road safety, food safety, air and water pollution and agricultural practices that are currently undermining health. It also recognises the need to improve social norms, reduce harmful practices, improve gender relations and tackle the rising mental health problems in rural and urban settings. The HNPSIP emphasises that more flexibility is needed if services are to be provided to those currently excluded or living in hard to reach areas. This flexibility includes seeking means of protecting the poor from often ruinous out of pocket expenditure on health services and medicines. Through risk protection programmes, better regulation and improvement in service quality more people will be given better access to care. As part of this approach national and local decision-makers will be encouraged to explore diverse and flexible partnerships to extend coverage of services through working more closely with the private for-profit and not for-profit sectors, including community participation/support. The challenge for the sector is to prevent ill health and provide better services for all within a heavily constrained financial environment. The government allocations to health remain low 1 MoHFW (2015) Report of the Strategic Thematic Group on MNC&AH. Report prepared as part of the 4th Sector Programme preparation process. 2 in terms of regional comparisons while performance is high. The MOHFW will like to concentrate on demonstrating improved performance across the sector and building the investment case for health funding as a foundation for future growth in the national prosperity. Achieving sustainable levels of financing for the sector will depend on a combination of managing the demand for health care through prevention and effective treatment, seeking efficiency gains based on reducing wastage and introducing betters ways of providing care, and through advocacy towards government and development partners for an increased investment. The 4th Sector Programme will be built on the ten key driving forces as mentioned below to be translated into strategies and actions. Ten Key Driving Forces of the HNPSIP (2016-21) 1. A stronger governance and stewardship role of the MOHFW, building capacities in leadership, management and regulation for better quality services 2. A restructured MOHFW, to increase performance, efficiency and accountability while removing duplication and waste. 3. The roll out of an upgraded Essential Services Package (ESP) with greater functional integration of services at district level and a functional referral system. 4. The development of new approaches and partnerships with the private sector and the community to ensure basic services reach the poor, the hard to reach, the disabled, elderly and those left behind. 5. A focused improvement in quality of care, including ensuring the implementation of a comprehensive health workforce strategy and action plan. 6. Promoting the importance of public health and increased investment in prevention, primary care and strengthening community engagement. 7. Tackling the rising burden of NCDs through cross-sectoral work to establish healthy lifestyles and healthy environment. 8. Tackling the burden of established and new communicable diseases. 9. The adoption of new technologies to strengthen surveillance, data quality and information systems to provide a strong evidence base for decision making. 10. Greater investment in health, ensuring a focus on managing demand, increasing efficiency and developing the evidence base for future health funding. The MOHFW has captured the spirit of the new health agenda in its vision and mission and has ensured that these are given high profile in the GOB’s 7th Five-Year Plan (2016-21) and the health related Sustainable Development Goals (SDGs). If fully implemented, this Health Nutrition and Population Sector Strategic Investment Plan (HNP SIP) will contribute towards a substantive and sustained improvement in the health and wellbeing of the people of Bangladesh. 3

SECTION 1: INTRODUCTION 1.1 Better Health for a Prosperous Society Bangladesh has made great strides in improving the health of its population through a combination of political engagement, socio-economic development and a range of health and health related interventions and services. Bangladesh is often cited as a success story with good progress against many of the Millennium Development Goals and related indicators as demonstrated in a series of independent evaluations and reviews across the sector. The independent Mid Term Review (MTR, 2014) 2 concluded that “good progress has been made in improving health outcomes for the people of Bangladesh since the start of the Health, Population and Nutrition Sector Development Programme (HPNSDP, 2011-16) as indicated by the decline in mortality rates and improvements in service delivery”. Despite this progress the government recognises that more needs to be done to ensure that the progress made in improved maternal, neonatal and child health, nutrition and family planning services is sustained and made available across the whole country including the more marginalised and impoverished sections of society. 1.2 Scope of the 4th Sector Programme The 4th Sector Programme outlined in this document encompasses the whole health sector and is relevant to all stakeholders working in health, nutrition and population. It outlines the on-going challenges and introduces new and emerging issues that need to be addressed. The new programme takes into account the importance of government’s role in stewardship and regulation, ensuring all providers are working to nationally agreed approaches and standards. It provides a framework for management of public and private (for-profit and not-for profit) sectors and calls for more focus on ensuring high standards of quality and accountability. The programme embraces the wider HNP agenda provided by the recently adopted SDGs and recognises the urgent need to engage society in the tasks of improving health and well-being. Provision of good quality services for all is at the heart of the programme approach, providing the direction to achieve the aims of Universal Health Coverage, equity and quality. It also recognises that improving health will require multi-sectoral action on the wide range of determinants of health. The 4th Sector Programme will be the first and the foundation stone of the three successive SWAps for realising the health targets of SDGs by 2030. This is why the agenda outlined in this document includes a number of new strategic directions and approaches. This 4th Sector Programme is also consistent with GOB’s Vision 2021, 7th Five Year Plan (FYP) and its policy framework on health, population and nutrition. It articulates a set of objectives to move the country towards its goal of Universal Health Coverage (UHC) by 2030. It puts people and choice at the centre of the strategy to prevent ill-health wherever possible and ensure effective treatment where it occurs. It focuses on finding solutions to providing services for those currently not reached in urban and rural settings. 2 Daniels, D and Kabir, H (2014). Mid term Review (MTR 2014) of the HPNSDP, 2011-2016. Ministry of Health and Family Welfare. Final report, October 2014. 4 1.3 The Policy Context Vision 2021 and 2041 Over the past few decades, Bangladesh has made remarkable progress in raising incomes, reducing poverty and improving social indicators. The economy has faced numerous challenges such as the global economic downturn of 2008-09 and a series of natural disasters to which Bangladesh is regularly susceptible. Owing to the exemplary resilience of its hardworking population, the country continues to make significant strides even against heavy odds, and is on the cusp of becoming a lower middle-income country. 3 The Government’s Vision 2021 defines several economic and social outcomes for Bangladesh to achieve by 2021. To convert this Vision into long-term development targets, a Perspective Plan 2010-2021 was prepared to be achieved through the implementation of the Sixth Five Year Plan (2011-15) and the Seventh Five Year Plan (2016-2020). Under the 6th FYP solid progress has been made in reducing poverty through a strategy of pro-poor economic growth. The 7th FYP outlines new strategies, institutions and policies to complete the remaining agenda of achieving the social and economic outcomes of the Vision 2021. The Government recognizes that in a market economy like Bangladesh, where the bulk of the economy is privately owned and managed, the role of planning is essentially indicative and strategic in nature. Transition from MDGs to the new SDGs The new sector programme coincides with the adoption of the United Nations’ Sustainable Development Goals (SDGs) by world leaders in New York on the 25 September 2015. The 2030 Agenda for Sustainable Development articulates an ambitious set of targets aimed at transforming the world by ending poverty, hunger and inequality, taking action on climate change and the environment and improving health and education. The 17 new Global Goals replace and expand the previously agreed Millennium Development Goals. Goal 3 – Good Health and Well-being – aims to ensure healthy lives and promote well-being for all at all ages. As reported by the UNDP, “SDG 3 aspires to ensure health and well-being for all, including a bold commitment to end epidemics of AIDS, tuberculosis, malaria and other communicable diseases by 2030. It also aims to achieve universal health coverage, and provide access to safe and effective medicines and vaccines for all” 4. Several of the other SDGs have an important bearing on health and wellbeing through improvements in hunger, food security and nutrition (SDG2), inclusive and equitable quality education (SDG 4), water and sanitation (SDG 6), environments (SDG 11 & 16), reducing inequality (SDG 10), gender equity and empowerment of women and girls (SDG 5). The Goal 3 targets are numerous and wide-ranging and cover issues of communicable and non- communicable diseases, lifestyle and healthy environments and provide a holistic framework for development of national responses. The SDGs provide the new background to looking at health, nutrition and population in a more holistic and multi-sectoral way and this is reflected in this 4th Sector Programme document for Bangladesh. National Health Sector Policy Framework National health policy 2000 was formulated aiming to provide basic health care to all, particularly the poor, with an emphasis on client centred reproductive health, maternal and child health and cost effective health service delivery through a package of primary health 3 Bangladesh Seventh Five Year Plan FY2016 – FY2020 4 www.undp.org 5 care services. The National Health Policy 2011 acknowledges ‘health’ as a right and its stated objectives are: to strengthen primary health and emergency care for all; to expand availability of client-centred, equity-focused and high quality health care services and, to motivate people to seek care based on their rights to health. It advocates for equitable access to health care by gender, disability and poverty to achieve better health for all. Similarly, National Population Policy 2012 and National Nutrition Policy 2015 have also been taken into consideration while formulating HNP SIP 2016-21. 1.4 Population and Demographic Transition A key factor in determining the strategic directions for the sector programme is the demographic situation and the rapid transitions that are taking place. The new sector programme recognises the importance of ensuring that the health of the young is protected for the future and that the need of an ageing population is catered for. It also recognises the substantial and continuing urbanisation of the population and its implications for service delivery. Careful consideration of population dynamics is key to ensuring that good investment and resource allocation decisions are made to maximise efficient use of the scarce resources available and ensure good targeting to reach those who are currently underserved. Figure 1, shows the impressive slowdown in population growth while reminding us that the population is still growing and in some areas of the country rapid growth is still taking place. Figure 2: Regional distribution of The UN estimates that population will peak at 203.7 Total Fertility Rate (TFR) million in 2059 5 and then start to slowly decline - this being one of the most rapid demographic transitions in the world (see Figure 1) with replacement levels already met in many parts of the country. Data from the latest BDHS (2014) shows that the total fertility rate for the three years prior to the survey (2012-14) stands at 2.3 births per woman with TFR in rural areas higher (2.4) than in urban areas (2.0). As highlighted in the health sector policy dialogue in 2014 between government and development partners there is still considerable work to be done both to maintain and consolidate the progress made in family planning as well as to tackle some of the regional variations that exist. Figure 2 shows variation in Total Fertility Rate (TFR) and Contraceptive Prevalence Rate (CPR) across the country. Other challenges such as those 5 Population Division of DESA, UN Secretariat: World Population Prospects – The 2012 Revision 6 related to early age of marriage, high teenage pregnancy rates, high caesarean section rates in some institutions, the high levels of Menstrual Regulation (MR) uptake are also causes for concern and reflect the fact that there remains a need to reduce the number of unintended and unwanted pregnancies. Figure 3 below shows the changing demographic composition of the population using data projections. As can be seen the young demographic profile at the turn of the century is rapidly changing and by the middle of the century there will be a very different and older profile, and by consequence an older population. This also underpins the importance given in this sector programme to prevention and treatment of chronic non-communicable diseases as well as beginning to think about issues confronting older people including geriatric care provision. Figure 3: Demographic composition (changing age structure) 6 The increase in urbanisation and the large mobile slum population, as well as the substantial number of migrant workers is considered as important in the new sector programme. This has a range of influences on the health of people due to exposure to new infections, with possibilities of bringing epidemic infections back to Bangladesh from other countries, lack of access to safe and clean environments and poor quality health care. A range of social issues are also evident with young families split when one of the parents seeks work away from home leading to a range of stress and other problems. 1.5 The State of the Nation’s Health Progress towards reaching the MDGs Recent surveys and reviews have concluded that Bangladesh has attained the target for MDG 4 on under five year old mortality and was on-track in achieving many of the other MDG targets. These are major achievements by the country that have occurred through extensive and coordinated action by government and development partners (MTR, 2014). Overall, significant progress has been achieved across several key health, nutrition and population outcomes, as further evidenced by the findings of successive Bangladesh Demographic and Health Surveys (BDHS). 6 El-Saharty et al (2013). Tackling Non Communicable Diseases in Bangladesh. World Bank. 7 Maternal, Neonatal and Child Health The decline in Maternal Mortality Rate (MMR) between 2001 and 2010 and further projected decline to 170/100,000 live births (UN interagency estimate) indicates remarkable progress. Figure 4 demonstrates the best estimates of maternal mortality decline. This is linked to fertility reduction, access to qualified maternal health care; and overall care seeking during the antenatal period. The reduction in neonatal mortality 7 is still less than the desired level and stands at around 24 per 1000 live birth1. Bangladesh has been able to reduce the under-five mortality below the MDG 4 target, and the rate now stands at 46 8, against the target of 48 per 1000 live births by the year 2015. Bangladesh has reduced the under-five mortality by 72% since 1990 with an annual rate of reduction of over 5.4%, which stands highest in the SAARC countries. The infant mortality rate is 38 deaths per 1,000 live births, and the child mortality rate is 8 per 1,000 children. Mortality and Morbidity in Bangladesh The burden of ill health in Bangladesh is changing with a very clear rise in the prevalence of non-communicable diseases. As presented in Figure 5 the top three causes of death in Bangladesh (2010) are NCDs, responsible for 40% deaths. Figure 5: Leading Causes of Mortality and Morbidity in Bangladesh, 2010 Estimates 9 18% % deaths 16% % DALYs 14% 12% 10% 8% 6% 4% 2% 0% The rise of Non-Communicable Diseases – An epidemiological transition The NCD Country Profile (WHO, 2014) reported that NCDs account for 59% of total death in Bangladesh (17% cardiovascular diseases, 11% chronic respiratory diseases, 10% cancers, 7 Strategic Report on STG #3: MNCH, FP, Nut-Food Safety 8 BDHS 2014 9 Murray et al. 2012 8 9% injuries, 3% diabetes and 10% other NCDs). In response to this epidemiological transition in Bangladesh, there is a need for a policy and legislative shift to meet the challenges of ever increasing NCDs. WHO definition of NCDs includes primarily cardiovascular diseases (heart disease and stroke), cancers, COPD and diabetes mellitus. They are linked to four shared risk factors: tobacco use, unhealthy diet, low physical activity and harmful use of alcohol. These risk factors contribute to maturation of the NCDs through a few intermediary risk factors: obesity, high blood pressure, abnormal glucose tolerance, and abnormal blood lipids. Other important factors include indoor air pollution, road traffic accidents, drowning, autism, mental health, drug abuse and suicide. NCDs are largely preventable by lifestyle modification and importantly treatable. 10 The SDG 3 (target 3.4) calls for a one third reduction in premature mortality from non-communicable diseases by 2030 11. This transition towards NCDs has a huge direct impact on financial vulnerability, particularly for the poor, and an indirect impact on the economy. The prevention and management of NCDs are largely governed by the available capacity of the health system, but the government’s role in NCDs is limited to providing health education at primary level and preventive and clinical treatment at tertiary level, with less focus on preventive clinical care at primary and secondary levels, while the private sector provides mainly treatment services. There is currently no good awareness-raising system to keep policy makers abreast of these concerns (El-Saharty et al. 2013) 12. The Health of Women The wider situation on reproductive age women is presented in Figure 6. It describes the main causes of female death amongst 15-49 year olds by category. It demonstrates the complex challenges that face women in particular. The on-going success of MNCH work will be somewhat determined by the ability of future programmes to account for causes of death that are prominent yet underserved, such as suicide. It is also clear that thinking about deaths associated with pregnancy and childbirth, while very important, is not sufficient. This graph demonstrates why more investment is needed in the health of the nation to reduce the high mortality, not to mention morbidity from a wide range of causes, many of which are currently not being addressed and are social and environmental in origin. Figure 6: Causes of female death (15-49 year olds), 13 Suicide 9% Adolescent Health Adolescent pregnancy and child bearing entail a high risk of maternal death among adolescents, and the children of the young mother have a higher level of morbidity and 10 Report on STG# 3 CDC, NCDC and AMC 11 https://sustainabledevelopment.un.org/?menu=1300 12 El-Saharty et al. 2013 13 Source: USAID (2014) BMMS Secondary Analysis 9 mortality 14. The birth rate among adolescents is currently 113, which is one of the highest in the world. It is estimated that annually there are about 569,000 births among 15-19 year adolescent girls in Bangladesh. These girls face a number of serious health risks arising out of early pregnancies, violence and inadequate nutrition. Directly linked to these issues is the practice of early marriage, a prevailing and persistent social norm across the country that is increasingly a subject of debate. The Bangladesh National ARSH strategy was formulated in 2006 and a corresponding action plan was developed in 2013. Communicable Diseases Bangladesh has achieved significant success in preventing and controlling communicable diseases, and as these are linked to poverty, it is envisaged that improvement in overall living conditions and an increase in household income will help in further reducing the burden of communicable diseases, especially HIV/AIDS, malaria and tuberculosis, and a range of Neglected Tropical Diseases (NTDs). During the last SWAps the country has scaled up the interventions for prevention and control of communicable diseases. The country is on-track to achieving its HIV-AIDS, TB and Malaria targets. Action taken on diseases targeted for elimination (Filaria, Kala-azar) has achieved the desired results. The leprosy elimination target has been achieved and the programme is in its post elimination phase. Nutrition - The Double Burden of Malnutrition The GOB has positioned nutrition as central to development and the process of mainstreaming nutrition has started. The Cabinet has endorsed the National Nutrition Policy (2015) and work has focused on developing a costed National Plan of Action on Nutrition (NPAN). The Bangladesh National Nutrition Council (BNNC) has been revitalized to coordinate the nutrition activities across the sectors and monitor the progress of both Nutrition Specific and Nutrition Sensitive interventions. Bangladesh is currently facing the challenge of addressing two “seemingly-paradoxical” nutrition concerns of under-nutrition (stunting, underweight and wasting) and over-nutrition (overweight and obesity), a phenomenon known as the double burden of malnutrition (DBM). Although under-nutrition has declined gradually since the 1990s, the prevalence remains high: in 2013, 36 per cent and 33 percent 15 of children under five years of age were found to be stunted (short for their age) and underweight (low weight for age) respectively. Moreover, under-nutrition does not seem to be a phenomenon that is common only amongst the poor people of Bangladesh as the under-nutrition rates amongst the richest income quintile are also relatively high – 17 per cent of children under-five years of age were underweight in the richest quintile in 2014. Only 29% of children under- two years in urban and 21% in rural areas get Minimum Adequate Diet (MAD). Among women, nutritional status has improved slightly, but under-nutrition continues to represent a serious issue for both women and adolescent girls. About 19% of women and 31% of adolescent girls aged 15-19 years were undernourished (Body Mass Index of less than 18.5) 16. Over the past decade, mixed progress has been observed in reduction of anaemia among women but anaemia continues to remain highly prevalent, affecting on average half of all women 17. There is, at the same time, a growing concern about the rise in over-weight in 14UN World Population Monitoring 2002- Reproductive rights and reproductive health: selected aspects. 15 Bangladesh Demographic Health Survey (BDHS) 1997, 2000, 2004, 2011, and 2014 16 BDHS 2014 17 UNICEF-Government of Bangladesh Mid-Term Review Report, Country Programme 2012 – 2016. 10 some section of adult women which needs to be tackled early to prevent the rise in obesity related health problems such as type-2 diabetes. 1.6 Governance and Stewardship of the Health Sector Governance and stewardship Governments are considered as "stewards" of their national resources and take on the task of maintaining and improving those resources for the benefit of their populations. The focus of governance and stewardship has been on increasing regulation, transparency and participation of citizens in institutional decision-making and accountability. A range of actions by government to increase regulation over the public and private sectors is needed to improve quality standards and ensure accreditation of individuals and organisations. In this context, the Ministry of Health and Family Welfare is considering its role in policy making and oversight and that of its agencies and departments in implementation, monitoring and supervision, and performance improvement. This aspect of the health system is a key element of the 4th Sector Programme as government revises its ways of working to provide governance and stewardship of the whole sector including both public and private stakeholders. This shift in emphasis and role requires functional and structural change. To perform its regulatory responsibility the MOHFW works through organizations like DGHS and DGFP. While regulatory responsibilities should be best vested through legal instruments, often government continues to perform such functions through executive orders or instructions. While Departments are directly accountable to MOHFW, statutory bodies have separate boards and separate governance arrangements that reduce the MOHFW’s influence over them. However, in general the MOHFW remains in a position to assert its control through peer pressure and if necessary through regulatory instruments. To be effective, ideally regulatory bodies should be independent and free from financial and other conflicts of interest. Institutional development More attention to clarifying roles and responsibilities and for rationalising the current institutional arrangements of the MOHFW is needed (MTR, 2014). To address the principle of efficiency as well as improved effectiveness across the public sector will require improvements in functioning of many departments including removing duplication of effort. A thorough organisational capacity assessment (OCA) is needed and should pay careful attention to an inclusive process and a change management strategy. Functional integration of current bifurcated structures, with its evident areas of duplication and unclear areas of responsibility needs to be addressed. The organisational assessment should develop a strategy agreed by all senior management to determine a more optimal structure and function at the Ministry involving all directorates, departments and institutions. 1.7 Strengthening Health Systems Human Resources for Health (HRH) Human resources are the most valuable health systems resource. Recently a Health Workforce Strategy has been developed by MOHFW. A comprehensive HRMIS capturing all necessary data is yet to be established and used. Implementation of the HWF Strategy has been fast-tracked and an action plan is in process of development. 11 Human Resources issues affect most OPs 18 in the MOHFW in one-way or another and as such this sector programme highlights its importance. There has been considerable recruitment during the HPNSDP with vacancy rates declining to around 15% in 2014 (compared to 20% in 2011). Over 7,000 doctors and 4,100 nurses have been recruited and in total over 42,000 positions across the sector have been recruited (MPIR, HPNSDP, MTR – 2014). At the last MTR the proportion of service provider positions functionally vacant at district level and below, by category, are Physicians: 46.1%, Nurses: 19.59%, FWV/SACMO/MA: 21.2%. Issues of skill mix and task shifting are now a priority for action. Health workforce development in the country, and for MOHFW, predominantly involves institutional education before entering the services. The quality of education in these institutions both in public and private sectors is mostly challenged by a shortage of qualified teachers for basic science subjects. Improved quality of medical education across all health professionals’ institutions and modernization and transformation of the medical education system to fulfil the aspirations of the SDGs and achieving Universal Health Coverage are now a major priority. Quality, standardization and accreditation issues remain major challenges. Building capacity and skills within the workforce is an area requiring considerable attention. Very large numbers of training course and workshops are held annually and during this sector programme more attention needs to be given to ensuring the effectiveness of all types of training being provided. In-service training demands a need-based structured curriculum. Historically trainings are conducted in an ad-hoc manner based on training modules developed to serve programme activities. This needs to change and a plan for in-service training and the use of a Training Management Information System (TMIS) should become an integrated part of the DGHS, DGFP and DNS. Recruitment of appropriate staff and their deployment and retention in the right job at the right place are important HRM functions. Vacancies in the health facilities are a common phenomenon and on an average 20% of the total sanctioned posts remain vacant. The vacancy rate is very significant in rural, remote and hard to reach areas. Skill mix imbalance is a priority concern for policy makers. The National Health Policy (2011) focuses on skill mix with standard ratios between physician, nurses and allied professionals based on the international standards. The current staffing pattern in the country needs to be improved to ensure the right people are in the right places and providing the right services. . The workforce is pre-dominantly linguistically and culturally homogenous and transferable across the country though deputation and deployment practices in the public health system. A number of challenges have been well documented through recent reviews such as keeping health workers in the rural and hard-to-reach areas; is still a big challenge for the health sector and providing continuous professional development, career planning and engagement opportunities could be important options to retain them. There is absenteeism of health personnel at the workplace and unauthorized absence is regarded as misconduct as per service regulation 19. Local monitoring and supervision mechanisms need to be strengthened in this regard and innovative models could be worked out to address the issues. 18 Five HR related OPs in HPNSDP (2011-2016) that are directly linked with overall HRM functions. The OPs are i) In-service training (IST) with DGHS; ii) Pre-service education (PSE) with DGHS; iii) Training, Research and Development (TRD) with NIPORT, iv) Nursing Education and Services (NES) with DNS and v) Human Resource Management (HRM) 19 The Government Servants (Discipline & Appeal) Rule, 1985 12 Procurement and Supply Chain Management The MOHFW spent considerable amount of funds in procurement of medicines, medical equipment, services and capacity building for this sector programme (3rdSWAp). MOHFW has introduced web-based supply chain portal for processing and approval of the procurement packages formed Procurement and Logistics Management Cell (PLMC), and developed Table of equipment (TOE) for 10, 50 and 250-bed hospital facilities. A review of Central Medical Stores Depot (CMSD) and development of TOE for 500-bed hospital are in process. The above measures have resulted in reduced overall lead-time for procurement of equipment by CMSD, improvements in the quality of documents prepared on procurement, and freeing up space in warehouses. However, the centralized procurement process, inadequate coordination among LDs in DGHS and between DGHS and DGFP, procurements by LDs for vertical programmes, no formal mechanism for stock control and distribution, inadequate storage space, inadequate capacity of CMSD, vacant posts in PLMC, inadequate maintenance budget for procured medical equipment and limited local expertise in bio-medical engineering are the major challenges. The limited synchronization between the procurement of equipment and drugs, civil works and deployment of human resources also leads to instances where buildings are constructed or equipment are procured but cannot be made operational due to inadequate staffing or inappropriate input-mix. Infrastructure Physical infrastructure development continues to attract the highest investment in MOHFW’s development budget. A comprehensive master plan for civil works is under preparation. This together with the work on TOE for hospitals and that of HRM on staffing will synchronize physical construction with supply of equipment and human resource in a timely manner. Physical facilities development or upgrading is to be based on detailed need assessments. In addition, the construction of UHCs in the tribal areas or the urgency of meeting central/regional warehouses for family planning or having facilities for drug storage in the hospitals need attention. The basic services in health facilities (such as a separate toilet for women and facilities for the disabled) and condition of residential facilities for staff and security measures such as boundary walls, bio-waste management systems are often ignored in renovation, repair and maintenance plans for all levels. This calls for the adoption of more objective, evidence-based criteria for deciding on prioritization for construction/maintenance, and a thorough assessment of maintenance followed by the development of a comprehensive maintenance plan for infrastructure and equipment. Due to inadequate quality and capacity of implementing agencies, the number of incomplete and non-functional physical facilities is expected to rise. Financial Management and Audit There has been significant improvement in budgeting procedure, resource allocation, resource tracking, financial monitoring and reporting because of the last three HNP SWAps. Further improvements in FM and Audit during HPNSDP period include the engagement of qualified FM Consultants to support FMAU and LD as a temporary measure; finalization of FMAU’s restructuring proposal by MOHFW and submission of the revised organization structure along with revised recruitment rules for FMAU to Ministry of Public Administration (MOPA) for final approval; drafting of an audit and FM strategy; training of FM officials and establishment of connectivity between Integrated Budget and Accounting System (iBAS) and FMAU; strengthening of the management of the revenue budget and audit functions by 13 putting them under the FMAU of MOHFW; timely production of Interim Unaudited Financial Reports (IUFRs); outsourcing of internal audit to private audit firms. However, Financial Management and Audit Unit (FMAU) lacks with appropriate organizational structure and human resources. Many OPs were found not being able to spend to a target of 90% of allocated amount. The inordinate delay in settlement of audit observations and delayed response from Foreign Aided Project Audit Directorate (FAPAD) are other challenges. There are also issues with the audit system for which the audit observations are not met timely or satisfactorily. Building the evidence base for decision making In recent years the MOHFW has made substantial improvement in its health information system (HIS) and eHealth, being recognized both at home and abroad. Bangladesh is to be one of the global champions in terms putting in place an effective and robust technology- supported M&E platform 20. However, the existing efforts will have to be sustained and new investments made to fit to the SDG principles, so that they become country-led, open, inclusive, participatory and transparent for all people and reported by all relevant stakeholders. To gain benefits out of the SDGs’ follow-up and review process in the health sector, the WHO is providing leadership through two recent developments. These are a 15- year Roadmap for Measurement and Accountability for Results in Health (MA4H) and Global Reference List of 100 Core Health Indicators. Capitalizing on the existing progress of MOHFW Bangladesh can be taken to the next level to fulfil the M&E needs of the 4th SWAp as well as for global reporting with the routine data generated through a country-led process. The MOHFW is also experienced in conducting population based health surveys and there are institutions both in public and private sectors to carry-out research and related products. To overcome current challenges and to progress, the MOHFW and its partners will have to pay attention to a number of issues. It will need to place evidence based planning, progress monitoring and decision making at the heart of 4th SWAp. It will need to improve integration of the health information and eHealth platforms existing among different agencies and stakeholders with a view to making a seamless national data capture, data flow, and data reporting system. Amongst other actions it will also need to introduce periodic routine data review and data-driven decision-making process at each level of management and organizations and improve coordination and harmonization across all data generation activities. 1.8 Financing the Health Sector In a vast majority of low- and middle-income countries, national health systems face financial sustainability challenges as donor funding declines 21. As the current economic climate has led donor governments to reduce spending in all areas, including global health initiatives, increased funding for global health may be unlikely in the current scenario 22. Macroeconomics and health The overall economy of Bangladesh is growing at around 6% per year despite slow implementation of economic reforms, and the global financial crisis and recession. With the overall GDP growth, funding in health is also increasing in absolute terms. However, the 20 paragraph 74 of UN resolutions on SDGs (A/74/L.1) 21 Katz et al. 22 Beane, Hobbs & Thirumurthy 14 percentage contribution of Gross Domestic Product (GDP) to health is still very low. Public health spending comprises less than 1% of the GDP and total health expenditure (THE) is 3.5% as of GDP. Per capita THE of US$ 27 is relatively low compared to Nepal (US$36), Pakistan (US$39), India (US$61) and Sri Lanka (US$ 89). The out of pocket expenditure is unacceptably very high at the level of 63.3% of THE; government spending is around 23% only, and voluntary health insurance payment was 5.25% of THE in 2012. The budget of Ministry of Health and Family Welfare (MOHFW) as a percentage of national budget is in continuous decline. MOHFW’s share of national budget reduced from over 6% in FY 2010/11 to 4.31% in FY 2015/16. The HNP budget as a percentage of GDP and the MOHFW’s ADP as a percentage of total ADP has been declining. The fiscal space of the country is restricted given the lowest tax-to-GDP ratios in the world that limits the government’s capacity to translate this growth into public revenues. A reprioritization towards the health sector needs strong evidence-based advocacy and negotiation with the Ministry of Finance (MOF). Sustainable health financing The government has consistently shown commitment in ensuring sustainable financing for health care in Bangladesh. A Health Care Financing Strategy (2012) has been approved which proposes to cover the entire formal and non-formal sectors and those below the poverty line under a common scheme. The HCFS (2012) has recently been embedded in the approved National Social Security Strategy (NSSS) 2015. The NSSS focuses on strengthening financial risk protection and extending health services and population coverage especially to the poor and vulnerable segments of the population to achieve universal health coverage. The government has taken the initiatives to pilot a health protection scheme for the poor (Shasthyo Shuroskha Karmasuchi -SSK) and garment workers (the Ready Made Garment Workers’ scheme). A social health protection scheme for the formal sector is being designed, the required law has been drafted and a communication strategy has been approved. A resource allocation formula has been developed by MOHFW. A considerable amount of resources has been invested in the health sector during the 3rd SWAp. Total revised estimated cost for the 3rd SWAp, i.e. HPNSDP (2011-16) was BDT 51, 571 Crore (about US$ 6.5 billion) 23 . Out of this, it was estimated that BDT 39,748 Crore (78%) will be contributed by Government of Bangladesh (GOB) and 22% to be financed by development partners (17% pool fund/RPA 24, 5% DPA). The absorptive capacity of the MOHFW has improved in recent years. During the first four years of 3rd SWAp implementation (2011/12-2014/15), utilization of annual development programme budget was 87% in 2011/12, which increased to 91% in 2012/13, 89% in 2013/14 and 83% in 2014-15. Utilization of the revenue budget was more than 95% during the first four years of the 3rd Swap. There is a high level of commitment from government to bringing health care as close to the communities as possible. This was made possible by establishing about 14,000 community clinics nationwide and prioritizing Primary Health Care for increased budget allocation. There is also an increasing emphasis on the complementary role of the private sector through public private partnership (PPP), outsourcing models and increased community engagement, such as is seen in the Chougachha and Narsingdi models. 23 PIP of HPNSDP, 2011-2016. 15 Despite the initiatives, in Bangladesh, households constitute a major financing source of the Total Health Expenditure at 63.3%, which is unacceptably high, followed by Government contribution at 23%, Development Partners at 8.4%, while voluntary health insurance payment was 5.25% of THE in 2012 (BNHA, 2015). Every year, 14.2% of the households face catastrophic health spending while 3.5% of the population falls into poverty due to health expenditures in Bangladesh 25 . Inadequate pre-payment mechanisms to protect the population from catastrophic spending, very little revenue raised through pre-payment of insurance contributions (0.2% of total health expenditure), slower than expected progress in SSK implementation, and little progress made in other pilot initiatives are major challenges. The experience of Demand Side Financing is also not very satisfactory. The budget of Ministry of Health and Family Welfare (MOHFW) as a percentage of national budget is on a continuous decline, it decreased from 6.1% in 2010/11 to 4.1% in 2015/16. It thus remains below the HNPSP target (10%) and the Sixth Five Year Plan target (12%). A number of development partners are leaving the sector. There has also been a shift in the priority at post-MDG era moving from health towards the new international targets focusing more on sustainable systems, climate change and environment. The government budget provided to public hospitals is allocated on the basis of number of beds and staff employed. The allocation is not linked to performance or results achieved. Proportion of allocation for repair and maintenance in revenue budget declined over time. Health spending disparities across wealth quintiles and geographic regions persists. Gender differentials in health status and health care access persist, though reduced over the past decades. Weak capacity in budget planning as well as poor procurement planning results in under spending of resources. In general, delay in disbursement of fund, the complex procurement process, and delay in settlement of claims (bills) in the CAO (Health) office and at District and Upazila account offices result in low utilization of resources. 1.9 Health, Nutrition and Population Services As part of improving health services good progress have been achieved in maternal, neonatal, child, reproductive and adolescent health and family planning services. Progress has also been made in the areas of nutrition and food safety, disease control and disease surveillance. However, the Annual Program Implementation Report (2015) highlighted some key indicators of low performing areas such as strengthening identification and management of MDR TB patients and scaling up infant and young child feeding. These areas should now be prioritized. Primary healthcare provision and informing people about health issues through behaviour change communication (BCC) activities have expanded. However, there has been more limited progress in service provision to hard to reach populations and various disadvantaged and marginalized groups. There is more work to do on developing the Essential Health Service Package (ESP), secondary and tertiary healthcare and in developing the relationship between public and private sector providers whether through partnership arrangements or through regulation and accreditation. More attention is needed to improve urban health, environmental health and the health implications of climate change, and better integration of services including those through alternative medical care services. 25 Household Income and Expenditure Survey, 2010 16 Essential Service Delivery The 4th Sector Programme emphasises the importance of delivering a package of high quality essential health services (ESP) through the various health delivery outlets in a holistic way. This includes partnership with private sector hospitals and clinics, AMC providers and will need to stress the importance of an effective referral system. This requires that services are available to all sections of society, addressing the current inadequate services to rural and urban hard to reach areas. Achievement of the sustainable development goal (SDG) for health and the ambition of UHC will depend to a large extent on providing high quality integrated primary health care delivered by strongly linked domiciliary services including counseling and referral, community clinics and comprehensive static health facilities at Union, Upazila and District levels. Meeting the ambitious targets requires registering, tracking and responding to each citizen’s needs. The Community Clinic (CC) is the lowest tier health facility and aims to be a one stop service outlet for health, family planning and nutrition services. It is meant for health education, health promotion, treatment of minor ailments and injuries, immunization, ANC, PNC, screening of NCD with referral to higher facilities for better management. Currently functional 13,136 CCs, and 308 more that are planned are providing services in the rural areas including hills, haor, char & coastal areas. It is Primary Health Care provision at the doorsteps of the community and acts as a unique example of PPP. The CC is a flagship programme of the Government of Bangladesh and is being recognized globally as a model for delivering universal health coverage. Maternal, neonatal and child health services Political commitment has been evident in the area of maternal, neonatal and child health (MNCH) and this is articulated in several policy and strategic documents and formed the basis of considerable progress. ‘Promise Renewed: Bangladesh Call for Action to End Preventable Child Deaths by 2030’, launched in July 2013 has prioritized 11 interventions focusing on maternal, newborn and child health. Bottlenecks have been identified and costed action plans developed. There are now national level benchmarks as well as a dashboard to monitor progress. The “Bangladesh Every Newborn Action Plan” (BENAP) identifies a set of priority maternal and newborn interventions. A wide consensus now exists for a comprehensive newborn care package including several high impact interventions. Revision of the Bangladesh Maternal Health Strategy and development of Standard Operating Procedures (SOP) for both maternal and newborn care are important steps taken. Maternal health services have improved steadily through ANC uptake (ANC4: 26 % 2011 to 31% in 2014) and access to skilled delivery (SBA delivery: 32% to 42%, facility delivery: 29 % to 37 %).. The BDHS (2014) indicates progress in postnatal care with 36% of mothers and children receiving check-ups from a medically trained provider within 42 days of delivery, importantly 34% of women and 31% of children receiving this within 2 days of delivery. More than 80 percent of the neonatal deaths occur within 7 days, 50 percent within first 24 hours of life and most of these deaths are at home without the care of a skilled birth attendant and are often unregistered. Despite the tremendous effort in reduction of maternal deaths nationwide, the country still loses 14 mothers a day1due to complication of pregnancy delivery and post-partum period and largely due to delivery by unskilled birth attendants at home and lack of appropriate care for obstetric complication from a skilled provider at facilities. Lessons show that there is high utilization of services if women friendly services can be made available nearer to the communities. Inequities exist across geographical regions and between different wealth 17 quintiles, which need to be tackled. MMR is the highest in Sylhet division (425 per 100,000 live births) and the lowest in Khulna division (64 per 100,000 live births) 26 . The increase in facility delivery is mostly at the private sector. Notably, 23 percent of all deliveries are conducted through caesarean section (CS). About four fifths of the deliveries in the private sector are by CS which is very costly for the poorest and quality of care in these facilities is yet to be monitored. Effective coverage of 24/7 C-EmOC 27 is now crucial to address maternal deaths resulting from pregnancy-related complications, provision of which relies on the availability of skilled human resources such as anaesthesiologists and obstetricians, equipment, drugs and infrastructure. Adolescent sexual and reproductive health services Bangladeshi teenage mothers are more likely to suffer from severe complications (e.g. obstructed labour, delayed labour, fistula, etc.) resulting in high neonatal mortality and both neonatal and maternal morbidities. Young women must have better information on availability of MR and PAC services. Due to lack of such comprehensive information and knowledge they are more likely to seek these services at a later gestational age, which is more risky. Almost twice as many newborn deaths (45 per 1000 live birth) occur among very young pregnant women, less than 20 years old, compared to older age 28. Teen pregnancy is also linked with stunting with the odds of a child becoming stunted significantly increased (by 22%) if born to a mother who is a minor 29. Neonatal health services Progress on neonatal mortality has been slow and more attention is needed. More than 80 percent of the neonatal deaths occur within 7 days, 50 percent within first 24 hours of life and most of these deaths are at home without the care by skilled birth attendants and are often unregistered1. These are largely preventable and treatable conditions – complications due to prematurity, intrapartum-related deaths (including birth asphyxia) and neonatal infections (sepsis, meningitis and pneumonia). Care during labour, around birth and the first week of life; and care for the small and sick newborn- have the greatest impact on ending preventable neonatal deaths and stillbirths 30. High coverage of interventions before, during and after delivery could save the most newborn lives as well as prevent maternal deaths and stillbirths. Further progress is needed to address newborn complications and deaths due to birth asphyxia, prematurity and infection through establishing Special Care Newborn Units (SCANU) and rolling out ETAT, sick newborn care and the “Helping Babies Breathe” (HBB) initiative. Child health services Despite the reduction in mortality over time, continued disparities are observed between richest and poorest quintiles, urban and rural areas and between divisions. Mothers’ education was found to be associated with under-five mortality, with the highest mortality rate (82) noted among mothers with no education compared to mothers with secondary education or higher (39). 26 BMMS 2010 27CEmOC is defined if any facility performs 6 Signal Functions for BEmOC (Parenteral Antibiotics, Parenteral sedatives, Parenteral Oxytocic, Manual removal of placenta, removal of retained products, Assisted vaginal delivery) plus Blood Transfusion, Caesarian Section 28BDHS 2011. 29Raj, A. et al (2010). The effect of maternal child marriage on morbidity and mortality of children under 5 in India: cross sectional study of a nationally representative sample.. BMJ 2010;340:b4258doi:10.1136/bmj.b4258 30Lancet Newborn Series 2014 18 As for under-five deaths, pneumonia, neonatal causes and drowning are major causes. Diarrhoeal deaths among under-five have decreased substantially over the last few years (2 per cent), however pneumonia remains the single most important cause (21 per cent) of under-five mortality followed by neonatal causes. Although deaths due to preventable communicable diseases continued to decrease over times, the share of deaths due to drowning has resulted in a sharp rise from 26 per cent in 2007 to 42 per cent in 2011 among the age group of 1-4 years. New focus is now needed to reduce these areas of mortality. Family planning services While exceptional progress has been made in family planning over several decades, disaggregated data shows where more attention is needed in terms of reducing inequities, ensuring sustainable services and meeting unmet need. The issue of adolescent pregnancy rates is linked to current practices of early marriage as well as the lack of information and supportive services for adolescent girls and young women. The need for more attention across the country to this group is recognised. Uptake of services is good and more is needed to ensure prevention of first pregnancy until at least age 18, and healthy pregnancy spacing and birth outcomes. BDHS (2014) provides a comprehensive overview of contraceptive use and summarises that, as of 2014, 62% of women use contraception and 54% use a modern method. Teenage pregnancy is recorded at 31percent for adolescents aged 15-19 and more common in rural areas. All-method discontinuation has declined from 36 percent in 2011 to 30 percent in 2014. One of the major strategies of DGFP is to increase the wider availability of LAPMs, now only 8% in the method–mix (BDHS-2014). Increased method choice can help meet family planning demand and reduce unmet need. Communicable diseases The Communicable Diseases Control area must remain a priority of the 4th Sector Programme especially linked to the equitable delivery of an essential package of HNP services based on the tiers of service delivery infrastructures and the available health workforce. Continued attention is needed to the major diseases such as tuberculosis, malaria and HIV/AIDS with special attention given to reach the hard-to-reach areas, and the most vulnerable population groups. Water-borne, vector-borne as well as some of the neglected diseases require more focused attention. As issues of drug resistance start to impact on effectiveness of treatment the MOHFW must engage in more work on medical practice and regulation. Secondary and tertiary care services The secondary level district hospitals are a key part of the overall public health care system providing specialist care services in addition to primary care. Considerable upgrading of hospitals has taken place under the last sector programme and this district hospital system provides a considerable proportion of overall services. Many people by-pass lower tiers of the health system preferring to seek initial care from the district hospitals. Here they are more likely to be seen by a medical doctor and where drugs and supplies are more available. The rapid expansion of the private hospital sector is also evident across the country with many new facilities opening. Quality of care and cost of services is an increasing cause for concern. The need for greater regulation of the private secondary and tertiary care facilities is well recognised and will be a focus of attention during this sector programme. More supervision and accreditation will be introduced along with clinical management protocols. More attention will be given to establishing the lower tiers of the system with appropriate referral systems in place, including improved patient tacking systems. 19 Continued attention will be given to supporting and monitoring Divisional level Hospitals, Medical College Hospitals and Specialised Hospitals. As for district hospitals the referral systems need to be strengthened. Blood transfusion services will also continue to be developed and expanded together with regulatory systems to ensure good practice. More attention will be given to working in partnership with the private sector hospitals and where appropriate service level agreements will be developed to improve access to specialist services for those that would not otherwise be able to afford such treatments. Nutrition Services Persisting high levels of under-nutrition, combined with rising levels of nutrition-related Non-Communicable Diseases (including obesity and diabetes), represents an avoidable and high economic cost, dampening potential growth and draining national resources. Good nutrition must be recognised as a fundamental condition for the country to reap the full benefits of the demographic dividend. Sustained mainstreaming of nutrition services within MOHFW and other ministries requires consistent policy and strong leadership of MOHFW. Overarching accountability and coordination mechanism need to be in place through concerted effort of different ministries and department at all level. The introduction of comprehensive nutrition interventions incorporating specific and sensitive interventions with a special focus on life style modification is important to address the double burden of malnutrition. Integration of these nutrition interventions in the services provided by community-based health workers linked to effective supervision is critical to ensure mainstreaming. In addition comprehensive BCC needs to be enhanced for curbing the double burden of malnutrition. Micronutrient deficiency among children aged less than five years old, indicated by anaemia is also high at 33.1% (Micronutrient Survey, 2013). The universal coverage of interventions to address factors that contribute to stunted growth and development include poor maternal health and nutrition, inadequate infant and young child feeding practices, and infection need to be achieved if the reduction of under-nutrition to be accelerated and sustained. The BDHS 2014 shows that the coverage of infant and young child feeding practices needs to be improved. Exclusive breastfeeding among infants less than six months old showed reduction from 2011 (BDHS 2011) from 64% to 55%. The timely and appropriate complementary feeding practices indicated by the minimum acceptable diet among infants and young children aged 6-23 months is still very low at 23%. Alternative Medical Care (AMC) services Alternative Medical Care is mainly focused on Unani, Ayurvedic and Homeopathic systems of medicines. Most of the treatments are derived from herbal, animal and mineral materials. These systems of medicine have been used in Bangladesh for many years, and traditionally these are used most by rural communities. Bangladesh is very rich in medicinal flora and these systems are closely linked to culture and diet. Alternative medicine is often the first place for people to seek medical attention. It is popular and generally seen as accessible, cheap, simple and without serious side effects. A National Strategy for AMC in Bangladesh is under preparation and one of the areas under discussion is the better integration of traditional or alternative medical care systems with modern medicine and public funded health services. Non-communicable diseases Tackling the rapidly growing non-communicable disease (NCD) is perhaps one of the major new areas of focus in the sector programme. This entails a two-pronged approach. 20 Prevention, with a focus on young people to head off the rise in NCDs, through lifestyle and environmental actions, and the support and care for those suffering from NCDs. Urgent attention is needed on both fronts to head of the human and financial costs that will occur if not addressed. Promoting healthy lifestyles NCD risk factor control though lifestyle intervention is now a priority. Without a lifestyle change focus the health system is likely to become rapidly overburdened by chronic diseases. The economic argument for this shift in emphasis is being recognised across the world. STEPS and GATS surveys show almost nine in ten adults have at least one risk factor. Three- quarter have two or more risk factors. Low intake of fruit and vegetables is the commonest. Tobacco use is still very high in Bangladesh. Salt intake is also very high. These risk factors are amenable to lifestyle and other interventions. Interventions will work better only if political and legislative support is provided. Promotion of healthy diet with high fruit and vegetable content that is readily available and that provides the nutrients required for health, growth and immunity is a major lifestyle choice for health. It avoids the problems of diets with excessive salt and sugar content, low fiber and over reliance on animal protein. This in turn deprives the person of the necessary daily intake of protective anti-oxidants. The markers of cardiovascular disease, diabetes, neoplasm and other non-communicable diseases are high cholesterol, high blood pressure. Linked to this is the need for the promotion of regular exercise among all age groups. Schools, businesses and local authorities need to look at ways to make exercise more accessible to people, living in crowded environments and provide opportunities for people through access to open spaces. Other lifestyle change areas include traditional and harmful practices. Substance abuse has a devastating and costly effect on individuals, families, and the country as a whole, whether it is the antisocial effect of recreational drugs or the insidious multiple harmful effects of tobacco. The matter requires an in-depth look at the reasons why people seek these substances, at how to break the dependency, and what alternatives there are for coping without them. Child marriage and marrying girls under 15 years of age also affect healthy life of under-aged mother and child. So, MOHFW needs to work on influencing the policy makers by providing evidence of the potential harm of child marriage. Gender based violence, suicide and mental health Promotion of gender relations amongst youth, education about consequences of bullying and other harmful acts through to more law enforcement for acts of violence, such as rape and harassment, are all part of a wider set of strategies that are needed to reduce pressures on people and especially women and girls. The health sector has an important role to play in advocacy and service provision. Mental health and well-being are fundamental to a healthy nation. MOHFW needs to promote mental health and well being including access to essential care. The priority areas to be addressed include: depression, psychosis, bipolar disorders, epilepsy, developmental and behavioral disorders in children and adolescents, dementia, drug use disorders, self- harm/suicide, etc. To address this problem, a comprehensive mental health service delivery plan needs to be developed with the aim of gradual expansion of service to address the growing need of psychological aspects of health. To uphold health rights and ethics, such 21 issues will be incorporated in all medical, nursing and other education curricula along with proper sensitization initiatives for the health service providers. Healthy environment The most immediate opportunity for the health sector to improve environment is through proper waste management at all facilities. There is a huge amount of improvement possible at all tiers of the system. Facilities could be provided with renewable energy sources and water catchment technologies. The health sector should also be lobbying and providing evidence of the positive effects of wider government efforts to provide green spaces and conservation of biodiversity efforts. The recognition of the link between biodiversity and health is growing rapidly and this is true for Bangladesh with its rich and diverse natural world. 22

SECTION 2: A PROGRESSIVE AND INCLUSIVE AGENDA FOR THE 4TH SECTOR PROGRAMME (HNPSIP, 2016-21) The development of the Bangladesh Health, Nutrition and Population Strategic Investment Plan 2016-21 is guided by Bangladesh’s Vision 2021, which acknowledges that improved health is a critical driver to the achievement of this vision. Vision 2021 aims to transform Bangladesh into a globally competitive and prosperous country with a high quality of life by 2021 by transforming the country from a developing country into a middle-income country. Health services in Bangladesh is primarily guided by its Constitution which says, ‘Provisioning of medical care Universal Health Coverage to improve material and cultural standard of living of the people’ (Article The goal of Universal Health Coverage has 15a of the Constitution). Within the been elevated in the global and national broader context of Bangladesh Seventh agenda in recent years and is part of the Five Year Plan (2016-20), the Sustainable Development Goals specific to government’s vision for the health, health. Endorsed by the World Health nutrition and population sector is to Assembly through a resolution in 2005, create conditions whereby the people of UHC is defined as access for all to Bangladesh have the opportunity to appropriate health services at an reach and maintain the highest attainable affordable cost. Universal coverage is level of health. It is a vision that associated with better health and equity, as recognizes health as a fundamental well as financial protection. The systemic human right and, therefore, the need to promote health and to alleviate ill health resilience provided by universal coverage and suffering in the spirit of social justice also contributes to poverty alleviation by (MOHFW 2004). reducing catastrophic health expenditures. Bangladesh aims to abstain from the The country is also committed to current path of increasing out-of-pocket achieving the universally agreed goals in spending (e.g., 63.3% as per NHA 2014) of specific areas as set out in the total health expenditures and moving declarations of various world summits, towards pooling health financing through the Sustainable Development Goals taxation, social protection or insurance (SDG) and the National Plan Document mechanisms and ensuring quality of care to are the policy guides for all sector cover large portions of the population. programmes including health. Bangladesh Strategic Investment Plan is also aligned to the goal of achieving Universal Health Coverage that highlights the right of every citizen of a nation to gain access to quality healthcare without incurring economic hardship. The 4th Sector Programme is designed to develop appropriate strategies and gear all concerted efforts for focused and accelerated improvements in increasing access and quality of healthcare and improving equity along with financial protection in order to meaningfully realize the UHC objectives. 23 2.1 Vision, Mission and Goal of the 4th Sector Programme Vision “To see the people healthier, happier and economically productive to make Bangladesh a middle income country by 2021” (Vision 2021) Mission “To create conditions whereby the people of Bangladesh have the opportunity to reach and maintain the highest attainable level of health” Overall Goal “To ensure that all citizens of Bangladesh enjoy health and well-being by ensuring access to quality and equitable healthcare and a healthy and safe living environment” 2.2 Guiding Principles On the basis of the experience in the previous health sector SWAp periods a set of underlying principles were identified in preparing the SIP for the 4th sector programme over the next five years. The intention is to ensure that all citizens have access to high quality services whether these are obtained from the public or private, modern or traditional providers. Quality is therefore the first key principle. The analyses undertaken during the numerous reviews of the health, nutrition and population sector have shown that gains made are often unequally distributed across all sections of society. The need to focus in the next programme on ensuring that all citizens are treated equally is seen as a central principle. The second principle is Equity. Resources are limited and the needs are great in the sector. While government and development partners remain committed to ensuring the aims and objectives as set out in this document are met the reality is that resources available are and will remain limited. One way to ensure progress is to work towards establishing efficient, transparent and accountable services. Reducing wastage and maximizing the impact of all available resources will be critical to achieving the targets being set. The third principle is therefore Efficiency. The MOHFW and GOB as a whole is committed to the principle of achieving Universal Health Coverage for the population. The government has signed up to this intention with the full recognition that this will be a huge challenge and will take time and effort to achieve. An overarching principle for the 4th Sector programme is that of Universal Health Coverage. 2.3 Strategic Directions The sector analysis by the MOHFW, through consultation with government, development partners and other health sector stakeholders, for the 4th HNP Sector Programme included assessment of progress under HPNSDP as well as emerging health issues across the country. Based on this analysis a set of eight strategic objectives has been formulated for the health sector over the five-year period from 2016 to 2021. These strategic objectives are grouped 24 into three components around governance, systems and services. An outline of the key outputs and priority actions under each strategic objective is presented in section 3 and related performance indicators are presented in the Sector Programme Results framework (Annex 2) Component 1: Governance and Stewardship of the sector  To strengthen governance and stewardship of the Strategic objective 1 public and private health sectors  To undertake institutional development for improved Strategic objective 2 performance at all levels of the system  To provide sustainable financing for equitable access to Strategic objective 3 health care for the population and accelerated progress towards universal health coverage Component 2: Stronger Health Systems  To strengthen the capacity of the MOHFW's core health Strategic objective 4 systems (Financial Management, Procurement, Infrastructure development)  Establish a high quality health workforce available to Strategic objective 5 all through public and private health service providers  To strengthen the evidence base for health sector Strategic objective 6 decision-making Component 3: Quality Health Services  To improve equitable access to and utilization of Strategic objective 7 quality health, nutrition and family planning services  To promote healthy lifestyle choices within a healthy Strategic objective 8 environment The strategic objectives have been categorized under three components, viz., Governance and Stewardship; Stronger Health Systems; and Quality Health Services. Each strategic objective has been defined in terms of specific objectives, major areas of activity and key indicators (see section 3). Some strategic objectives are further divided into specific objectives and outputs depending on their scope. Indicators, milestones and targets are further developed in 25 the 4th HNPSIP Results Framework (Summary in Annex 2) and outlined in detail in the Results Framework document and the Programme Implementation Plan. This allows budget allocation by components and activities, linking the budget with objectives and forms the basis for a more results based financing approach. 2.4 Cross-cutting issues Gender, Voice and Accountability in health Gender has important health implications for women in terms of access of services, engagement in risk behaviours, exposure to risk factors, understanding information about disease management, prevention and control. To achieve Sustainable Development Goals (SDGs) approaches that focus on gender issues including male engagement are needed. Gender would be considered at all stages of planning, design, budgeting, implementation and monitoring of the HPN sector. The Gender, NGO and Stakeholder Participation Unit (GNSPU) of MOHFW has worked on the development of a Gender Equity Strategy (2014) and will lead and coordinate the process of implementation over a period of ten years (2014-24). The primary goals are to respond to the needs and priorities of women and girls; prevent and respond to gender violence including prevention of child marriage and early pregnancy through strengthening health system. Bangladesh has one of the highest rates of domestic violence in the world, an estimated 50% of women in Bangladesh will experience violence in their home. In 2010, 35% of ever- married adolescents living in rural areas, and 40% living in urban areas had experienced some form of physical violence by their husbands. Sadly, domestic violence is thought to be a major contributor to maternal mortality, research has found that 14% of deaths among pregnant women were a result of injury due to violence. Female empowerment also influences health outcomes. The BDHS 2014 indicates a decline in under-five mortality rates as women’s participation in decision making increases. In the case of women who make no decisions, under-five mortality rate is 45 deaths per 1,000 live births, compared with 42 deaths per 1,000 live births for women who participate in all four decisions regarding their own health care, major household purchases, child health care, and visits to their family or relatives. Gender based violence and female empowerment would be addressed through the health sector plan as part of a comprehensive response. The health sector has a unique role to provide GBV screening and health care services unique to survivors of domestic violence, especially related to rape and sexual assault. A multi-sectoral response to gender based violence and gender overall would be prioritized in this health sector plan. Poverty alleviation - Reaching the Hard to Reach and vulnerable populations The tribal population in Bangladesh ranges from 1.5 to 2.5 million and constitute about 1- 1.5% of the total population of Bangladesh. There are about 45 different tribal groups spread across the country. The proportion of the tribal population in the 64 districts varies from less than 1% in the majority of districts to 56% in Rangamati, 48.9% in Khagrachari and 48% in Bandarban in the Chittagong Hill Tracts (CHT). Available disaggregated data shows clearly the disparities between sections of society. Reaching the geographically, socially and culturally more marginalised section of society is a major concern that will be addressed during this sector programme. Disaggregated data will be collected and monitored to demonstrate how progress is being made. This in turn will inform decision making on 26 priority action and resource allocation. The GOB’s approach is clear as indicated in the Vision 2021, that describes the political commitment to ensure skilled, motivated health service providers are in the right places to ensure that poor, disadvantaged, displaced populations and other vulnerable communities are cared for. Bangladesh is going through significant social and demographic changes, including rapid urbanization. At present about 27% of people of Bangladesh live in urban areas. DGHS has 35 urban dispensaries in urban areas and provides outpatient services including EPI and maternal and child health to the urban population. The primary and secondary care services to the urban poor, including over one million garment workers in urban slum areas, is a major concern. Urgent attention is needed to introduce a structured comprehensive primary healthcare package for the urban population. Current roles of the MOLGRDC and MOHFW in providing urban primary health care services are mentioned under ESP (section 4.0). The importance of public health The need to tackle the rise in Non-communicable and Communicable diseases through prevention is now an essential and urgent priority. Without reducing the rise in NCDs the already over stretched health system will become overwhelmed. The epidemiological transition is now evident and this needs to drive a change in policy focus that puts public health at the heart of the 4th Sector programme. Intense action needs to be on ensuring that people of all ages, but especially the young, adopt healthy lifestyles. This includes more work on improving people’s understanding of diet and exercise. Reducing salt and sugar intake, eating a balanced diet, avoiding tobacco and other harmful substances, and taking regular exercise are all key determinants of a healthy life. In support of self-responsibility, there may be need to adopt legislation to create healthy environments and opportunities for all, including the poor, to have access to safe and clean environments and safe food and water. This is a medium to long term endeavour and the benefits in terms of population well-being will take time to appear, however preventing the rise of ill-health will not be accomplished by the health care system alone. 2.5 Partnerships for health Partnership with the private sector In the Vision 2021, the government sets the goal of becoming a middle-income country by 2021. Participation of the private sector through PPPs is considered as an important route to achieving this goal. There is an increasing emphasis on the complementary role of the private sector through public private partnership and the critical importance of non-state actors. PPP objectives in healthcare are to contribute to the overall sustainability of the national health system, promote equity and access to primary care and affordable hospital care, promote equity in financing health services, and promote financial sustainability in the public sector. MOHFW has already initiated implementation of two dialysis centers at National Institute of Kidney Diseases and Urology (NIKDU), Dhaka and Chittagong Medical college Hospital respectively. Besides, review of the rehabilitation of two railroad hospitals using private sector management with the idea to implement pilot projects on a large scale is under consideration. The private sector also has a role to play in areas where public facilities are absent or functioning poorly. Private sector facilities can play a key role in provision of services especially in hard to reach areas. Contracting out non-functional health facilities to private 27 (for profit and not-for profit) providers is an option with a clearly defined negotiation, monitoring and supervisory role of the government. Community engagement and ownership There already exist many good examples of community participation in Bangladesh. Among them, two models are particularly worth paying attentions and drawing lessons learned. One is called “Chowgacha model,” basing experiences of Chowgacha Upazila Health Complex (UHC) for more than 20 years. Out of this model, new model has been emerging from Jhenaidah district hospital since 2012. The characteristics of these two models are: 1) Hospital centered model, meaning community mobilization initiated by hospital leaders for hospital improvement; 2) strengthening record keeping for generating data and use of data for decision-making; and 3) building up a participatory accountability mechanism for hospital management involving local administration, authorities and elites. These models tell us that if hospital staff are sincere and provide quality services, clients will come to the hospital to seek services even though the problem of limited resources still remains. Another prominent example of community engagement is demonstrated by Community Clinic Project (RCHCIB) of the Government, at present, reformed as Operational Plan of community based health care (CBHC) under DGHS. In contrast with Chowgacha/ Jhenaidah model, this model can be regarded as a Community centered model in character. The RCHCIB introduced a GOB led and structured community engagement framework consists of community group and community support groups. Community group (ex-community clinic management committee) is responsible in daily management of CC operation and resource mobilization while community support group is engaged in promotion of CC services, providing support to patients/clients, and raising awareness on health among community people. Creating CSGs was newly introduced during HPNSDP but CSGs have gradually being accepted as the government recognized platform of community mobilization for different community based interventions including MNH, nutrition and family planning. This model can be considered as a good example of public –private (e.g., NGOs and research institutions) partnership and multi-Ministerial collaboration for the purpose of ensuring primary health care services in Bangladesh. Consequently, the utilization of community clinic services and client satisfaction has been increasing constantly and more local government bodies coming forward to contribute to the improvement of CC services. Multi-sectoral approaches As the SDGs begin to gain traction in national level discussions on development it is clear that the HNP sector needs to work closely with other sectors. The MOHFW has a role to engage with other Ministries whose work has a bearing on HNP. Given that much remains to be done to bring the rates of stunting and micronutrient deficiencies down, issues that affect access to a safe, affordable and nutritionally adequate diet and impact nutritional status also need to be addressed. This will require concerted effort and action across multiple sectors e.g., food, agriculture, fisheries and livestock, social protection, education and health in order to improve dietary diversity, food quality and safety, and dietary practices. Additionally, close linkages with WASH and women’s sectors would need to be strengthened. Similarly, convergence and coherence in nutrition and food safety across sectoral policy domains and linking with mechanisms having adequate cross sectoral governance and coordination mechanisms in place is essential. 28 There is also scope for health related evidence to inform decisions on issues such as air and water pollution, food safety and agricultural practices, urban and school planning that incorporates green spaces and exercise facilities, legislation on issues such as roads, harmful substances and social policies including the role of law enforcement. Collaboration around healthy lifestyles and healthy environment can play a major role in keeping the burden of NCDs under control. 29

SECTION 3: STRATEGIC PRIORITIES FOR THE 4TH SECTOR PROGRAMME Strategic Framework of the 4th Sector Programme The eight strategic objectives have been formulated that in aggregate cover all aspects of the health sector including governance and stewardship, health systems, health services and the wider determinants of health. This framework presents the strategic objective with a set of output level objectives and broad indicative activity areas that are linked to detailed activity planning to be included in the HNP Programme Implementation Plan (PIP). A full set of indicators, targets and milestones are available in detail in the accompanying Results Framework 31 document (outline presented in annex 2). 3.1 Component 1: Governance and Stewardship Strategic objective 1: To strengthen governance and stewardship of the public and private health sectors Strengthening of governance and stewardship involves a substantial evolution in the way the sector is managed. There needs to be considerably more focus on stewardship and regulation on the part of the MOHFW and more emphasis on developing partnership between the public and private sectors in ensuring high quality care for all as the country works towards Universal Health Coverage. To do this will require a review of capacity in key areas of stewardship and regulation at different levels of the government system combined with a range of institutional changes in function and structure. Outputs Priority activities • Organisational capacity assessments of key Directorates, Departments, Agencies and Professional bodies 1.1 Strengthen the capacity of • Capacity strengthening programme (staff and skills) MOHFW in governance, • Strengthening of regulatory bodies and clarification of roles and leadership and management responsibilities • Introduction of mentoring scheme for senior managers • Enact / amend laws, including o Law for regulating private medical and dental and nursing colleges 1.2 Improve the legal and o Amend Private Clinic Act operational framework on o BMDC Act governance and stewardship • Development and introduction of standards and accreditation systems for the public and private sectors. 31 Detailed definitions and source for each indicator is provided in the Results Framework document 30 • Build capacity in governance and accountability across local levels of health system • Expand local accountability, transparency and governance 1.3 Improve local governance mechanisms and accountability in health • Scale up active community participation in operating hospital and community health programmes (learning from existing models such as the Chougachha Model) • Inclusion of public health in inter-ministerial policies through evidence based advocacy • Capacity building amongst national and local decision-makers on 1.4 Promote inclusion of public the role of public health health in inter-ministerial • Agency level (joint) strategy and planning on important inter- policies through collaboration Ministerial issues: tribal health, nutrition, food safety, climate with relevant bodies change, use of chemicals in agriculture. • LCG and Health Council meetings consider health related inter- ministerial issues Strategic objective 2: To undertake institutional development for improved performance at all levels of the system Clear institutional roles and responsibilities are fundamental to improved performance across the sector. Ensuring the correct functions are taking place at the appropriate level of the system, that the institutional arrangements are effective and that there is strong coordination and harmonisation at all levels will enable the efficiency and equitable use of resources. The current institutional set up at national and sub-national levels needs to be reviewed early in the new programme with a view to rationalisation, removal of duplication, establishment of new functions and an overall clarity of roles and responsibilities. Organisational Capacity Assessments (OCAs) of all key institutions will provide a mechanism for self-assessment and capacity planning and monitoring of continuous improvement. Outputs Activities • Assessments of organizational capacities, structure, operational plans, and related resourcing to maximize efficiency and effectiveness • Implementation of agreed action plans from assessments (e.g. 2.1 Rationalisation of reorganization of FMAU) institutional arrangements and functions within MOHFW • Strengthen aid effectiveness arrangements, practices and reporting • Review existing coordination mechanisms including use and functioning of committees. • Improved management and administrative structures and functioning at all facilities from District hospitals down to 2.2 Develop and make functional Community Clinics. institutional arrangements at • Set up institutional arrangements for engaging communities at all District and below. levels from District to Community Clinic, including feedback mechanisms. 31 2.3 Ensure oversight and • All laws would be examined in light of human resource needs management capacity is in place • Institutional strengthening in support of Health workforce for human resource planning and development across the strategy and planning sector • Review of regulatory and accreditation bodies and develop new competencies and entities for specialized activities 2.4 Establish new • Establish mechanisms for development and monitoring of health organizational entities and standards capacity for new stewardship and regulatory role • Collaboration with LGD and a permanent institutional mechanism on urban health Strategic objective 3: To provide sustainable financing for equitable access to health care for the population and accelerated progress towards universal health coverage A major focus over the next 5 years will be to increase the total health funding available for essential health care services. This will be achieved through demonstrating the positive economic gains of investment in health as well as ensuring efficient, effective and equitable resource allocation. Financing of the sector will come under increasing pressure from the rise in population, the ageing of the population and the rapid rise of non-communicable diseases. While per capita investment in health by government is still low and the economic growth continues in a positive direction, the outlook for proportionate rise in resources from government is not assured. Growth and sustainability in the finances for health will be a combination of managing demand for services, the efficient use of available resources and establishing a convincing investment case for government, development partners and the private sector. Three scenarios are provided in section 6 for the HNPSIP financial envelop. The degree to which senior management and its partners can achieve progress in the issues above will have a considerable influence on which of these scenarios actually happens. Outputs Priority Activities • Evidence based advocacy for increased government budget allocation for the health sector (based on regular PER and NHA) • Explore new and innovative sources of financing for the health sector: o Tobacco tax (‘sin taxes’) allocation to health 3.1 Increase overall financial o New taxes on environmental pollutants resources in the health sector o A Trust Fund in line with the NHFS o Private sector investment in health systems o Public Private Partnerships to mobilize resources. o Research into innovative financing • Evidence based advocacy for increased on and off budget funding from Development Partners. • Implement the Health Care Financing strategy through close coordination with the NSSS - national social health protection 3.2 Achieve equitable access to scheme - to strengthen financial risk protection and extend health services and financial services and population coverage with the aim to achieve protection, especially for people universal health coverage. in the bottom 40 percent • Explore pooling mechanisms, as part of the national social health protection scheme, via contributions from the formal sector and the middle and upper-middle classes. • Complete pilot and implement the resource allocation formula. 32 • Increase budget allocation to public health/primary health care activities. • Increase supervision and monitoring systems across all tiers of the health system • Reduce wastage across procurement practices, especially in area 3.3 Enhance efficiency in of infrastructure development. financial resource allocation • Explore contracting out (including PPP) highly specialist services, and use non-functional facilities, and facilities for underserved hard to reach populations to the private (for profit and not-for profit) sector. • Promote results-based financing as a strategy used to improve health systems efficiency • Improve coordination between sector programme and DP- supported off-budget programmes 3.2 Component 2: Health systems strengthening Strategic objective 4: To strengthen the capacity of the MOHFW's core health systems (Financial Management, Procurement, Infrastructure development) Three core systems that underpin administration and operations of the sector are highlighted under this objective: Procurement and supply chain management The focus is on improvement of the procurement process, including strengthening procurement planning, distribution and contract management. It will also look at improved quality and efficiency, capacity and regulation of the pharmaceutical sector. Procurement needs to be based on actual needs, better coordination between DGFP and DGHS and avoidance of procurement from multiple sources. Infrastructure development The focus is on improved coordination, completion of infrastructure into active service centres, new construction in less attended areas only, and developing and implementing comprehensive maintenance plans for both infrastructure and equipment with adequate budget. Public financial management The focus is to overcome the existing challenges and make the FM&A of the next sector programme more transparent while reducing the financial and fiduciary risks in the next sector programme. These three systems have been highlighted in sequential reviews of the last two sector programmes for more attention. Building capacity in terms of systems and skills is key as is the strengthening of internal supervision and control systems. Substantial efficiency gains could be made if these three core systems are improved. 33 Outputs Priority Activities 4.1 To ensure availability and quality • Strengthen procurement planning, process, of medical products including life- distribution and contract management saving drugs, vaccines, contraceptives • Improve quality and efficiency of procurement and necessary equipment through an effective, efficient and transparent • Strengthen capacity of CMSD and other departments procurement and supply chain • Improve regulation of the pharmaceutical sector management process • Improve coordination between different departments involved in infrastructure development 4.2 To ensure efficient investment on • Make the completed physical structures into active physical infrastructure through service centres enhancing effective use of existing • Prioritize new construction to be focused on areas infrastructure and making balance among new construction, maintenance that lack facilities and repair • Develop comprehensive maintenance plans for both infrastructure and equipment • Strengthen Financial Management at individual, 4.3 To make the Financial processes and systems levels Management and Audit more • Increase capacities of the OP management and transparent and reduce the financial directorates and fiduciary risks in the next sector • Strengthen the Audit System programme • Establishing advisory role of FMAU • Quickening fund release Strategic objective 5: To establish a high quality health workforce available to all through public and private health service providers This objective includes specific objectives related to the roles and responsibilities of all cadres at all tiers of the system, recruitment and retention, quality, efficiency and medical education. It includes all public, private and AMC health workers. Human resources for health have been identified by all stakeholders in the sector as a key strategic priority. It is an issue that cuts across all the other strategic objectives as people are at the centre of all systems and services. A range of important priorities has been highlighted in the Human Resources for Health report (STG, MOHFW, 2015) 32. The need for a comprehensive review of HRH and the implementation of the Health Workforce Strategy and corresponding Action Plan is a major priority. Improvements in the way staff are selected, training, distributed and supported are recurrent themes in all reports looking at the health sector. The need for an improved human resources information system linked to DHIS has been advocated as has the need to tackle issues of skill mix, task shifting and contracting or outsourcing (MTR, 2014). A thorough review of capacities and competencies linked to improved pre-service training and in-service support is needed. Careful consideration is needed as part of the Health Workforce Strategy to where and how to allocate resources for production of new health workforce of all disciplines. The resourcing of new medical colleges needs to be done based 32 MoHFW (2015). Strategic Thematic Area: HRH – STG Report – August 2015 34 on thorough analysis. Academic institutions that produce the required range of skills such as midwives, nurses, laboratory technicians, etc. must be fully considered as must the incentives and requirements of health workforce once qualified. The current health workforce is insufficient to provide quality health care services needed. More must be done to ensure the marginalised and remote areas have health workers that will work in these areas. The Health Workforce Strategy would look beyond the public sector to include AMC and private sector health workers and look creatively at how these different parts of the overall health sector can work together more effectively and efficiently. The regulatory frameworks and capacities needed to develop the HRH strategy and implement the Action Plan would also be put in place and the resources provided to enable the managers responsible to carry out their tasks. Outputs Priority Activities • Finalise and implement integrated Health Workforce Strategy • Finalise and implement 5-Year comprehensive Health Workforce Action Plan, costed and prioritised. 5.1 Ensure availability of • Review the organogram of all health and family planning facilities competent and adequate and entities number of workforce as per health systems need • Address shortage and skill mix, including ratio imbalance, task shifting (see HWF strategy) • Develop and implement policy on outsourcing service delivery. • Improve quality of public and private pre-service health workforce education system (including for AMC providers) • Integrated in-service training, linked with career development. • Capacity development to ensure better management within district level and below 5.2 Develop and sustain quality health workforce at all level • Introduce and/or strengthen quality assurance of medical education at both private and public sector institutions through licensing and accreditation • Review professional licensing and accreditation of health professionals • Rationalize job descriptions of HWF at different level of services based on changing needs • Recruitment and retention planning, including incentives to address distribution issues particularly for 5.3 Recruit, deploy and retain underserved/disadvantaged areas, appraisals and career health workforce equitably planning. • Introduce innovative, unbiased and decentralized health workforce deployment and transfer system. • Gender sensitive HWF planning and implementation • Establish one HRIS that is linked to national HIS 5.4 Use evidence to support • Establish monitoring framework for implementation of HWF decision making in improving HRM Action Plan 35 Strategic objective 6: To improve health measurement and accountability mechanisms and build a robust evidence-base for decision making. Based on the experiences, situation assessments and comprehensive analyses of the HNP sector programme’s annual reviews in the past years, appropriate and strategic advocacy will need to be carried aimed at health sector managers so that they make better use of data and evidence in HNP planning and decision making. Support to strengthening and effectively using national HIS will have to be continued along with ensuring adequate funding. An institutionalized system for regular HIS training and updating of skills of staff, keeping in mind their specific needs, will have to be established. The key principles of national HIS and eHealth would be building on existing resources, standardization, interoperability, harmonization, integration and efficiency in every aspect such as in data collection, selection of software and hardware, engagement of human resources, and effective data sharing and use by all relevant stakeholders. Key research organizations will have to be strengthened and possibilities of harmonization of population based health surveys will have to be explored. An effective mechanism will be created for the utilization of all the survey and research findings. Outputs Activities • National scale up of the electronic tracking system of citizen’s health • Improve integration of the health information and eHealth 6.1 Move towards fully digital platforms existing amongst different agencies and routine health information stakeholders. system by 2021 • Strengthen the use of ICD-10 coding system in healthcare facilities • Make routine mechanism for evidence based decision making in MOHFW • Implement the M&E Strategy and Action Plan (MESAP) • Monthly OP-wide ADP Review, both on financial and physical progress. 6.2 Strengthen sector programme monitoring and • Prepare six-monthly program implementation report (SmPR) evaluation (M&E) processes and annual program implementation report (APIR) through effective utilization of • Annual Programme Reviews (APR) by Independent Review evidences available from all Team (IRT) and ensure use of APIR data generated by PMMU possible sources (routine data, in APR surveillance, CRVS, survey, research, etc.) • Institutionalize Data Quality Assurance (DQA) mechanisms • Improve coordination and harmonization of the population based health surveys • Develop inventory of survey and research publications and Enhance efforts for disseminating data, reports. 6.3 Establish partnerships with • Establish Indicator Reference Group relevant institutions for • Promote innovations in data production and utilization facilitating data demand, updating and utilization in • Strengthening community engagement and feedback through MOHFW and its agencies and data and information sharing for promoting transparency and departments accountability. 36 • Develop and implement multi-year, comprehensive training 6.4 Develop and implement plans multi-year, comprehensive HIS, • Conduct orientation of LDs and core OP staff in Planning, eHealth and M&E training plans Monitoring and Coordination; for capacity building of • Conduct organizational assessment and restructure and managers and staff strengthen the MIS units on all required dimensions of national HIS. • Allocate sufficient and adequate fund to sustain, expand and further strengthening HIS, eHealth and M&E activities 6.5 Increase budgetary • Support specific agencies, organizations and institutions under allocation for HIS, eHealth and MOHFW (NIPORT, NIPSOM, HEU, BMRC, IEDCR) to conduct M&E activities to sustain and planned surveys timely further build on the progress • Develop resource mobilization strategy for sustaining and increasing budget for HIS, eHealth and M&E activities. • Strengthen the key research institutions • Strengthen BMRC to play its desired role as the competent focal national health research institution • Strengthen NIPORT to play its desired role as the competent focal national FP research institution • Strengthen the coordinating role of Planning Unit in DGHS for 6.6 Promote research culture research across MOHFW and develop • Review and update the National Health Research Strategy research plan 2009 • Mainstream academic/operational research with national health priorities • Build up capacity of the policy makers, health managers and health professionals on utilization of data and research findings. 3.3 Component 3: Provision of quality health services Strategic objective 7: To improve equitable access to and utilization of quality health, nutrition and family planning services This strategic objective includes the main service delivery component of the 4th sector programme. It captures primary, secondary and tertiary services including preventive and curative services. It is the major cost driver of the sector where the majority of human resources and supplies are focused. A major focus would be on achieving improved service integration while ensuring individual services are of a high quality and accessible to all. There is a clear emphasis on the need to scale up and strengthen community-based public health interventions towards achieving the goal of equity and to enhance the quality of health services. Innovative approaches to improving efficiency are essential as is ensuring motivated staff present at their designated posts to deliver quality care to all of the population. Collaboration between the public and private sector will be a key element of ensuring access to specialist services as well as functional care in hard to reach areas and for vulnerable groups. This section includes: 1) Maternal, Neonatal, Child and Adolescent Health, 2) Family Planning, 3) Communicable and Non-Communicable Diseases, 4) Nutrition and Food safety; and 5) Alternative Medical Care (AMC). It addresses the pluralistic service delivery that exists in Bangladesh and includes the public and private sectors. 37 MNC&AH services remains a key area for health provision in this sector programme and is a major component of the proposed Essential Services Package. Particular attention will be needed to ensure improvement in quality of services and their expansion into hard to reach and other underserved populations. The issue of neonatal mortality has been flagged as an area of special attention as progress has been slow during HPNSDP. The existing family planning programme will be strengthened through delivering regional packages in less well performing divisions/pockets. Shifting of existing method-mix of contraceptive use to include an emphasis on long acting and permanent methods (LAPM) will continue to be promoted through informed voluntary choice and counselling. Other FP approaches will be targeting newly-wed couples, particularly adolescents to delay the first birth; addressing the existing unmet need and reducing the discontinuation through improving collaboration with DGHS and others to ensure services of skilled medical personnel like doctor, nurse and paramedics. The mainstreaming of nutrition needs to be prioritized throughout every level of the health system and integrated effectively into maternal and child health and family planning services (MNCH & FP). Better intra-ministerial coordination, planning and management is required to ensure that nutrition services are meaningfully delivered and the levels of severe malnutrition and stunting are reduced. At the same time the dual burden of nutrition needs to be recognised and attention given to the rising problem of over-nutrition, poor diet and food safety. The rise in NCDs is now well documented and recognised by MOHFW decision-makers as a major area for action in the sector programme. The current rise in morbidity and mortality will not be manageable within the resources available to the government for health care provision. While treatment services must be provided the access to specialist tertiary care will be limited and in many cases available through private facilities or where some form of PPP arrangement is in place. The combined approach to prevention and treatment is recognised as essential if the rise in NCDs is to be managed. Similarly, the importance of providing prevention and treatment for communicable diseases continues to be a priority. The rise in drug resistant TB combined with an alarming rise in antibiotic resistance amongst many pathogens is reaching a crisis point. Rationale use of drugs in now urgently needed, as is their limitation in agricultural usage. Strengthened programmes are needed for the range communicable diseases such as HIV and STDs, vector and water borne diseases. The use of AMC in support of many NCDs also needs to be recognised and promoted. Outputs Priority Activities • Definition and implementation of Essential Health Service 7.1 Establish service level Package (ESP) as per service delivery tiers integration across tiers of the • Implementation of functional integration of services approach, system including role out of including collaboration with private sector providers (new) ESP and establishment of • Establishment of effective referral system including ambulance effective referral systems services 38 • Upgrade UH&FWCs to provide 24/7 normal delivery and primary care for sick newborns • Endorse National Adolescent health strategy and implement 7.2 Achieve effective and action plan equitable coverage of evidence • Endorse Maternal Health Strategy, prioritise facility delivery, PNC based high impact maternal, and PPFP neonatal, child and adolescent health (MNC&AH) care • Implement BENAP (including new interventions) interventions • Implementation of national midwifery strategy, and increased facility delivery • Continuation and expansion of safety net programmes (e.g. DSF) • Strengthen FP services for post-partum, post MR/ PAC • Implement regional service package for FP (HTR, CHT, urban 7.3 Achieve effective and poor and low performing areas) equitable coverage of family • Raise awareness regarding method mix including LARC&PM, planning services delay of first pregnancy and birth spacing among adolescents • Implement National Nutrition Strategy • Strengthen strategic leadership and investment required to complete and consolidate mainstreaming of nutrition services 7.4 Improve nutritional status of • Increase coverage and quality of preventive community outreach the population and tackle the services dual burden of over and under • Increase facility readiness to deliver nutrition services including nutrition. monitoring • Pay attention to severe acute malnutrition • Strengthen inter-ministerial and multi-sectoral collaboration on nutrition and food safety (e.g. institutionalization of NPAN) • Development and implementation of effective, integrated, sustainable, and evidence-based public policies for non communicable diseases 7.5 To reduce mortality and morbidity of NCDs in Bangladesh • Strengthening the capacity and competencies of the health system through strengthening measures for the integrated early detection, management of non for control of risk factors, and communicable diseases and their risk factors. health service delivery options • Development and strengthening of capacity for surveillance of for early detection and non communicable diseases management. • Provision of services for conventional and non-conventional NCDs, in particular, mental health, GBV, suicide, injuries and poisoning • Intensify programme for control, detection and management of 7.6 To reduce mortality and morbidity due to Communicable tuberculosis, especially MDRTB Diseases in Bangladesh through • Develop and implement special programme on rational use of strengthening of measures for antibiotics control of risk factors, and • Strengthen programme on vector borne diseases, including health service delivery options elimination programmes for malaria, kalaAzar, filariasis for early detection and • Strengthen priority programmes, e.g. hepatitis, typhoid, dengue, management. HIV/STDs 7.7 To provide equitable access • Endorse and implement the AMC Strategy and Action Plan to high quality Unani, Ayurvedic • Strengthen AMC regulatory authority to regulate practitioners & Homeopathic medical service through a certification/registration system for all citizens of Bangladesh • Raise awareness about AMC and treatments especially for NCDs 39 • Build-up capacity of AMC service providers by conducting orientation, workshop & training and increase collaboration with local health facilities • Promote environmental and health value of medicinal plants and importance of promoting their conservation and cultivation Strategic objective 8: To promote healthy lifestyle choices and a healthy environment Investments in lifestyle choices and healthy environments will reduce the future costs of treating the rapidly expanding incidence of chronic non-communicable diseases. The projected increase in NCDs if unchecked will require huge investments in specialist medical centres, diagnostic equipment, highly trained specialist health staff and expensive pharmaceuticals. Given the funding gap that exists in the health sector, this will be a financial burden that the country will find difficult to afford. Reaching the young with effective public health messages will be key to averting NCDs. Outputs Priority Activities • Evidence based advocacy for enforcement of legislation • Introduction of appropriate measures in line with legislation e.g. 8.1 Establish legislative no smoking zones framework for healthy lifestyle • Develop guidance and health related evidence for promotion of and healthy environment green urban spaces and recreation areas for the public • Support legislation on air standards and controls in Industrial areas • Capacity development, including pre and in-service curricula, on lifestyle choices, public health and school health 8.2 Establish a clear strategy • Promotion around healthy diet, the hazards of salt, oil and sugar, and plan of action for lifestyle and need for high fruit and vegetable intake choice • Action to stop smoking and substance abuse • Public education campaigns about the benefits of exercise • Develop lifestyle and environment strategy in collaboration with other Ministries and stakeholders 8.3 Integrated communication • Establish youth reference group for creative development of strategy based on new media strategies to connect with young people platforms, including BCC • Develop and implement social media strategy • Roll out of targeted knowledge products via media platforms • Promote safe and healthy environments within health facilities, household, workplaces and schools, including overall cleanliness, ordinary and medical waste management, sanitation facilities, • Improved protection of water sources at community level and in 8.4 Establish inter-sectoral urban slum environments collaboration on healthy • Promote importance of air quality especially involving cooking environments, including private sector engagement fuels and urban air controls especially linked to vehicle emissions • Promote value of urban Green spaces including in new urban developments. Promote the important of biodiversity and health • Promote Road and Waterway safety 40

SECTION 4: AN ESSENTIAL HEALTH SERVICE PACKAGE - THE FIRST MILESTONE ON THE ROAD TO UNIVERSAL HEALTH COVERAGE An Essential Health Services Package (ESP) An efficiency-oriented package of essential services of low cost and modest ambition has been advocated in many countries and this approach remains a priority in Bangladesh with lessons learnt from implementing past SWAps. The current ESP is composed of five components: i) Reproductive Health Care; ii) Child Health Care; iii) Communicable Disease Control; iv) Limited Curative Care; and v) Behaviour Change Communication. An updated version of ESP has been proposed with additional components (and sub-components) of prevention and control of Non-Communicable Diseases (NCDC) and Nutrition services. Under the 4th health sector programme the intention is to implement a cost-effective ESP as a strategy for ensuring equitable access to quality health, nutrition and population services for the entire population of the country with a view to attaining Universal Health Coverage (UHC). The current proposal for the Essential Service Package (see annex 1 for indicative elements) has been developed by updating and modifying the existing one, based on the following key considerations: • Ensuring equity and efficiency for universal access to and utilization of quality HNP services at various tiers; • Prioritizing service components that have high impact on disease burden, and potential for improving health and nutrition services, are cost effective, and can be delivered successfully provided a skilled health workforce is available at each level; • Establishing an effective referral system to keep the continuum of care throughout the hierarchal infrastructure; • Giving special attention to the varying needs of hard to reach (HTR) and vulnerable population groups; and • Keeping in view long term sustainability of the services and community engagement at all levels. Bangladesh has a good network of infrastructure but there are still challenges related to the availability of adequate and appropriate health workforce. This proposed version of Essential Service Package is intended to encourage care seeking for common ailments at lower levels, help in establishing a referral system to the higher level facilities, and improving the quality of care at each tier of service delivery. Implementing ESP by Tiers The Essential Service Package (ESP) will be delivered through four tiers of service delivery to strengthen Primary Health Care (PHC) with the goal of achieving Universal Health Coverage (UHC). • Community level: Domiciliary services; satellite clinics; outreach services; and Community Clinic (CC). • Union Level: Health & Family Welfare Center (UHFWC); Sub-Centers and MCWC. • Upazila Level: Upazila Health Complex (UHC) and MCWCs. • District Level: District Hospital (DH) and MCWC. 41 Tier-1: Community Level facilities • Domiciliary Visits; Satellite Clinics; and Out-Reach Services • Domiciliary Visit: Field staff both from DGHS and DGFP conducts house-to-house visits in the community for providing services to the clients in their respective geographical work areas. • Satellite Clinics and Out-Reach Services: Satellite clinics (8 in each union per month) and EPI Out-Reach Services (24 per month in each union) are providing designated services through Health and Family Planning field workers. • Community Clinic (CC): 14,000 Community Clinics have been established, one per 6000 people to provide health care service to the door step of the community. Each Community Clinic is served by Community Health Care Provider (CHCP), a Health Assistant (HA) and a Family Welfare Assistants (FWA). Tier-2: Union Level Facilities (UHFWCs; Sub-Centres; and MCWCs at union) Union Health and Family Welfare Centres (UHFWCs) are located at Union level. These facilities are staffed with a Doctor, a Family Welfare Visitor (FWV); a Sub-Assistant Community Medical Officer (SACMO) and a Pharmacist. There is provision of residential accommodation (for SACMO and FWVs) in upgraded UHFWCs. There is also provision of office space for the Family Planning Inspector (FPI) in the UHFWCs. ); Tier-3: Upazila Level Facilities (Health Complex (UHC) and MCWCs at Upazila) The Upazila Health Complex (UHC) is the first level referral center established at Upazila. These hospitals have been upgraded to 50 bedded facilities. These are staffed with Upazila Health and Family Planning Officers (UHFPO), Resident Medical Officers (RMO), Medical Officers (MOs), Medical Officer-MCHFP, Upazila Family Planning Officers (UFPO), Specialist Doctors (Consultants); Staff Nurses; Lab. Technologists; and a cadre of field staff. The Upazila Health Complexes have both outpatient and inpatient facilities. Tier-4: District Level Facilities (District Hospital and MCWCs at District) Out of the 64 districts 59 have District Hospitals and these are in the process of being upgraded from 100 to 200-250 bed hospitals in phases, with provision of trained manpower and necessary equipment. District hospitals are specialized health care facilities with consultants from relevant disciplines to provide services. The district hospitals will serve as the secondary referral centre. Maternal and Child Welfare Centres (MCWCs) in the districts are providing maternal, neonatal, child and family planning services. These facilities are staffed with trained Medical Officers and FWVs. Effective implementation of the ESP largely depends on the following key elements and supportive policy and strategic directions:  Standard set of staff by number and categories considering the level and capacity of infrastructure, equipment (ToE), and uninterrupted supply of drugs and commodities.  Technical capacity and managerial skills of staff and high level of motivation.  Effective supervision at all tiers of service delivery.  Access to new technology involving scaling up ICT and telemedicine/e-Health.  ESP Implementation Guideline and Standard Operating Procedures (SOP). Functioning of an Effective Referral System Following activities would be taken to establish an effective referral system: 42 • Development and implementation of Referral Guidelines. • Orientation of service providers on their roles and responsibilities. • Introduction of steps for implementation of HNP services with provision of financial back up for the poor.. • Defining referral criteria at each level of service from Community to Union, Upazila and District level. • Establishing support facilities with transportation, referral slips, referral register, preferential treatment at the higher facility where referred to, etc. Special Attention to Hard to Reach and Vulnerable Populations Providing services to the population of hard to reach (HTR) areas and vulnerable population remain as a major challenge in the HPN sector. This will be addressed through following approaches: • Increased participation of NGOs and private sector agencies. • Mobile clinics and organized specialists’ visit. • Enhanced inter- ministerial and inter –sectoral coordination. • Promoting e-Health system. • Enhanced budget and financial support. Essential Service Package for Urban Areas Urban primary health care (PHC) services are the responsibility of the MOLGRDC allocating provision of preventive and limited curative care responsibilities to the City Corporations and Municipalities 33. Though the secondary and tertiary level health care facilities are providing PHC services in the urban areas, but the PHC services for the urban population, and particularly for slum-dwellers, need more attention to meet the increasing demand of urban population. Since 1998 urban primary health care project (UPHCP) is being implemented in phases by the city corporations and municipalities through contracted NGOs in addition to provision of contraceptives, vaccines and out-patient PHC services by the secondary and tertiary hospitals under the MOHFW. The non-project urban areas are also being served by the health facilities of MOHFW. To reach the urban poor, there are around 4000 satellite centres and 35 urban dispensaries (under DGHS) for outdoor patient services including EPI and MCH services. Many NGOs provide PHC as well as some specialized services (e.g. 52 HIV/AIDS clinics; 158 PHC centres, 34 comprehensive centres; 56 DOTS centres; and 47 VCT centres; etc.). An Essential Service Package should now be implemented in urban areas by stakeholders under the guidance of MOLGRDC, MOHFW and NGOs. The MOHFW will coordinate and play the stewardship role and provide necessary technical support with a view to ensuring quality HNP services to the urban population. In the 4th SWAp equitable access to a quality package of essential health care services is emphasized. An effective referral linkage amongst the tiers must also be established to achieve the goal of universal access to and utilization of services at all levels. The Draft Essential Service Package components are detailed in Annex 1. This has been developed based on the existing ESP, and through wide consultation amongst Line Directors, Programme Managers and Deputy Programme Managers of all concerned service components under DGHS and DGFP, Development Partners and other stakeholders. 33 Municipal Administration Ordinance, 1960; Pourashava Ordinance 1977; City Corporation Ordinance, 1983; and Local Government, Pourashava Act 2009. 43

SECTION 5: HNPSIP IMPLEMENTATION AND PERFORMANCE MANAGEMENT 5.1 Organisation and Management MOHFW structure and function There has been considerable discussion during the HPNSDP about the need to improve the organisational arrangements within the MOHFW. The MTR 2014 recommended that, “a review of the institutional and organisational set up of the MOHFW should be commissioned as part of the preparations for the next sector programme. This should look at key functions and organisational issues and include consideration of restructuring, such as number of Task Groups (TGs), Operational Plans (OPs) and the current DGHS and DGFP arrangement”. This has also been debated at the Policy Dialogue in 2014 and again the need to look at improving the effectiveness of sector management was seen as important. In the development of the HPNSDP strategic plan, the number of OPs was reduced to 32. This was a positive step forward to both reducing the complexity of budgeting and planning as well as a modest rationalisation of functions to remove elements of duplication. However, managing a large number of OPs efficiently and effectively still remains a challenge. It is therefore important to review the number of OPs for better coordination and effective SWAp implementation for the next sector programme, whilst at the same time merging or reformulating OPs where overlapping responsibilities and duplication exist. This will be accomplished through careful analysis of existing OP’s purpose and activities. There may be many opinions about the best structure and function of the MOHFW. One approach is to look to maintain the current divisions into DGHS and DGFP and strengthening these in areas of core responsibility. GOB has taken a policy decision to restructure MOHFW into two Divisions, in place of the current single Division, with a view to improving administrative efficiency and providing better service. The Ministry however will have a single PIP for the next sector programme to achieve strategic objectives agreed in the HNP SIP. The 4th Sector programme is well timed to initiate such a revision of structure and function and to move to a more rationalised organisation. Committees and decision-making Consultations with HNP sector government and non-government officials highlighted the need to improve the way policy and strategy are formulated and reviewed. This should be seen as a process of continual improvement as there are many recognised positive aspects to the current situation. The joint Annual Programme Review (APR) process, Mid Term Review (MTR) and Policy Dialogue are all cited as useful. However, as noted in the MTR (2014), the “current mechanisms for HNP sector policy and strategy dialogue between MOHFW (and other Ministries) and DPs would be reviewed with a view to establishing a more effective mechanism”. Various joint task groups (TGs) and technical committees (TCs) operate under the sector programme. These arrangements will continue to work during the 4th Sector Programme and additional task groups may also be formed with new membership when new issues and challenges arise. More specific attention will be given to setting meeting agenda agreed in advance, papers provided in advance, more time for discussion, and appropriate level of participation for making the TGs and TCs more effective. This also relates to meetings such as the LCG (Health). The LCG sub-group on Health will be the meeting point where the senior 44 management structures of the MOHFW meet with the representatives of the DPs in the sector. MOHFW and the DPs would work together to make the LCG sub-group more effective. Aid Coordination /Aid effectiveness The establishment of a large “pooled fund”, financed by the development partners has certainly contributed to improve working relationships between the government and its development partners. In this aid modality practice since the beginning of SWAp in 1998, the World Bank has undertaken the responsibility to manage the pool fund on behalf of the DPs through a Multi Donor Trust Fund (MDTF). Experience acquired with the funding modalities under the three sector programmes may serve to improve effectiveness of SWAp implementation for the next sector programme. HPNSDP had 32 different OPs under MOHFW and different agencies and effective coordination among them is immensely important. For more effective SWAp implementation, steps would be taken to focus on improved coordination and functional relationships within MOHFW and agencies under it, for example between DGHS and DGFP service delivery strategies, and with other relevant ministries, notably MOLGRDC and MOCHTA. Some major players (Development Partners), continue to provide complementary support through vertical instruments that are not well integrated with government implementation arrangements. During the 4th Sector Programme work would be done to improve coordination and to bring in the off-budget contributions into the GOB- DP coordination platforms. Restructuring key implementation institutions Financial management and procurement constitute key support functions in Program implementation. Over the years, the challenges of financial management of the increasingly large SWAp and ensuring highest standards of transparency and accountability led MOHFW to take various administrative steps together with steps to strengthen oversight and control systems. As part of MOHFW’s intentions to improve functioning of the Financial Management and Audit Unit (FMAU), steps have been taken to restructure it. The proposal of FMAU’s reorganization has been undergoing scrutiny for approval of the relevant ministries (e.g., Ministry of Public Administration, Ministry of Finance) of the Government. The restructuring of FMAU has also been included as part of the Integrated Fiduciary Assessment Action Plan (IFAAP) to improve its oversight capacity. Moreover, actions to resolve audit issues will be further strengthened in the 4th Sector Programme to ensure continued support and investment of DPs in the HNP sector. Similarly, MOHFW has taken a series of steps for improving efficiency in procurement during the current Program with TA support. HPNSDP also introduced a new institution - the Procurement and Logistics Management Cell (PLMC) assisted by a TA team to support system change in procurement and logistics management of supply chain. These efforts have led to visible improvement in results and so, support for continuation of PLMC during the next sector programme is essential. Moreover, an assessment has been started to establish the staffing structure of a strengthened Central Medical Stores Depot (CMSD), which also forms part of the IFAAP. Performance monitoring and sector reviews As in previous sector programmes the Results Framework (RFW) will be the main tool against which progress will be measured during annual reviews and the mid-term review of 45 the sector. Adjustments can be made at the time of these reviews to the annual milestones and targets based on measured and verified progress. Six-monthly, Annual and Mid-term reviews currently prepared by Programme Management and Monitoring Unit (PMMU) provide an opportunity for government and the Development Partners to jointly review progress, assess aid performance and review the allocation of resources and prioritisation of activities. In support of monitoring progress across the different aspects of the sector’s performance, work must be continued to produce good quality data from both routine and periodic surveys and studies. New data sets will be developed to meet the needs of assessing performance in new strategic priority areas such as NCDs and lifestyle and healthy environment issues. As these data become available the RFW can be further developed. A Programme Management and Monitoring Unit (PMMU), assisted by a technical assistance support team (TAST) was set up in 2012 in order to provide technical support to the Planning Wing of MOHFW in monitoring & evaluation, coordination work and in tracking the performance of HPNSDP. The PMMU has produced six-monthly and annual implementation progress reports on a regular basis, which fed into the annual programme reviews of HPNSDP. These activities have produced useful results in gaining management efficiency by the implementers, the policy makers and the Development Partners. The contribution of PMMU in program monitoring is also well recognized (MTR 2014). Continuation of PMMU during the next sector programme is essential with a view to effectively handle monitoring and management functions of a mega programme like the 4th SWAp. Risk mitigation strategies and management An important aspect of the sector investment plan is a comprehensive assessment, tracking and management of risk. This includes political, institutional, financial, programmatic and environmental components. As part of the management of the sector a risk matrix will be prepared in consultation with the stakeholders, and that will form the basis of risk management. Where risks cannot be mitigated a plan for management of these risks will be put in place. As part of on-going management of the Programme implementation regular review of the risks will be undertaken. This would also be part of the annual and mid-term review process. Coordinated Technical Assistance The pooled TA fund titled “Joint Donor Technical Assistance Fund (JDTAF)” as a new initiative of HPNSDP implementation, is an effective institutional arrangement for sector management and TA coordination. On behalf of the DPs, the JDTAF is coordinated and managed by DFID. A Technical Assistance Committee (TAC) comprising MOHFW, agencies under it and DP representatives oversee the TA proposals, review and recommend for endorsement by the government. A database has been developed with 130 national and 32 international consultants. A Harmonized TA Plan for FY 2014-15 was developed for effective TA coordination. This mechanism will be continued in the 4th Sector Programme and efforts will be made to expand the number of partners contributing to the JDTAF. A focus will also be on ensuring a good knowledge management system relating to all the evidence created is put in place. 5.2 The HNPSIP documentation A set of key documents has been produced for the 4th Sector Programme. These all have a specific purpose and are interlinked (see figure 7 below). The HNPSIP document provides the overall strategic direction for the five-year sector programme. It translates the political 46 and policy decisions into a set of strategic objectives and indicates a number of measurable and achievable targets. The 4th Sector programme Results Framework (RFW) provides the detailed indicators, data sources and specific targets and milestones that will be the basis for assessing progress year on year. These are aligned to the strategic objectives and outputs in the HNPSIP document. The Programme Implementation Plan (PIP) is the development document for the sector to be approved by the Executive Committee for National Economic Council (ECNEC). The PIP provides the detail against which each operational plan (OP) will include its activities along with budget. The PIP is arranged in such a way as to link actions and budgets to objectives. This will allow better budget management and better decision- making around where to invest resources and how to ensure harmonisation of individual OP work plans. Figure 7: 4th Sector Programme documentation Programme Implementation Plan (PIP), 2016-20 The Programme Implementation Plan (PIP) linked to this SIP will be produced to provide a detailed and comprehensive action plan that provides a breakdown of all strategic objectives and summary activity areas. Under each Strategic Objective and Output detailed activities are provided that contribute to achieving the respective objectives. Process indicators with milestones and targets are provided against which progress in implementation of the activities can be measured. The detailed breakdown provides a basis for budgeting across the whole sector. Activity areas are assigned to relevant OPs and their partners. The PIP provides the opportunity for all on budget funding to be identified and linked to the overall sector programme. It also provides the opportunity for detailing out all implementation and management mechanisms of the sector programme. Results Framework (RFW), 2016-20 Linked to the objectives in the SIP are a set of performance indicators, milestones and targets. The Results Framework provides a logical hierarchy of indicators that are linked to the three components of the HNPSIP and the eight strategic objectives. Each indicator is described in detail together with the means of verification (source) and other information such as periodicity. The outcome and output level indicators are presented in annex 2. These will become the basis of the joint government - development partner annual review and mid-term review of the sector. 47

SECTION 6: INDICATIVE BUDGET OF THE 4TH SECTOR PROGRAMME 6.1 Government Expenditure Trends in the HNP Sector The MOHFW is financed from a combination of GOB non-development and development budgets, and external finance from development partners for supporting development expenditure. With MOHFW being a service delivery organization, the major portion of the cost is borne out of revenue budget for the service providers. The majority of the expenditure is therefore incurred through the non-development budget (Figure 8). Only 42% of the total MOHFW expenditure was from the development budget in 2014-15, which was slightly higher in comparison to the previous years (37% in 2013-14, 39% in FY 2012-13 and 34% in 2011-12). Figure 8: MOHFW Expenditure: Non-Development and Development 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 199719981999 20002001 2002 200320042005 2006200720082009 201020112012 20132014 Pre HPSP HNPSP HPNSDP SWAp MOHFW Revenue MOHFW Development Utilization The MOHFW’s absorption capacity has increased during the 3rd SWAp implementation period (2011-16). Utilization of the development budget has increased from an average rate of 72% in the pre-SWAp period to around 80-85% during the three SWAp periods. Utilization of the development budget was 80-85% during the first two SWAp periods (1998-2011). During the first four years of HPNSDP implementation (2011-15) – the third SWAp, overall utilization of annual development programme budget was 88.4%. Utilization of non-development budget allocations has consistently remained high because of the permanent nature of its expendable items. Utilization of the non-development budget was more than 95% during the first four years of the 3rd SWAp (HPNSDP period) as well. In the first four years of HPNSDP, the proportion of GOB contribution in MOHFW budget (both non- development and development) was 79%, and that of Development Partners’ (DP) was 21%. An analysis of non-development budget by line item shows that its major share is allocated for salary and allowances. The allocation for salary and allowances increased from 55% in 2005/06 to 64% in 2014/15, mainly for recruitment of health personnel and introducing a new pay scale in 2010/11. Allocation for medical and surgical requisites (MSR) increased to 11% in 2014/15 from 6% in 2005/06. In addition to provision of salary and operational costs of a huge set of service providers, a certain portion of the GOB non-development budget allocations is spent every year for small equipment, medical and surgical requisites (MSR), as 48 well as maintenance of public and autonomous hospitals (e.g., Bangabandhu Sheikh Mujib Medical University). Besides, private sector health research organizations such as the National Foundations on Heart, Kidney and ENT, and international organization like icddr,b get regular grants from MOHFW’s non-development budget allocations for provision of HNP services in the country. All these added together form a significant development expenditure borne out of MOHFW’s non-development budget from GOB source. In the last five years (2011/12-2015/16), Taka 1,003.7 Crore has been allocated as ‘Grants-in Aid’ to nearly 42 organizations under the non- development budget. The allocation for these grants constituted 3.2% of MOHFW’s non- development budget over the same period (2011/12-2015/16). On average, the allocation for Grants-in Aid has grown at 9% per annum since 2011/12. Moreover, a considerable amount of funds are allocated to Non-Government Organizations (NGOs) as special grants (one time) in each year through the non-development budget. 6.2 HPNSDP Expenditure Structure and Budget Implementation Total estimated cost for the 3rd SWAp, i.e. HPNSDP (2011-16) was BDT 56, 993 Crore (about US$ 7.7 billion). Out of this, it was estimated that Taka 43,420 Crore (76%) will be contributed by Government of Bangladesh (GOB) and 24% to be financed by development partners in the form of project aid (PA). Development budget was estimated to be 39% of the HPNSDP cost, which was 53% for HPSP and 44.3% for HNPSP. HPNSDP was revised following the mid-term review in 2014 at a total estimated cost of BDT 51,082.41 Crore (about US$ 6.5 billion), of which 78% is GOB’s contribution and the rest 22% as PA. 38% of the total cost has been earmarked for development budget expenditure. In the ADP of MOHFW, the allocations for 32 OPs constitute a large share. Allocation for 32 OPs of the total MOHFW’s ADP allocation was 54% in 2012/13, which increased to 77% in 2014/15. The total allocation for 32 OPs under HPNSDP was Taka 3,499 Crore in 2014/15 of which Taka 3,283 Crore had been released (94% of allocation) and Taka 2939 Crore was spent (84% of allocation). In 2014/15, out of total OP expenditure, the contribution of GOB was 42%, and that of PA was 58%. The development budget fund is also allocated for parallel/discrete projects of MOHFW. The allocation and expenditure for the 25 parallel projects under the development budget was Taka 2,765 Crore (95.2% GOB and 4.8% PA) and Taka 2676 Crore (97% GOB and 3% PA) respectively in the previous four years (2011/12 - 2014/15). Over this period, expenditure was 95% of released fund. MOHFW’s ADP allocation and expenditure for these parallel projects constituted 18.4% and 20% respectively over the period (2011/12 - 2014/15). 6.3 Resource Envelope for the 4th Sector Programme MOHFW needs to achieve efficiency gains through improved budget management, which in turn will bring additional benefit to the sector. Efficiency gains can be realized from an improved procurement process, needs-based infrastructure development, and appropriate maintenance of equipment. Deciding on new methods of payment may help enhance efficiency in resource allocation. Moreover, allocating resources based on a resource allocation formula can enhance efficiency in resource use. Reducing absenteeism of staff, ensuring an appropriate staff-mix and enhancing quality of care can also contribute to efficiency gain. The economy of Bangladesh has been growing at a rate of over 6% for a decade or so and the macro-economic indicators are showing positive signs of sustained economic growth for the next decade. The GDP growth rate for FY 2015-16 has provisionally been estimated at 7.05% by the Bangladesh Bureau of Statistics (BBS), the highest ever. It is likely to have a sustained GDP growth of around 7% over the next five years. Moreover, domestic resource mobilization is expected to increase as a result of various measures taken by the National Board of Revenue (NBR). Over the next five years, both the number of tax payers and the coverage of 49 VAT collection are expected to increase. All these provide the basis for a fair assumption that resource availability will increase over the next five years. The resource envelope for the 4th HNP Sector Programme therefore needs to be estimated based on these forecasts. MOHFW is likely to get a higher allocation than that mentioned in the Seventh Five Year Plan (SFYP) in both the development and non-development budgets of MOHFW. Moreover, it seems reasonable to present the resource envelope for the 4th Sector programme with three different scenarios. It is therefore rationally assumed that MOHFW’s budget will be increased by 10% as a low case scenario, 15% as a moderate case scenario and 20% as an optimistic case scenario respectively during next five years. The Medium Term Budgetary Framework (MTBF) projection shows that the estimated non- development and development budget for 2016/17 is Taka 8,114 Crore and Taka 5,884 Crore respectively. The SFYP of Bangladesh projects a total development budget of Taka 41,340 crore to be channelled to the health sector. As 97% of the total health budget is being allocated for the MOHFW, the development budget for MOHFW for the next five years is expected to be Taka 40,100 Crore as per the SFYP. Low Scenario The Medium Term Budgetary Framework (MTBF) projection shows that the estimated non- development budget for 2016/17 is Taka 8,114 Crore and for 2017/18 is Taka 8,925 Crore. Using the average growth rate of 10% of the non-development budget in the above mentioned years, a projection has been made for the non-development budget for 2018/19 (Taka 9,818 Crore), 2019/20 (Taka 10,800 Crore), and 2020/21 (Taka 11,880 Crore). The total estimated non-development budget for 2016-21 thus stands at Taka 49,537 Crore (US$ 6,192 million). The MTBF also projects Taka 5,884 Crore as the development budget for 2016/17. Assuming 10% growth in development budget for the next five years, the total development budget stands at Taka 35,922 Crore (US$ 4,490 million). Therefore, the total estimated budget for the MOHFW is Taka 85,459 Crore (US$ 10,682 million) for the next sector programme, inclusive of the development and non development budget. Table 1: Low Scenario Resource Envelope for HNP SIP (2016-21) - In Crore Taka Budget by type 2016/17 2017/18 2018/19 2019/20 2020/21 Total Non-development 8,114 8,925 9,818 10,800 11,880 49,537 budget Development budget 5,884 6,472 7,120 7,832 8,615 35,922 Total budget of 13,998 15,398 16,938 18,631 20,494 85,459 MOHFW Assumption: Non-development and development budgets grow at an annual rate of 10% Moderate Scenario The SFYP of Bangladesh projected a total development budget of Taka 41,340 Crore to be channelled to the health sector. As 97% of the total health budget is being allocated for the MOHFW, the development budget for the MOHFW for 2016/17 is assumed to be Taka 8,020 Crore. Assuming a 15% annual growth, the total estimated development budget for 2016-21 stands at Taka 54,074 Crore (US$ 6,759 million). MTBF projection shows that the estimated non-development budget for 2016/17 is Taka 8,114 Crore. Similarly, assuming a 15% annual growth, the total estimated non-development budget for 2016-21 stands at Taka 54,708 Crore (US$ 6,839 million). Therefore, the total estimated resource envelope for the MOHFW is Taka 108,782 Crore (US$ 13,598 million) in a moderate case scenario for the next sector programme, inclusive of the development and non development budgets. 50 Table 2: Moderate Scenario Resource Envelope for HNP SIP (2016-21) - In Crore Taka Budget by type 2016/17 2017/18 2018/19 2019/20 2020/21 Total Non-development 8,114 9,331 10,731 12,340 14,191 54,708 budget Development budget 8,020 9,223 10,606 12,197 14,027 54,074 Total budget of 16,134 18,554 21,337 24,538 28,218 108,782 MOHFW Assumption: Non-development and development budgets grow at an annual rate of 15% Optimistic Scenario: Considering SFYP’s allocation, a total development budget of Taka 41,340 Crore is to be channelled to the health sector. Assuming that 97% of the total health budget goes to MOHFW, the development budget for MOHFW in 2016/17 stands at Taka 8,020 Crore. Assuming a 20% annual growth in budget allocation, the total estimated development budget for 2016-21 stands at Taka 59,682 Crore (US$ 7,460 million). MTBF projection shows that the estimated non-development budget for 2016/17 is Taka 8,114 Crore. Assuming a 20% annual growth, the total estimated non-development budget for 2016-21 stands at Taka 60,381 Crore (US$ 7,548 million). Therefore, the total estimated budget for MOHFW is Taka 120,063 Crore (US$ 15,008 million) in a optimistic case scenario for the next sector programme, inclusive of the development and non development budget. Table 3: Optimistic Scenario Resource Envelope for HNP SIP (2016-21) - In Crore Taka Budget by type 2016/17 2017/18 2018/19 2019/20 2020/21 Total Non-development 8,114 9,737 11,684 14,021 16,825 60,381 budget Development budget 8,020 9,624 11,549 13,859 16,630 59,682 Total budget of 16,134 19,361 23,233 27,880 33,455 120,063 MOHFW Assumption: Non-development and development budgets grow at an annual rate of 20% Table 4 below summarizes the three case scenarios based on which a rational budget for the 4th Sector Programme may be worked out. Table 4: Resource Envelope for the 4th Sector Programme (2016-21) - In Crore Taka Scenario Budget by type Low Moderate Optimistic Non-development budget 49,537 54,708 60,381 Development budget 35,922 54,074 59,682 Total budget of MOHFW 85,459 108,782 120,063 The resource envelope for the HNP sector is likely to be enriched further from Development Partner’s off-budget contributions channelled through the NGOs and other non-state actors. Discussion with DPs indicates that off-budget DP contributions are also likely to increase to the extent of two to five percent over the next five years. Irrespective of DP financing and potential private sector investment, GOB financing to the HNP sector has to be increased substantially during the next five years with a view to: (a) Reducing out-of-pocket expenditures from the current level of about 63% and implementing health protection schemes, particularly for the lowest two quintile income groups and thus enhancing equity; 51 (b) Strengthening governance and stewardship of MOHFW and agencies under it by updating existing laws, formulating new laws, rules & regulations and strengthening institutional capacity for ensuring compliance; (c) Strengthening the health systems (e.g., CMSD for procurement, DGDA for rational drug use, FMAU for transparency and accountability, MIS and eHealth for strong supervision and evidence based decision making, medical and nursing education, etc.); (d) Focusing on NCDC (both prevention and cure), urban health, public health, tribal health, geriatric health, mental health and autism, environmental health and life-style change; and (e) Improving service quality at all stages of service delivery, enhancing efficiency gains and reducing wastage and duplications. 52 ANNEXES

Annex 1: The Essential Service Package (draft service outline) Essential Service Package (ESP) by Service Delivery Tiers Note: • The ESP Template describes four tiers viz. i) Community (include: Domiciliary services; Satellite clinics; Outreach centre and Community Clinics); ii) Union (includes: Union Health and Family Welfare Centres (HFWC); and Sub-Centres/Rural Dispensary (SC/RD); iii) Upazila (include: Upazila Health Complex (UZHC); and iv) District (include: District Hospital and Maternal and Child Welfare Centre (MCWC). • The first column lists Component/sub-components of ESP from each tier and the (√) mark in next columns signifies that service is available/will be offered from the facility. • An onward referral system to next tier/higher level facility is considered for the continuum of quality care under ESP. [Dom.=Domiciliary; Sat.Cl.=Satellite Clinic=Union Health & Family welfare Centre; SC=Union Sub-centre; RD=Rural Dispensary; UZHC=Upazila Health Complex; DH=District Hospital; MCWC=Maternity and Child Welfare Centre] Community Union Upazila District Component and Dom. Sat. Cl./ CC UHFWC USC/RD UZHC DH MCWC Sub-Component Outreach Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH) Registration of eligible couples √ √ √ Registration of pregnancy √ √ √ √ Birth registration √ √ √ √ √ √ √ √ Maternal Health Care Screen/ √ √ √ √ √ √ √ Ante Natal Care (ANC) Refer √ (Trained √ √ √ √ √ Normal Vaginal Delivery HR) BEmOC √ √ √ √ √ Ante partum Hemorrhage √ √ √ Prevention Managemen Management Management & Manageme Management Post Partum Hemorrhage Prevention & refer & refer refer nt CEmONC √ Selected √ √ Postnatal care √ √ √ √ √ √ √ √ Management of Eclampsia √ √ √ √ √ Management of Puerperal sepsis √ √ √ Early management of Obstetric Fistula √ √ Management of genital prolapse √ Family Planning Services √ √ √ √ √ √ √ √ Short acting contraceptives (Condom, Pills, Injectable) LARC (IUD, Implant), √ (IUD) √ (IUD) √ √ √ PM ( NSV, Tubectomy) selected selected Post Partum contraception and post MR √ √ √ √ √ Contraceptive services Management of Gender-based Violence (one- √ √ stop crisis cell) Maternal Nutrition Distribution of Vit-A √ √ √ √ √ √ √ Iron Folic Acid and Calcium √ √ √ √ √ √ √ Supplementation Menstrual Regulation and Post Abortion Care (PAC) Menstrual Regulation-MR √ √ √ √ √ Post Abortion Care-PAC √ √ √ √ √ Newborn and Child Health Care Umbilical cord care with 7.1% Chlorhexidin √ √ √ √ √ √ √ √ Initiation of early breast feeding √ √ √ √ √ √ √ √ Thermal Care √ √ √ √ √ √ √ √ Management of Birth asphyxia √ √ √ √ √ Newborn eye care (White reflex) √ √ √ √ √ √ √ √ 53 Community Union Upazila District Component and Dom. Sat. Cl./ CC UHFWC USC/RD UZHC DH MCWC Sub-Component Outreach Pre-term and low birth weight baby √ √ √ management Expanded Programme on Immunization (EPI) √ √ √ √ √ √ √ Integrated Management of Childhood illness √ √ √ √ √ (IMCI) Screening and referral of Autism spectrum √ √ √ √ √ √ √ √ disorder (ASD) Management of Autism spectrum disorder √ √ √ (ASD) Management of Child Malnutrition Growth Monitoring and Promotion (GMP) √ √ √ √ √ √ Infant and Young Child Feeding (IYCF) √ √ √ √ √ √ √ √ Management of Moderate Acute Malnutrition √ √ √ √ √ √ √ √ (MAM) Management of Severe Acute Malnutrition √ √ √ √ √ √ (SAM), uncomplicated Management of Severe Acute Malnutrition √ √ (SAM), complicated Adolescent Health Care Counseling on puberty, safe sexual behavior, √ √ √ √ √ √ mental health, HIV-AIDS, Tobacco & drug abuse Counseling on prevention of early marriage √ √ √ √ √ √ √ √ and delaying pregnancy Prevention and management of √ √ √ √ √ RTI and STDs Iron Folic Acid Supplementation √ √ √ √ √ √ √ Communicable Disease Control (CDC) Management of Diarrhoea √ √ √ √ √ √ √ √ Identify suspect cases of TB and refer for √ √ diagnosis Diagnosis and treatment of TB √ √ DOTS (follow up and compliance) √ √ √ √ √ √ Distribution and promotion of Long Lasting √ √ √ √ √ √ √ Insecticidal Nets-LLIN Diagnosis and treatment of Malaria √ √ √ √ √ √ Treatment of severe malaria cases √ √ Identify suspected kala-azar and refer for √ √ √ √ √ √ diagnosis Diagnosis and treatment of kala-azar √ √ Diagnosis and management of Hepatitis √ √ √ √ √ √ √ Treatment of Intestinal Parasites (Deworming) √ √ √ √ √ √ Diagnosis & management of Dengue Fever √ √ Diagnosis & management of Typhoid √ √ Non-Communicable Disease Control (NCDC) Screening for hypertension and referral √ √ √ √ Management of Hypertension (incl. non-drug √ (non- √ (non- √ (non- √ √ √ treatment drug) drug) drug) Screening for Diabetes Mellitus and referral √ √ √ √ (non- √ (non- √ (non- √ √ √ Management of DM (incl. non-drug treatment drug) drug) drug) Management of Chronic Obstructive √ √ Pulmonary Disease (COPD) Identification and referral of Cardiovascular √ √ √ Diseases (IHD, Stroke) Diagnosis and management of IHD √ √ Diagnosis and management of stroke √ √ Early detection of breast and cervical cancer √ √ √ through screening Mental illnesses - recognize , counsel ,primary √ √ treatment and referral First Aid of Drowning √ √ √ √ √ Identification and referral of Arsenicosis √ √ √ Management of Arsenicosis √ √ Common Illness and Injury First aid and treatment of minor injury, cuts, √ √ √ √ √ burn etc. RTA related injury √ √ Management of Poisoning and snakebite √ √ 54 Community Union Upazila District Component and Dom. Sat. Cl./ CC UHFWC USC/RD UZHC DH MCWC Sub-Component Outreach Emergency Care (one Annex to be added) √ √ √ √ √ Common Skin, Eye, Ear and Dental Diseases Treatment of Scabies, Ringworm, Impetigo, √ √ √ √ √ √ dermatitis Treatment of Conjunctivitis and Corneal Ulcer √ √ √ √ √ √ Early detection of cataract and visual √ √ √ √ √ √ impairment √ Management of cataract and visual impairment Management of Acute and Chronic √ √ √ √ Suppurative Otitis Media Management of hearing impairment √ Treatment of common dental diseases √ √ (gingivitis, bleeding gums, carries, tooth extraction) Differently abled and Senior Citizen Promote and support health behavioral change √ √ √ √ √ √ √ √ Geriatric corner √ Behaviour Change Communication Sensitization and promotion for increased √ √ √ √ √ √ √ √ utilization services offered at each level √ √ √ √ √ √ √ √ Promote personal hygiene practices (also in school health package) Promote health, family planning, nutrition, √ √ √ √ √ √ √ √ child survival and safe motherhood Promote healthy lifestyle for NCD control, √ √ √ √ √ √ √ √ including mental health Education on causes, prevention and control √ √ √ √ √ √ √ √ of communicable diseases Awareness on climate change, food safety, √ √ √ √ √ √ √ √ injuries (incl. poisoning and snakebite) and healthy aging Awareness on sexual and reproductive health √ √ √ √ √ √ √ √ rights, prevention of gender-based violence and early marriage Distribution of regionally focused BCC/IEC √ √ √ √ √ √ √ √ materials Providing need based BCC/IEC support in √ √ √ √ √ √ √ √ order to increase awareness and community participation Nutrition education and Good Hygiene Practice √ √ √ √ √ √ √ √ (GHP Awareness on prevention of Diarrhoea √ √ √ √ √ √ √ √ Awareness of prevention of hearing √ √ √ √ √ √ √ √ impairment Education and information service for senior √ √ √ √ √ √ √ √ citizen Promotion of oral hygiene √ √ √ √ √ √ √ √ Community engagement for prevention of √ √ √ √ √ √ Drowning Promoting arsenic free water √ √ √ √ √ √ Awareness on prevention of Cancer √ √ √ √ √ √ √ √ Awareness on prevention and control of √ √ √ √ √ √ √ √ malaria, kala-azar, 55ilarial and dengue Awareness on use of LLIN for malaria control √ √ √ √ √ √ √ √ Awareness on prevention and control of √ √ √ √ √ √ √ √ Hepatitis Advocacy and awareness development on √ √ √ √ √ √ √ √ PPFP and Post MR/PAC -FP 55 ESP-Urban (Component Services) By Tiers [CRHCC=Comprehensive Reproductive Health Care Centre; PHCC=Primary Health Care Centre] Domiciliar CRHCC Satellite PHCC Service Delivery Activities Clinic y Antenatal Care 1 Pregnancy Registration, Regular Follow-up and update including √ maternal deaths 2 Counsel women and husband / family on Nutrition, care (rest) danger sign, clean delivery, Trained birth assistance, delivery planning, √ √ √ √ Preparation for possible emergency, breast feeding, and Contraception 3 Antenatal care (check weight, height, eyes, blood pressure, edema, urine √ √ √ sample, blood sample) 4 Obtain antenatal history √ √ √ 5 TT Vaccination (pregnant women) √ √ √ 6 Fe/Folate Supplementation √ √ √ √ 7 Detect early, refer promptly women with danger signs/ complications √ √ √ √ 8 Mobilize community to arrange transportation, blood donors for obstetric emergencies, (blood will be supplied to EOC referral locations for √ √ screening prior to possible use) Delivery Care (NVD & CS) 1 Create awareness on safe and clean delivery √ √ √ √ 2 Conduct clean and safe delivery by skilled health personnel at facility √ level 3 Detect early and refer promptly women with Danger signs or √ √ √ √ complications Postnatal Care 1 Counsel women/family on diet, Exclusive Breast Feeding (EBF), Infant and Young Child Feeding (IYCF), danger signs (mother & infant ), √ √ √ √ immunization, Post Partum Contraception, Birth Spacing 2 Provide Postnatal Care √ √ √ 3 Provide post partum contraceptive √ √ √ √ 4 Vitamin A Supplementation within 42 days of delivery √ √ √ √ 5 Detect early and refer promptly women with danger signs/complications √ √ √ √ Menstrual Regulation 1 Encourage use of post MR FP methods √ √ √ √ 2 Create awareness on unsafe abortions and its complications √ √ √ √ 3 Provide MR on medical grounds only √ √ 4 Provide contraceptive supplies √ √ √ √ 5 Detect complications and refer promptly √ √ √ √ Post Abortion Care 1 Encourage use of post abortion FP methods √ √ √ √ 2 Encourage MR within safe period √ √ √ √ 3 Provide PAC √ √ 4 Detect complications and refer promptly √ √ √ √ Population & Family Planning Services Family Planning 1 Eligible Couple Registration, regular update √ 2 Create awareness on Family planning with emphasis on permanent and √ √ √ √ longer acting methods 3 Counsel on appropriate method √ √ √ √ 56 Domiciliar CRHCC Satellite PHCC Service Delivery Activities Clinic y 4 Provide contraceptive supplies- Temporary Methods (Pill, Condom, √ √ √ √ Injectable) 5 Provide Long Acting & Permanent methods (IUD, Implant, NSV) √ √ 6 Provide Permanent method (Tubectomy) √ 7 Treat/refer for side effects and complications √ √ √ √ 8 Refer for other methods (Sterilization, IUD, Implant) √ √ 9 Provide ECP √ √ √ Neonatal Care Neonatal Care 1 Counsel women/family on Exclusive Breast Feeding (EBF), Infant and Young Child Feeding (IYCF), hygiene, cord care, danger signs (mother √ √ √ √ and newborn), prevent hypothermia, immunization 2 Health education for mothers on cleanliness and care for the newborn √ 3 Provide Neonatal Care √ √ √ 4 Detect early and refer promptly neonates with complications √ √ √ √ Child Health Care Immunization Program – EPI 1 Mobilize caretakers to have their children fully immunized by 12 months √ √ √ √ of age 2 Conduct immunization sessions √ √ √ 3 Surveillance and notification including acute flaccid Paralysis, measles √ √ √ √ and neo-natal tetanus Immunization Program – NID 1 Observe National Immunization Program √ √ √ 2 Child to Child Search √ Diarrhea 1 Detect, manage and refer severe cases with “danger signs” √ √ √ √ 2 Advise caretaker on correct home care (fluids, feeding, referral) √ √ √ √ 3 Advise caretaker on prevention √ √ √ √ Measles 1 Detect and manage; refer severe/complicated cases √ √ √ √ Acute Respiratory Infections 1 Treat pneumonia with oral antibiotics √ √ √ 2 Advise caretaker on correct home care √ √ √ √ 3 Detect and manage; refer severe/complicated cases √ √ √ √ Other Childhood Illness 1 Detect and manage; refer severe/complicated cases (including drowning, √ √ √ √ accidental poisoning, autism, disability, other injuries etc.) Reproductive Health Care RTI/STI Care 1 Counsel on RTI/STI & related Infertility √ √ √ √ 2 Health Education on RTI/STI & related Infertility √ 3 Supply condoms √ √ √ √ 4 Refer for complaints of vaginal discharge, lower abdominal pain, genital √ √ √ √ ulcers, swellings in groin in men 5 Follow syndromic approach √ √ √ 6 Supplier management √ √ √ 7 RTI/STI Screening √ √ Other Reproductive Health Care 57 Domiciliar CRHCC Satellite PHCC Service Delivery Activities Clinic y 1 Identify & Refer Out of Breast Cancer, Cervical Cancer, Fistula etc. √ 2 Other Reproductive Tract Disease √ √ 3 TT Vaccination (19+ non pregnant women) √ √ √ Adolescent Health Care 1 Counsel/create awareness of sexuality, safe sex, menstruation, special nutrition, hygiene, TT vaccination; reducing early marriage, pregnancy; √ √ √ √ high risk behavior, psychological issues, gender issues to both girls and boys 2 Identify and treat anemia for girls and boys √ √ √ 3 Identify and treat RTI/STI for girls and boys √ √ √ 4 Identify and treat Dysmenorrhea and other RH problems √ √ √ 5 TT Vaccination (adolescent girls) √ √ √ Nutrition (N) Maternal Nutrition 1 Create awareness on Nutritional issues; promote health and caring √ √ √ √ practices that prevent Malnutrition 2 Counsel pregnant & lactating women (+ Husband/ Family) on diet. √ √ √ √ 4 Provide elements such as community nutrition including nutritional assesment with targeted supplementation as per national program, √ √ √ √ detection & referral of severe cases of malnutrition Child Nutrition 1 Promote (& support) exclusive breast feeding, Correct weaning and child √ √ √ √ feeding practices 2 Provide elements such as community nutrition including GMP with targeted supplementation as per national program, detection & referral of √ √ √ √ severe cases of malnutrition Control of Micronutrient Deficiency 1 De-worming of Under 10 high risk Children √ √ √ 2 Promote consumption of iodized salt √ √ √ √ 3 Vitamin A for post partum lactating women √ √ √ √ 4 Vitamin A for children (6 months to 6 years) √ √ √ 5 Vitamin A Supplimentation for sick children (ARI, diarrhea, severe √ √ √ malnutrition, measles) 6 Detect and manage children with night blindness & Refer other cases √ √ √ √ 7 Detect and refer suspected iodine deficiency cases √ √ √ √ Communicable Diseases Control Tuberculosis Control 1 Counseling on prevention of communicable diseases 2 Detect and refer suspect cases √ √ √ √ 3 Support and promote DOTS √ 4 Advise patients/families/close contacts on TB Symptoms and treatment √ √ √ compliance 5 Defaulter tracing √ 6 Promote self-reporting of patients √ √ √ Other Communicable Disease Control 1 Counseling on prevention of communicable diseases 2 Detect and refer suspect cases √ √ √ √ 3 Advise patient/families/close contacts on symptoms and treatment √ √ √ √ compliance 4 Diagnosis, Treatment and referal of Leprosy, Malaria, Dengue, SARS, √ √ Kala-zar, Filariasis, Enteric Fever, Hepatitis etc. 58 Domiciliar CRHCC Satellite PHCC Service Delivery Activities Clinic y Non-Communicable Diseases Control 1 Detect and Refer Suspected cases of Diabetes, Mental Health and √ √ √ √ Cardiovascular disease etc. 2 Support and promote preventative/control measures √ √ √ √ 3 Advice patients to seek treatment, improve lifestyle and promote self √ √ √ √ reporting Limited Curative Care and First Aid 1 Provide Basic First Aid for Common injuries (cut, burn, fracture, etc) √ √ √ Emergency Care 1 Treat Medical Emergencies – Management and Referral of Pain, high fever, shock, asphyxia, poisoning, drowning and other incidence of √ √ emergencies Minor Infection & Disease Control 1 General Health Checkup, Asthma, Skin Diseases (Scabies etc.), Dental Diseases, Ear diseases, Peptic Ulcer, Geriatric care and Other Minor √ √ √ Ailments Primary Eye Care 1 Clinical Consultation; Medical Treatment, Refraction Test, Prescribed/Provided Spectacles, Identification and refer out for Cataract √ Surgery Disaster Management 1 Extended services for any emergency outbreak within the scope of work √ √ √ √ Behavior Change Communication (BCC) Health Education 1 Health Education on cross cutting all categories above √ 2 Health Education on Personal hygiene, hand washing, gender awareness √ 3 Awareness on availability of PHC services (branding) at UPHCSDP √ centers Clinical Counseling 1 Clinical Counseling on cross cutting all categories above √ √ √ Diagnostic & Emergency Transport* (DET) Diagnostic Service 1 Blood Grouping, Urine for Pregnancy √ √ √ 2 Blood for Routine (TC, DC, ESR, Hb), Cross Matching, Sugar, Platelet Count, Serum Bilirubin, CRP, RF, Widal, ASO Titre, BT, CT, MP, KOS, √ √ WetMount, Hbs Ag, Hepatitis B Confirmation, VDRL, TPHA etc. 3 Urine for Routine (Sugar, Albumin, PS, Phosphate) etc. √ √ 4 Stool for Routine (Occult Blood, RS), Floatation Method etc. √ √ 5 Biochemical Tests √ √ 6 Ear Swab, Puss Swab, High Vaginal Swab, Skin Scrapping Fungus, √ √ Mauntox etc. 7 VIA √ 8 Ultra-sonogram √ 9 Sputum (AFB) √ Emergency Transportation Service 1 Ambulance Service √ Violence Against Women* (VAW) 1 Identify and register cases, provide medical care √ √ √ √ 2 Refer victims for legal assistance, counseling and Crisis management √ √ 3 Provide psychological support √ √ √ √ 4 Increase community awareness √ 59 Domiciliar CRHCC Satellite PHCC Service Delivery Activities Clinic y Miscellaneous 1 Medical Waste Management √ √ √ 2 Diet for admitted patients √ 3 Evening Clinic √ √ 4 Medicine distribution √ √ √ 5 Monitoring & Quality Assurance √ √ √ √ 6 Record Keeping & Reporting √ √ √ √ 7 Financial Management √ √ √ 8 Regular update of Pro-poor listing, pregnancy registration, eligible couple √ registration etc. 60

Annex 2: 4th Sector Programme Results Framework Results Framework for the 4th HNP Sector Program 2016-21 MEANS OF TARGET RESULT INDICATOR VERIFICATION & BASELINE & SOURCE 2021 TIMING Goal: GI 1. Under 5 Mortality Rate (U5MR) BDHS, every 3 years 46, BDHS 2014 37 All citizens of Bangladesh enjoy GI 2. Neonatal Mortality Rate (NNMR) BDHS, every 3 years 28, BDHS 2014 21 health and well-being. GI 3. Maternal Mortality Ratio (MMR) BMMS; MPDR 176, WHO 2015 34 105 GI 4. Total Fertility Rate (TFR) BDHS, every 3 years 2.3, BDHS 2014 1.7 GI 5. Prevalence of stunting among under-five BDHS, every 3 years; 36.1%, BDHS 2014 25% children UESD, every non-DHS years GI 6. Prevalence 35 of diabetes and hypertension BDHS, every 3 years; Dia: 11.2%; Hyp: 31.9%, Dia: 10%; Hyp: 30% among adult women NCD-RF, every 2 years BDHS 2011 GI 7. % of public facilities with key service BHFS, every 2 years FP: 38.2; ANC 7.8%; CH FP: 70%; ANC 50%; CH readiness 36 as per approved Essential Service 6.7%, BHFS 2014 50% Package Program Objective: To ensure quality and equitable healthcare for all citizens of Bangladesh by gradually achieving Universal Health Coverage (UHC). Component 1: MOHFW’s governance and stewardship roles strengthened Result 1.1 Legal and operational 1.1.1 Governance and Stewardship Action Plan Admin records; APIR GSAP developed and GSAP implemented framework on governance and implemented in line with milestones approved, Planning stewardship in place Wing 2016 34 http://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/ 35 Estimated as elevated blood sugar and blood pressure among women and men aged 35 years or older 36 Defined as facilities (excl. CCs) having a) for FP: guidelines, trained staff, BP machine, OCP and condom; b) for ANC: guidelines, trained staff, BP machine, hemoglobin and urine protein testing capacity, Fe/folic acid tablets; c) for CH: IMCI guideline and trained staff, child scale, thermometer, growth chart, ORS, zinc, Amoxicillin, Paracetamol, Anthelmintics 61 Result 1.2 Overall sector 1.2.1 Number of public and non-public facilities Admin records; APIR Process initiated, a) Accreditation governance improved accredited Planning Wing 2016 mechanism established; b) 22 MCH, 59 DH and 50 non-public hospitals accredited 1.2.2 % of DPs submitting annual reports on off- APIR 54%, MPIR 2014 100% budget activities 1.2.3 Incremental budget for MOHFW ensured ADP; APIR 14.0% increase of ADP Annual increment of between FY’11-16, APIR ADP >15% 2015 Component 2: Health systems strengthened to increase performance and efficiency Result 2.1 Quality workforce 2.1.1 % of service provider positions BHFS, every 2 years Physician: 30.5%, Physician: 15%, made available in health sector functionally vacant in public facilities, by Nurse: 7.8%, Nurse/midwife: 4%, category (physician, nurse/midwife, Paramedic: 7.1%, BHFS Paramedic: 4% paramedics) 2014 Result 2.2 Core systems (FM, 2.2.1 % of OPs with spending >80% of ADP ADP; APIR 50%, APIR 2015 80% infrastructure, procurement) allocation strengthened 2.2.2 % of serious audit objections 37 settled APIR 68%, APIR 2015 80% 2.2.3 % of procurement packages tracked under Admin records NA 90% SCMP Result 2.3 Disease surveillance 2.3.1 No. of performance monitoring reports Reports; APIR 4 (HB, MIS/FP AR, APIR, 08 (APIR, SmPR, MISs, and implementation monitoring prepared and disseminated annually SmPR) NIPORT, DGDA, DNS, strengthened to promote HEU 38) evidence-based decision making 2.3.2 Number of districts under RHIS scale up Admin records Pilot ongoing at 01 64 district (Tangail) and 2 upazilas of Habiganj 37 As defined by the World Bank 38 For HEU, the report will be Public Expenditure Review (PER) 62 Component 3: Quality basic services reach the disadvantaged population to progress towards UHC Result 3.1 Public health services 3.1.1 % of children less than 6 month receiving BDHS, every 3 years; 55.3%, BDHS 2014 65% strengthened to promote exclusive breastfeeding UESD, every non-DHS healthy behavior years 3.1.2 % of infants age 6-23 month are fed with BDHS, every 3 years; 22.8%, BDHS 2014 45% minimum acceptable diet UESD, every non-DHS years 3.1.3 % of women age 15-19 who have begun BDHS, every 3 years; 30.8%, BDHS 2014 25% childbearing UESD(?), every non-DHS years Result 3.2 Equitable coverage of 3.2.1 Contraceptive Prevalence Rate (CPR) BDHS, every 3 years; 62.4%, BDHS 2014 75% ESP ensured UESD, every non-DHS years 3.2.2 % of delivery by skilled birth attendant BDHS, every 3 years; 42.1%, BDHS 2014 65% (SBA) UESD, every non-DHS years 3.2.3 CPR (modern methods) in lagging regions BDHS, every 3 years; Syl: 40.9%, Ctg: 47.2%, 60% UESD, every non-DHS BDHS 2014 years 3.2.4 % of public health facilities without stock- BHFS, every 2 years Drugs 39: 66%, FP Drugs: 75%, outs of essential medicines/FP supplies methods 40: 84.4%, BHFS FP methods: 90% 2014 3.2.5 % of births in health facilities by 2 lowest BDHS, every 3 years; 15.0% : 69.5% = 1:4.6, 1 : 3.5 socio-economic groups UESD, every non-DHS BDHS 2014 years 3.2.6 ANC coverage (at least 4 visits) BDHS, every 3 years; 31.2%, BDHS 2014 50% UESD, every non-DHS years 39 Defined as availability of at least six of eight essential medicines of a DDS kit: amoxicillin tablet/capsule, amoxicillin syrup, cotrimoxazole, paracetamol tablet, paracetamol syrup, tetracycline eye ointment, iron tablet, and vitamin A capsule. 40 Defined as availability of See Table 3.14 of BHFS 2014 Preli Report 63 3.2.7 TB case detection rate NTP MIS, every year 53%, GTBR 41 2014 75% 3.2.8 Measles immunization coverage among CES, every year 86.6%, CES 2014 95% children under 12 months Result 3.3 Quality of care 3.3.1 % of public health facilities with staff BHFS, every 2 years 9.9% 42 75% improved trained in IMPAC (labor management and CNCP) in last 24 months 3.3.2 No. of districts implementing Admin records 10, CIPRB 2014 43 64 comprehensive maternal perinatal and newborn death review 3.3.3 % of public facilities with regular quality Admin records NA 100% DHs, 70% UHCs, assurance activities 44 50% of UHFWCs and CCs 41 Global Tuberculosis Report 2014 by the World Health Organization (WHO) 42 Staff in facilities up to union-level trained in integrated management of pregnancy and child birth (IMPAC) during the last 24 months 43 http://www.ciprb.org/wp-content/uploads/2015/01/MPDR-Fact-Sheet.pdf 44 QA activity to be specified by HEU/HSM; check baseline with HEU 64 65