STATUS REPORT ON MACROECONOMICS AND HEALTH Bangladesh

STATUS REPORT ON MACROECONOMICS AND HEALTH Bangladesh

1. INTRODUCTION The Government of Bangladesh is constitutionally committed to "the supply of basic medical requirements to all levels of the people in the society" and the "improvement of nutrition status of the people and public health status". Therefore, the Government seeks to create conditions whereby the people of Bangladesh have the opportunity to reach and maintain the highest attainable level of health. The Commission on Macroeconomics and Health (CMH) of the World Health Organization (WHO) examined and established the relationship between investing in health in one hand and economic development and poverty reduction on the other. The CMH produced a report which breaks new ground in providing evidence based recommendations linking investments in the health sector to economic growth and poverty reduction and CMH recommended low and middle income countries to establish National Commissions on Macroeconomics and Health (NCMH), or similar mechanisms. The recommendation of CMH will help achieving the task of scaling up through: 1) assessing health priorities, 2) establishing a scaling up strategy, 3) working together with other health-related sectors, 4) ensuring a sound macroeconomics framework, and 5) preparing an epidemiological baseline, operational targets, and a financing plan, together with WHO and the World Bank. This country paper contains initiatives, activities, programme that has been under taken and planned. This also contains salient features of the next three-year Health, Nutrition and Population Sector Programme of the Government of Bangladesh, from July 2003 to June 2006. 1.1 Health Status Against the present socio-economic conditions of Bangladesh, health and population sector performance in terms of immunization coverage of children under five, fertility decline, and increasing contraceptive prevalence rate (CPR) were, in fact, remarkable. The proportion of fully immunized children has reached 60.4 percent. By the early nineties, the total fertility rate had come down to 3.3 from the level of 6.3 in the mid-seventies. During the same period, CPR increased to 54 percent from the level of 8.5 percent, while life expectancy at birth had increased to 61 years by the late nineties, from the 48 years in the mid-seventies. While there has been substantial progress in disease prevention and control and a decline in childhood communicable diseases, new and old infectious diseases, such as malaria, tuberculosis and acquired immunodeficiency syndrome (AIDS) are important threats to health for the years ahead. Projections are uncertain because of the potential of travel and trade, urbanization, migration and microbial evolution to amplify these diseases. The emergence of drug resistant malaria and tuberculosis further increases the risk. 1

Figure showing achievements of health indicators over the years: 1973 1998 140 140 120 100 80 57 60 47 40 19.9 17 30 20 4.8 3 1.5 3 0 CBR CDR GR IMR MMR Source: Bangladesh Health Bulletin 1998-99 1.2 Nutritional Status In spite of efforts to reduce malnutrition in children, high rates of malnutrition continue and micronutrient deficiencies remain common. These hamper physical and cognitive development and exacerbate the cycle of poverty and deprivation. Chronic energy deficiency, protein energy malnutrition, low birth weight, micronutrient deficiency are all serious problems in Bangladesh. Although it affects people of all ages, the children, women and the female adolescents are mostly affected. Anemia caused by iron deficiency among women and adolescent girls is one of the growing concerns of the Government of Bangladesh. Almost half (49 percent) of the women are suffering from anemia (Hb <11.0 gm/dl). But among children aged 6-11 months, this is alarmingly high at 78 percent 1. Among adolescent girls aged 11-16 years 43 percent were anemic (Hb <12.0 gm/dl), and about 4.6 percent were below 10.0 gm/dl. Rural women and the poor were the worst sufferers 2. 1.3 Population Status The current population of Bangladesh is estimated as 130 million. 3 The density of population per sq. km. is 876, sex ratio (males per 100 females) 103.8, number of households is 25.4 million, with average households size 4.8 persons (as against 5.5 persons in 1991), the annual growth rate in 2001 is 1.48 percent. The total fertility rate has declined to 3.3. About 23.4 percent of the population is urban and 76.6 percent is rural (Census 2001, Bangladesh Bureau of Statistics). 1 2 3 Bangladesh Bureau of Statistics (1999), Pocket Book of the Year. National Vitamin A Survey (1998), Helen Keller International and Institute of Public Health and Nutrition Population Census, 2001, Preliminary Report, August 2001, Bangladesh Bureau of Statistics. 2

The life expectancy at birth for both sexes was 61 years in 1998 4. The under 15 population constitutes above 40 percent of population, which is high. This has serious implications for the continuing population growth due to population momentum and future demands on Bangladesh's infrastructure and the labor market. The number of urban poor has increased from 7 million in 1985 to 12 million in 1999 and their health indicators are worse than those of the rural poor 5. According to the 2001 population census, the urban population in Bangladesh is 29 million and has increased at the rate of 38.02 percent during the last ten years, which is about 4 times the rural rate 6. 1.4 Health, Poverty and Inequities It is known that poverty is a major cause of under nutrition and ill health; it contributes to the spread of disease, undermines the effectiveness of health services and slows population control. Morbidity and disability among the poor and disadvantaged groups lead to a vicious spiral of marginalization, to their remaining in poverty, and in turn, to increased ill health. In Bangladesh, poverty is widely recognized as a multi-dimensional problem involving income, consumption, nutrition, health, education, housing, crisis-coping capacity, insecurity, etc. Poverty refers to all forms of economic, social, and psychological deprivation occurring among people lacking sufficient resources for a minimum required level of living. Whatever the dimension is, we know for sure that abject poverty among the mass of the people is the hard reality, and that is the central reason to put this agenda at the center of the debate. The profile of human deprivation reveals that about 50 percent of the people of Bangladesh are income-poor (head count index) while 77 percent of people lack basic or minimally essential human capabilities: capacity to be well-nourished and healthy, capacity for healthy reproduction, and capacity to be educated and knowledgeable. The number of urban poor has also increased from 7 million in 1985 to 12 million in 1999 and their health indicators are worse than those of the rural poor 7. The majority of the population living in urban slums is at the level of extreme poverty. Because the problem is so huge in magnitude, only a strong political commitment combined with an integrated approach will make it possible to achieve a breakthrough. Poverty, along with other factors like inadequate information, leading to poor health-related behavior, also underlies a large part of the burden from tuberculosis, malaria, HIV/AIDS, complications associated with pregnancy and delivery, and childhood illnesses including acute respiratory infections, measles, and diarrhea diseases. According to WHO, these conditions are responsible for two thirds of the deaths among children and young adults living in Asia and Africa. 8 The impact of these conditions goes beyond the suffering of those who are affected directly. Evidence shows that they threaten economic growth and together constitute an enormous hurdle to achieving national growth and prosperity. Life saving medicines and tools to treat or prevent these conditions are available and at relative low cost 9. But to have any 4 5 6 * 7 8 9 Bangladesh Bureau of Statistics, 2000, Statistical Pocket Book. Ministry of Health and Family Welfare (2001), Expanded Programme of Immunization, National Plan of Action, 2001-2005, Revised Draft Population Census, 2001, Preliminary Report, August 2001, Bangladesh Bureau of Statistics. Adapted from Conceptual Framework of Health, Nutrition and Population Sector Programme (HNPSP) July 2003 June 2006 Ministry of Health and Family Welfare (2001), Expanded Programme of Immunization, National Plan of Action, 2001-2005, Revised Draft World Health Organization, Massive Effort against Diseases of Poverty Barkat A, and M Majid, Overview of Diseases of Poverty in Bangladesh, research paper presented at national seminar organized by Partners in Population and Development (PPD) and South-South Centre at BRAC Centre, Dhaka on 25 th May, 2001 3

significant impact on poverty, this will require increased equity of access and increased coverage of interventions directed at these conditions, which are already included in the Essential Service Package (ESP). The table below shows health and health service inequality in Bangladesh: Bangladesh 1996/7 Health, Nutrition, Population and Poverty: Total Population Quintiles Population Poor/Rich Indicators Poorest Second Middle Fourth Richest Average Ratio HNP Status Indicators IMR 96.3 98.7 97.0 88.7 56.6 89.6 1.701 U5MR 141.1 146.9 135.2 122.3 76.0 127.8 1.857 Children Stunted (%) 50.5 50.8 41.9 34.8 23.5 41.3 2.149 Children Under-weight (% moderate) 60.3 53.5 49.2 41.8 28.1 47.6 2.146 Children Under-weight (% severe) 28.7 26.2 21.7 13.1 5.6 19.8 5.125 Low Mother's BMI (%) 64.4 57.4 53.3 48.3 32.6 52.0 1.975 Total Fertility Rate 3.8 3.8 3.5 3.1 2.2 3.3 1.727 Age Specific Fertility Rate (15-49 years) 187.0 171.0 170.0 133.0 91.0 147.0 2.055 HNP Service Indicators Immunization coverage (%) -Measles 62.1 59.8 74.1 78.5 82.6 69.9 0.752 -DPT3 60.4 60.7 73.3 76.4 83.2 69.3 0.726 -All 47.2 43.7 60.8 58.8 66.7 54.1 0.708 -None 18.3 14.5 12.4 5.4 4.9 12.0 3.735 Treatment of Diarrhea (%) -Prevalence 9.1 7.4 7.5 7.3 6.4 7.6 1.422 -ORT use 62.4 54.2 61.8 61.0 68.2 61.0 0.915 -Seen Medically 21.7 17.7 21.2 28.1 23.8 22.2 0.912 -% Seen in a Public Facility 9.3 5.7 6.1 8.5 13.9 8.3 0.669 Treatment of ARI (%) - Prevalence 12.6 14.8 13.8 11.3 10.7 12.8 1.178 - Seen Medically 22.9 29.1 31.8 39.1 50.6 32.9 0.453 - % Seen in a Public Facility 6.6 10.0 12.2 12.6 14.2 10.7 0.465 Antenatal Care Visits (%) - to a Medically Trained Person 14.3 16.0 22.0 31.8 58.6 26.4 0.244 - to a Doctor 9.0 10.2 15.6 22.5 51.0 19.6 0.176 - to a Nurse or Trained Midwife 5.4 5.8 6.4 9.3 7.5 6.8 0.720-2+ visits 9.4 11.8 13.6 21.8 50.5 19.5 0.186 Delivery Attendance (%) - by a Medically Trained Person 1.8 2.5 4.1 9.0 29.7 8.1 0.061 - by a Doctor 1.3 1.5 2.4 5.4 20.1 5.2 0.065 - by a Nurse or Trained Midwife 0.5 1.0 1.7 3.6 9.6 2.8 0.052 - % in a Public Facility 0.8 1.1 1.0 2.7 8.6 2.4 0.093 - % in a Private Facility 0.1 0.1 0.3 1.0 8.7 1.6 0.011 - % at Home 98.3 98.5 97.7 95.5 80.6 95.0 1.220 Use of Modern Contraception (%) - Females 38.8 40.8 43.7 38.8 48.5 42.1 0.800 - Males 45.5 46.1 51.3 45.1 54.4 48.5 0.836 Source: 2002 World Development Indicators, World Bank 4

2. POVERTY, HEALTH AND DEVELOPMENT 2.1 Health Poverty Diagnosis: Health is an important indicator of development. Effective planning for poverty reduction should be based upon sound evidence on the nature and extent of socio-economic inequalities, how they arise, and what are the resulting problems. This process is often labeled a Poverty Diagnosis. The draft interim-poverty Reduction Strategy Paper (i-prsp) makes a good start on an overall poverty diagnosis for national poverty reduction purposes. It summarizes the extent of, and recent trends in, poverty in Bangladesh based upon financial and social indicators. However, further work is required for the purposes of pro poor planning for health. Expressed concisely, a poverty diagnosis for health for Bangladesh would comprise the following: The identification of key health-poverty variables and poverty indicators; An assessment of the extent of, and trends in, socio-economic inequalities in health; An assessment of who the poor are and the differences amongst them; An analysis of the health-poverty process and the factors that contribute to socio-economic inequalities in health; An identification and analysis of the major health problems of the poor and the consequences of those problems for the poor; A critical appraisal of the capacity of current data and information systems to support pro-poor health planning and the subsequent monitoring and evaluation of poverty reduction activities and outcomes. 2.2 A Major Development Engine: Poverty is a major contributory factor to poor health. Poverty and the associated characteristics are overcrowded housing, limited assets, inadequate nutrition, low levels of education and poor environment, which inevitably increase susceptibility to ill health. For these reasons, diseases such as tuberculosis, malnutrition, diarrhea and malaria are often termed diseases of the poor. Similarly, poor health often leads to and reinforces poverty, both through the high costs of health care, and the effects of ill health on household income and productivity. Ill health and its consequences can drive the nearly poor into poverty, or the moderately poor into more sever poverty. Considering the above fact, the Government has given emphasis to pro-poor health care. Following steps would be considered to address pro-poor health strategy: ** Better understanding of health-poverty linkages and processes; Spending more: broadening and deepening the resource base; Spending better: doing the right things in the right way; Spending on right groups: determining how costs and benefits are to be distributed; Strengthening data and information for pro-poor health planning: implementation and monitoring. ** Adapted from Annex-7, Strategic Issues in Health Sector Development, A National Strategy for Economic Growth, Poverty Reduction and Social Development, December 2002 3. EXPENDITURE PATTERN IN BANGLADESH A nation-wide survey on health expenditure conducted in 1998 reports that Bangladesh spent a total of Bangladeshi takas 54,700 million (US$ 1,308 million) on health in 1996/97, equivalent to 3.9% of GDP. This stands to US$ 11 per capita expenditure. Of the total expenditure, 13% was spent from revenue budget, 18% from development budget, 3% from other public revenues, 3% from non-profit NGOs, and 63% by households. This is presented in the figure below. Of the per capita expenditure about one third (US$ 4) was public sector spending and two thirds private spending. Out of the household expenditure, 46% spending was on purchasing drugs from private 5

pharmacies. Contribution of for-profit firms and private insurance in health care financing is about non-existent. A more up-to-date estimate of per capita health spending is US$ 13 (WHO, 2000). Figure: Source of Funds for Bangladesh's health care system Other public revenue, 3% Non-prof., NGOs, Domnors, 3% Firms & Private Insurance, 0% MOHFW Revenue Budget, 13% MOHFW Development Budget, 18% House holds, 63% House holds MOHFW Revenue Budget Other public revenue MOHFW Development Budget Non-prof., NGOs, Domnors Firms & Private Insurance Source: Bangladesh National Health Accounts 1996/97 A second round of National Health Accounts Survey is underway, providing detailed expenditure pattern in disaggregated fashion by source, function, provider, age, socioeconomic classification and by geographic region up to district levels. What CMH recommended: It has estimated minimum financing needs to be around US$ 30 to US$ 40 per person per year to cover essential interventions. The least-developed countries spend average approximately US$ 13 per person per year in total. However, optimum expenditure is suggested average approximately US$ 24 per capita per year, of which budgetary outlays are US$ 13. Among the action agenda, the financing strategy envisaged an increase of domestic budgetary resources for health of 1 percent of GNP by 2007 and 2 percent of GNP by 2015. Countries should also take steps to enhance the efficiency of domestic resource spending, including a better prioritization of health services and the encouragement of community-financing schemes to ensure improved risk pooling for poor households. It also put emphasis on the donor finance needed to close the financing gap, in conjunction with best efforts by the recipient countries themselves. What Bangladesh can do: Considering at least US$ 13 per capita per year for essential services and the resources available for this, there exists a huge resource gap. The gap is wide when it is considered US$ 30-40. In this context, better and efficient utlization of existing resources and tapping out-of-pocket expenditure through developing some alternative mechanism may be better options. Only recently the Government has been actively considering alternative financing by introducing social health insurance, community health insurance, user fees and other similar mechanisms. Various empirical evidence say that through user fees only 5% additional resources could be generated. Social insurance is not likely to generate substantial resources for health in the immediate term but needs further exploration. However, in both cases the caution is that the administrative cost may be a concern to manage these mechanisms. 6

4. PROGRESS OF MACROECONMICS AND HEALTH EFFORTS 6.1 Specific MOHFW responses to date on CMH and Poverty: The Government of Bangladesh has undertaken a good number of activities and more activities to be taken during the financial years 2003 to 2006. Some of the activities are stated in brief hereunder: Preparation of background paper on poverty reduction strategy: On March 2001, the Ministry of Health and Family Welfare produced a background paper entitled Towards a Poverty Strategy for the health, nutrition and population sector. High-level inter-ministerial global study tour: On February 2002, the Ministry of Health and Family Welfare organized a two-week global study tour aimed at supporting national efforts to improve the pro-poor focus of sectoral planning in health and population. The study tour team comprised senior officials of the Ministry of Health and Family Welfare, Ministry of Finance, University of Dhaka and the country office of the UK Department for International Development (DfID). The study tour encompassed a series of discussions and presentations with professionals and other informants in the key health and development organizations, specifically, with representatives of the World Bank in Washington; with senior staff of WHO in Geneva and those working on its Commission on Macroeconomics and Health; with senior officials of DfID in its London headquarters and, with those working on DfID-supported health and poverty issues, primarily through its London-based Resource Centre. Additionally, the tour included a visit to Bolivia to see at first hand how that country, widely regarded as one of the PRSP successes, met the challenge of developing its own PRSP. Dissemination workshop on CMH report: On May 04, 2002, the Ministry of Health and Family Welfare with assistance from World Health Organization, Bangladesh, organized a dissemination workshop on the Report of the Commission on Macroeconomics and Health. The keynote speaker was Dr. Sergio Spinaci, Executive Secretary of the CMH, WHO, Geneva, Switzerland. The workshop was very well attended with high-level participation, including the Principal Secretary and Cabinet Secretary; the Secretary, Ministry of Finance; the Secretary, Planning Division; the Secretary, Ministry of Education; Secretary, Economic Relations Division; the Secretary, Ministry of Health and Family Welfare; the WHO Representative in Bangladesh; the Head of DfID, Bangladesh. The workshop was well represented from other ministries that have a health producing function, from development partners, NGOs, civil society and so on. More than 300 distinguished guests and participants attended the inaugural session. 107 participants attended the group works (39 women, 68 men) representing government, NGO, private sector, civil society and development partners. After a long, lively discussion, groups came up with a number of recommendations on four theme areas: (i) strategic guidelines for pro-poor planning, (ii) how the next sector programme should be made pro-poor, (iii) how the health sector programme should be financed, and (iv) implications of CMH for Bangladesh. There was a detailed discussion in the Group Exercise regarding the formation of NCMH or its equivalent in Bangladesh, the group recommended not forming a new committee but to perform the functions of NMCH or its equivalent through the existing committee of the Ministry of Health and Family Welfare. The group also recommended prioritization of the existing ESP to give more coverage and ensure an appropriate level of service. Bangladesh Response to the Report of CMH in Geneva: On June 17-18, 2002 at WHO, Geneva, Switzerland, the Secretary, Ministry of Finance, the Secretary, Planning Division, and the Secretary, Ministry of Health and Family Welfare presented a Bangladesh Response to the Report of the Commission on Macroeconomics and Health. 7

Formation of Bangladesh NCMH: The Ministry of Health and Family Welfare has established a National Committee on MacroHealth and Poverty Reduction Strategy (NCMHPRS). The Committee is chaired by the Minister of Health and Family Welfare and co-chaired by the State Minister of Finance and Planning. As described in its terms of reference, the Committee s role is to scale up essential health intervention to achieve the objectives laid down in the Bangladesh National Strategy for Economic Growth and Poverty Reduction (Bangladesh i-prsp). Essential Interventions: CMH report affirms that a large burden of poor health is attributable to a small number of conditions for which cost-effective interventions already exist. This fact is already recognised in Bangladesh and to overcome this large burden, ESP was introduced in the previous Health and Population Sector Programme 1998-2003, popularly known as HPSP. ESP was broadly targeted towards the most vulnerable especially poor, women and children. By content (it contains the basic health interventions and have five broad components): - reproductive health - child health - limited curative care - communicable disease control - behaviour change communication By level (it is provided at the primary level, mainly "upazilla" and below) By geography (it is mainly delivered at the rural areas to the rural population, 76.6% of the total population) By allocation (prioritize allocation for ESP - now roughly more than 65% public health expenditure is allocated to ESP services) The Government is committed to strengthen and better target ESP in the next Health, Nutrition and Population Sector Programme (2003-2006). Currently the Ministry of Health and Family Welfare spends about 65% of its resources on ESP, about one eighth of the estimated requirement. That means there is a clear need for major scaling up of ESP expenditures in Bangladesh. Access to GFATM: The Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) can support the scaling up process by providing funds to country level programmes. Bangladesh has successfully participated in the GFATM very recently. It has received a grant for an amount of US$ 19.97 million for HIV/AIDS. A funding proposal for tuberculosis and malaria is under consideration of the GFATM fund management authority. Access to GAVI: Bangladesh has also successfully accessed a grant of US$ 3.66 million from the Global Alliance for Vaccines and Immunization (GAVI) as first instalment. After satisfactory spending of this amount, Bangladesh will be awarded with an amount of US$ 3.6 million as a second instalment. Access to Global Health Research Fund: The Ministry of Health and Family Welfare requires access to Global Health Research Fund (GHRF). As mentioned later, the government will undertake a good number of research and study and prepare guidelines to scale up resource, establish supporting effective decentralization, exploring alternative health care financing, improving alternative medical care (e.g. preparation of scientific herbal pharmacopoeia) and developing broad partnership it will need a considerable fund for the purpose. In addition to this health and population research institutes undertake 8

regular research and studies in the field of health service delivery, health planning and management, health economics, health human resources and projection and so on. Health Economics Unit of the Ministry of Health and Family Welfare and the Bangladesh Medical Research Council have the ability to conduct research and manage contracting out. We would like to propose that the forum starts lobbying. Reaching services Close-to-Users: The constraints that deprive millions of poor need access to health services that go well beyond immediate funding. CMH emphasises closeto-client (CTC) health services at the community level, where actual health services are delivered. Key elements of a CTC level service involve efficient and adequate staffing, essential drugs and medical supplies, appropriate infrastructure, transport, communications and logistics, better management with greater local accountability and involvement. There is provision in the National Health Policy for one "Upazila" (sub-district) Health and Family Welfare Complexes (UHFWC) per union covering a population of approximately 25,000. About 4,000 such centres are functional and 275 are under construction. Each UHFWC is staffed with one graduate doctor and the required number of supporting staff, including paramedics. The promotion, preventive and curative services are provided on daily basis at the centre. The later constitutes first referral centre of the health system. The Government of the People s Republic of Bangladesh is committed to provide effective health care to every citizen of the country. The people in the rural area, which constitutes 76.6% of the population, are the most deserving one. The Government constructed approximately 11,000 Community Clinics (CCs) for every 6,000 population within less than 30 minutes walking distance at village levels to provide selected services at the doorsteps considering the people s need. The Government has planned to activate those by providing more providers and medicines. At the same time it has been planned to contract out some of the CCs to the NGOs on pilot basis. Recently, the Government has planned to introduce 'vouchers' on a pilot basis. It is considered as the first point of contact with the formal system. In addition to that satellite clinics and domiciliary services are also continuing. 6.2 Finance Division's response to date on CMH and Poverty: Scaling up allocation: Interim Poverty Reduction Strategy Papers (i-prsp) projects substantial increase in Public Health Expenditures over next three-years Plan (40% increase as share of GDP) as shown in the table below: 2000-01 (base year) 2003-04 2004-05 2005-06 Billion Tk % GDP Billion Tk % GDP Billion Tk % GDP Billion Tk % GDP 21.92 0.87 41.50 1.30 46.25 1.32 51.75 1.34 This projection is dependent upon optimistic assumptions about overall macroeconomic performance and real per capita GDP growth. It also assumes that most of growth is on the development budget. Although there is a significant rate of growth in public health spending as projected (2003-06) in the i-prsp, it will be far away from developing and providing a comprehensive ESP services in absolute monetary terms. Moreover, due to the emergence of a double burden disease in low income countries the content of existing ESP need to be expanded to incorporate major prevalent non-communicable diseases, coverage to be extended to provide services for the urban poor, quality of services need to be improved. Therefore, 9

there is a need to prioritise within ESP, in terms of what to include and who to benefit. Also a need to increase other resources (e.g. international donor agencies, household out of pocket expenditures and others) for effective ESP delivery. The Mid-Term Macroeconomic Framework as referred to in the i-prsp 10 has indication of revenue/gdp ratio increment from 10.6 percent in fiscal year 2003 to 11.9 percent in fiscal year 2006, and the tax/gdp ratio from 8.3 percent to 9.7 percent during the same period. As a result, total government expenditure as a proportion of GDP will increase from 15.3 percent in fiscal year 2003 to 16.4 percent in fiscal year 2006. The size of the Annual Development Programme will grow from 5.8 percent of GDP in fiscal year 2003 to 6.9 percent in fiscal year 2006 indicating expanded and improved absorption capacity of key sectors in utilizing additional development resources. Ministry of Finance has also indicated that considering 2001-2002 financial year, poverty reduction spending (14.5% of GDP), over the three years in the social sector will increase to 16.5% i.e., 2.0%. Therefore, considering 30.64% as health s historical share of social expenditure, the sector may draw additional resource. All these indicate that an effective pro-poor Health, Nutrition and Population Sector Programme will be able to attract and consume more resources. 7. NEW HEALTH, NUTRITION AND POPULATION SECTOR PROGRAMME (HNPSP) OF BANGLADESH Within the broader context of Bangladesh's National Strategy for Economic Growth and Poverty Reduction (Bangladesh i-prsp), the goal of the health, nutrition and population sector is to achieve sustainable improvement in the health, nutrition, and reproductive health, including family planning of the people, particularly of vulnerable groups, including women, children, the elderly, and the poor. The main purpose of HNPSP 2003-2006 will be to increase availability and utilization of user-centered, effective, efficient, equitable, affordable and accessible quality services for a defined ESP, along with other selected services. HNPSP will involve local government bodies/agencies to enhance the programme output through peoples' participation. Priority objectives: *** The success of the HNPSP strategy will be measured by the level of: (i) reducing maternal mortality and morbidity, (ii) re-accelerating fertility reduction, (iii) reducing child malnutrition, (iv) reducing infant and under-five mortality, and (v) reducing the burden of tuberculosis and other infectious diseases. Targets for these five prioritized objectives (Table: Targets for Five Prioritized HNPSP Objectives) are fully consistent with the health, nutrition and population sector-related Millennium Development Goals as incorporated into the Government s Poverty Reduction Strategy, also including the elimination of the disadvantages of female children with regard to mortality between ages one and four. Implementation of HNPSP will, therefore, be on of the pillars for the successful implementation of the Poverty Reduction Strategy of the Government of Bangladesh. During the HNPSP, it is intended to continue to allocate at least 65 percent of sectoral resources to an ESP that will achieve the highest attainable health benefits by delivering cost-effective interventions for major causes of preventable morbidity and mortality, especially those affecting the poor. In addition, the NHPSP sets out several initiatives for making sectoral activities across the board more pro-poor. These include participation of the poor in local-level planning, improved targeting of health services to the poor, and preferential allocation of sectoral resources to poor and underserved geographic areas of the country. 10 Bangladesh National Strategy for Economics Growth and Poverty Reduction, April 2002 10

*** Adapted from Conceptual Framework of Health, Nutrition and Population Sector Programme (HNPSP) July 2003 June 2006 Table: Targets for Five Prioritised HNPSP Objectives HNPSP Priority Objective Unit of Measurement Objectively Verifiable Indicator Benchmark (with Reference Period and Source) Projected HNPSP Baseline Mid- 2003 Target Mid- 2006 Reducing Maternal Mortality Met need for Emergency Obstetric Care: Percentage of deliveries with obstetric complications managed at GOB EOC facilities 12.6% (2002; UMIS estimate based on EmOC reports from 218 GOB facilities) 13.0% 25% Maternal deaths per 1,000 live births 3.2 1 (1999; Bangladesh MHSM Survey) 2.8 1,2 2.6 1,2 Reducing the Total Fertility Rate Lifetime number of births per woman at current-period agespecific fertility rates 3.3 (1998-2000; BDHS 1999-2000) 3.3 3 2.9 3 Reducing Malnutrition Percentage of underweight children age 6 to 59 months (weight-for-age Z-score < - 2) 50.9% (Child Nutrition Survey of Bangladesh 2000) n.a. 30% (only in NNP upazilas) Percentage of severely underweight children age 6 to 59 months (weight-for-age Z- score < - 3)) 12.9% (Child Nutrition Survey of Bangladesh 2000) n.a. 5% (only in NNP upazilas) Reducing Infant and Under-five Mortality Infant deaths per 1,000 live births Deaths in children under 5 per 1,000 live births 66.3 (1995-1999; BDHS 1999-2000) 94.0 (1995-1999; BDHS 1999-2000) 48.9 4 38.9 4 69.4 5 54.0 5 Reducing the Burden of TB 6 Case detection: Percentage of newly incident sputum-positive pulmonary TB cases identified and reported 34% (DOTS centre reports to NTB for 2002). 37% 65% Cure rate: Percentage of registered sputum positive pulmonary TB cases who converted to sputum negative and finished treatment 83.7% (DOTS centre reports to NTB for 2002). 84% 85% 1 2 considering 80 percent of deaths from sibling history as maternal deaths linear projection based on three data points (Streatfield) 3 based on projected CPR of 55% in mid-2003 and 62% in mid-2006 and contraceptive methodmix as shown in Chapter 4 (Streatfield) 4 linear projection based on nine data points (Streatfield) 5 linear projection based on eight data points (Streatfield) 6 Recent data on incidence and prevalence are not available Other prioritization criteria relevant to sectoral resource allocations are (i) meeting the health needs of vulnerable groups: women, young children, and the elderly; (ii) a renewed commitment to fertility reduction within the broader context of reproductive health, and (iii) responsiveness to emerging sectoral priorities, such as non-communicable disease control, public health concerns and the sectoral reform agenda. 11

By re-invigorating programme efforts directed at improved maternal health, reduced child mortality, reduced fertility and disease control, HNPSP is expected to contribute significantly to the achievement of health-related Millennium Development Goals. These include: Table: Health-related Millennium Development Goals with 1990 or 1995 as Benchmark Required annual rate of progress (acc. to MDG 1990 or 1995 baseline) Projected rate of progress during HNPSP Are HNPSP performance targets on track for MDG? Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate Annual reduction by 3.6 per 1,000 Annual reduction by 3.3 per 1,000 yes Reduce by three-quarters, between 1990 and 2015, the maternal mortality rate Annual reduction by 7.5 per 100,000 Annual reduction by 6.7 per 100,000 yes Have halted by 2015, and begun to reverse, the spread of HIV/AIDS. Have halted by 2015, and begun to reverse the incidence of malaria and other major diseases Not quantified Not quantified Uncertain; further intensification of HNPSP program efforts may be required Currently planned HNPSP programme efforts for disease control, particularly for tuberculosis control in urban areas and in urban slums may, however, prove inadequate to reverse the annual incidence. Coverage and effectiveness of control programmes for HIV/AIDS, tuberculosis and malaria will, therefore, be closely monitored so that they may be further intensified, if needed. The PRSP of the Government of Bangladesh considers in particular the human development dimensions of poverty, i.e., deprivation in health, deprivation of education, and deprivation of nutrition as well as related gender gaps. This places the Ministry of Health and Family Welfare, along with other social-sector Ministries, at the centre of the stage for the achievement of PRSP targets. Table: Major Health-related Goal Posts under an Accelerated Social Development Strategy with 2000 as the Benchmark Year Development Indicators 2000 (Benchmark) 2004 2006 2015 Infant Mortality Rate (IMR) 66 56 48 22 Child Mortality Rate (<5-MR) 94 80 70 31 Maternal Mortality Ratio 320 295 275 147 Percent Children Underweight 51 48 42 26 The Millennium Development Goals focused upon in the PRSP address the following health, nutrition and population-related targets: (i) reduce infant and under-five mortality rates by 65% and eliminate gender disparity in child mortality; (ii) reduce the proportion of malnourished children by 50 percent and eliminate gender disparity in child malnutrition; (iii) reduce maternal mortality by 75% and (iv) ensure availability of reproductive health services to all women. Targeted improvements in Health Sub Sector: 12

By the end of HNPSP, the Ministry of Health and Family Welfare expects to have either basic or comprehensive emergency obstetric care available at all UHCs and to offer comprehensive emergency obstetric care at all district and medical college hospitals. By that time, almost twice as many women in need of emergency obstetric care should have access to and be using a health facility of the Government of Bangladesh for management of a delivery complication (50% compared to only about 13 percent at present). The proportion of children who have been immunized against childhood immunizable diseases has remained virtually stagnant for the last decade. During HNPSP, the Government of Bangladesh will give a big push to increase child immunization rates to 85 percent and will, to that end, intensify local-level planning, logistics, and monitoring. Bangladesh has already been free of confirmed cases of polio since August 2000, but polio eradication can only be certified at the regional level, i.e., after the South Asia region as a whole will have been polio-free for three years. In communicable disease control, the main emphasis during HNPSP will be on tuberculosis control. Tuberculosis control is one of several programmes of the Ministry of Health and Family Welfare that are implemented in close collaboration with NGOs. Current cure rates for tuberculosis are already near the desired level of 85 percent, but case detection has been lagging. During the HNPSP, the Ministry aims to increase the case detection rate from an estimated level of 37 percent in 2002 to 65 percent, which will be very near the global target of 70 percent. The Ministry aims, in addition, to make further progress with leprosy control, which has already been eliminated at the national level, but remains above the elimination threshold in 10 districts or municipalities. The Ministry will also continue and intensify its disease control programmes in districts where malaria, kala-azar and filariasis are endemic and will also assist city corporations with more effective control of dengue. In addition, the Ministry will work to strengthening managerial arrangements and stepped-up implementation of HIV/AIDS prevention and control so as to curb infection rates among high-risk groups and prevent transmission to the general population. The HNPSP will, finally, respond to the increasing need for prevention and management of non-communicable diseases and will also initiate a more effective response to public health problems. With respect to arsenicosis, the health sector response must be complementary to that by the Department of Public Health Engineering. During the HNPSP period, the Ministry of Health and Family Welfare will expand case identification and reporting and medical management of symptoms of arsenicosis from currently 44 upazilas to 166. In addition, the Ministry is reviewing how best to engage its Institute of Epidemiology and Diseased Control for public health surveillance on communicable and non-communicable diseases and on risk factors. Proposed Nutrition Sub-sector Programme: In view of the still very high rates of child malnutrition in Bangladesh, which are among the highest in the world, the Government Poverty Reduction Strategy rightly includes among its goals to reduce by half, by the year 2015, the currently observed rates of child malnutrition. In the meantime, it is planned to increase the number of upazilas offering area-based community nutrition interventions based on the model of the Bangladesh Integrated Nutrition Project from currently 61 to 225 by mid 2002/03. In the upazilas brought under community nutrition interventions, very substantial improvements in nutrition status are expected to result: Severe underweight in children under two reduced to five percent and moderate underweight reduced to 30 percent; 50 percent of pregnant women should achieve a weight gain during pregnancy of at least 9 kg, thereby reducing the incidence of low birth weight to less than 30 percent; 13

Prevalence of anaemia among adolescent girls and pregnant women reduced by one third. In addition to area-based community nutrition interventions, addressed to the abovementioned targets, the HNPSP will also support national-level nutrition interventions. These include the continuation of twice-yearly high-dose vitamin A supplementation, which has been successful in substantially reducing the prevalence of vitamin A deficiency in children under six, as well as post-partum supplementation of newly delivered women with vitamin A, iron and folate supplementation of pregnant women and adolescent girls, improved technologies for the iodine fortification of table salts, breast feeding promotion and protection, as well as a national-level media campaign on feeding and caring practices that will improve the nutritional status, health and well-being of young children, adolescent girls and pregnant and breast-feeding women. Proposed Population Sub-sector Programme: Compared to hospital-based emergency obstetric care and outpatient treatment of reproductive tract infections and sexually transmitted diseases at the Upazila Health Complexes, which are the responsibility of the Health Services Directorate, an even greater volume of reproductive health services is being delivered and will be delivered by the Family Planning Directorate. These include, in addition to family planning, antenatal care, safe delivery by skilled birth attendants or family health visitors with midwifery training, obstetric first aid at upgraded union health and family welfare centres, as well as comprehensive emergency obstetric care at the currently 64 maternal and child welfare centres. Training in safe delivery practices for normal deliveries will also include essential newborn care practices, which are considered the key to achieving targeted reductions in neo-natal mortality. After earlier internationally acclaimed gains in fertility reduction, fertility levels in Bangladesh, as measured by the total fertility rate, became virtually stalled at the levels already achieved in the early 1990 s. One of the priorities is, therefore, to re-accelerate fertility decline. The Ministry of Health and Family Welfare intends to achieve this result by re-establishing the earlier system of household registration and regular home visiting by female family welfare visitors for family planning motivation, provision of temporary methods, referrals for clinical methods and advice or referral for side-effects management. By intensifying motivational efforts and increasing the supply of family planning services, an increase of contraceptive prevalence, from a current level of about 55 percent to 62 percent by mid 2006 is aimed for. This, together with a more effective method mix and lower discontinuation rates for temporary methods, should then result in a lowering of the total fertility rate from currently about 3.2 to 2.8 by mid 2006. Agreed Action Plan for Reform Agenda As part of the Government of Bangladesh s commitment to the reform in the health, nutrition and population sector to make services pro-poor, increase demand side financing, promoting public private partnership, ensuring good governance, shifting government s role towards purchaser, there has been agreement between the government and the developing partners of Bangladesh. For this we will have to conduct additional empirical works as identified in the agreed action plan for reform agenda. There has already been agreement to start initial activities. Those are mentioned below. We anticipate that timely and focused research and technical support will promote addressing systemic issues in integrating specific pro-poor health policies and initiatives into existing policy processes and health systems. We also believe that both parties commitment to this action plan can only achieve desired goals. 14

Actions Required to be taken When 1. Pro-poor Strategy for the Ministry of Health and Family Welfare 1.1 Developing terms of reference for identification of the poor (Study 30 th September 2003 for demand side subsidy) 1.2 Developing guideline for targeting of resources to poorer districts 31 st December 2003 and upazilas 1.3 Finalizing terms of reference for governance study August 2003 2. Non-Public Sector Service Provision: 2.1 Developing and approval of strategic framework for non-public 30 th November 2003 service contracting 2.2 Recommendations for contracting non-public sector service 31 st December 2003 3. Developing framework for comparative study for public- private 30 th September 2003 provision 4. Collection and re-cycling of user fee 31 st January 2004 4.1 Preparation of guide lines for user fee utilization 31 st December 2003 4.2 Policy decision on user fee July, 2004 5. Guide lines and strategy for health insurance Guidelines by 30 September 2003 and Strategy by December 2003 6. Decentralization action plan December, 2003 8. Restructuring of Financial Management Unit 9FMU), Accounts, 30 th October 2003 Report & I T (ARIT) and Programme Finance Cell (PFC) 9. District Health, Nutrition and Population Coordination Committee 30 th September 2003 10. Local Level Planning Initiatives (LLP): Conduct a review of staff needs (including the number of vacant posts) to be completed by 30 th November 2003 and June 2004 30 th November, 2003 11. Umbrella bill on hospital autonomy Winter Session 2004 9. CONCLUSION The Government of Bangladesh is constitutionally committed to "the supply of basic medical requirements to all levels of the people in the society" and the "improvement of nutrition of the people and public health". Within the broader context of Bangladesh's National Strategy for Economic Growth and Poverty Reduction (Bangladesh i-prsp), the Government seeks to create conditions whereby the people of Bangladesh have the opportunity to reach and maintain the highest attainable level of health. It is a vision that recognises health as a fundamental human right and, therefore, the need to promote health and to alleviate ill health and suffering in the spirit of the social justice. This vision derives from a value framework that is based on the core values of access equity, gender equality and ethical conduct. Bangladesh is one of the world's most densely populated countries, with about US$ 380 per capita income and facing major health and economic challenges. The CMH estimates that the cost needed to provide essential health interventions in developing countries such as Bangladesh is approximately US$ 30 to US$ 40 per person per year. Current health spending in Bangladesh is significantly below the threshold, and there is a clear need for scaling up investments in health. With this per capita income, how far it would be possible to increase allocation for essential interventions remains a challenge. However, the Government is committed to allocate at least 65% of resources for essential services at rural levels. Bangladesh's new Commission on Macroeconomics and Health will work with the WHO and international development agencies to strategize on ways to mobilize increased health care investments in an effective manner. Bangladesh believes that these recommendations can only be implemented when both the developed and developing countries can proceed hand-in-hand and the international 15

agencies like the World Bank, the International Monetary Fund, WHO, the World Trade Organization etc. help to build a smooth road map to achieve such goals. 16