Global Health Initiative: Bangladesh Strategy

Interagency Program Strategy 2011-2015

Acronym List

• AusAid Australian Aid
• BCC Behavior Change Communication
• BDHS Bangladesh Demographic and Health Survey
• BRAC Bangladesh Rural Advancement Committee
• CCM Country Coordination Mechanism
• CDC Center for Disease Control
• CPR Contraceptive Prevalence Rate
• CSP Community Service Provider
• Dfid U.K. department for International Development
• DG Democracy and Governance
• DG/FP Directorate General of Family Planning, Bangladesh
• DG/HS Directorate General of Health Services, Bangladesh
• DOD/ODC U.S. Department of Defense/Office of Defense Cooperation
• DOT Direct Observable Treatment
• ESP Essential Services Package
• EU European Union
• FANTA-2 Food and Nutrition Technical Assistance Project -2
• FP Family Planning
• FTF Feed the Future
• FFP Food for Peace
• GHI Global Health Initiative
• GHI/B Global Health Initiative/Bangladesh
• GIS Geographic Information System
• GOB Government of Bangladesh
• GTZ German Technical Cooperation
• HIS Health Information System
• HHS Health and Human Services
• HIV/AIDS Human Immune Virus/Acquired Immune Deficiency Syndrome
• HNPSSP Health, Nutrition, Population Sector Strategic Program
• ICDDRB International Center for Diarrheal Disease and Research/Bangladesh
• HR Human Resources
• JICA Japan International Cooperation Agency
• M4H Mobiles for Health
• MCC Millennium Challenge Corporation
• MCH Maternal and Child Health
• MOHFW Ministry of Health and Family Welfare
• MOLRD Ministry of Local and Rural Development
• MDG Millennium Development Goal
• M&E Monitoring & Evaluation
• NGO Non-Governmental Organization
• NIH National Institutes of Health
• OIC Organization of the Islamic Conference
• PAO Public Affairs Office
• RH Reproductive Health
• SSFP Smiling Sun Franchise Project
• TB Tuberculosis
• UN United Nations
• UNAIDS United Nations AIDS
• UNFPA United Nations Fund for Population Activities
• USAID United States Agency for International Development
• USDA United States Department of Agriculture
• USG United States Government
• VOA Voice of America
• WB World Bank

1. Rationale for the Global Health Initiative in Bangladesh

The Global Health Initiative (GHI) in Bangladesh offers an opportunity for the United States Government (USG) to reach out to the most populous part of the Muslim world suffering from rapid population growth and poverty, by providing immediate assistance and support for the country’s efforts to ensure health and nutrition services, and stabilize population. Bangladesh could be showcased as a development model as it links three Presidential Initiatives[1] to help to lift its people out of poverty while sharing USG foreign policy priorities in governance and security. Identified in 2005 by Goldman-Sachs as one of the “Next 11” emerging economies, Bangladesh has both potential as well as severe challenges for stabilizing population and protecting human health. Over the next five years, the USG will help Bangladesh to adopt and scale up proven interventions to: increase use of long-term family planning methods; reduce maternal mortality; reduce neonatal and other under-five mortality; improve nutritional status; reduce the burden of Tuberculosis (TB); and keep HIV/AIDS prevalence below 1%.

The GHI “whole-of-government” approach brings together each Mission Dhaka agency’s exceptional core competencies for strategic programming. The GHI is perfectly timed for enhancing USG support to the Government of Bangladesh’s (GOB) Health, Population, and Nutrition Sector Strategic Program (HPNSSP) for 2011-2016. The new sector program offers an excellent platform for Mission Dhaka to reengage in the sector and regain its technical leadership role. Mission Dhaka’s GHI FY2011 – 2015 strategy includes improved efficiencies and innovative approaches and builds on its past and on-going successful population, health and nutrition programs while incorporating GHI principles.

A major shift in USG assistance is occurring with GHI and a new USG/GOB partnership has formed. The GOB has reached out to the USG for help in: strengthening its capacity to lead the design of their next sector program; placing technical advisors in the MOHFW to staff its Project Preparation Cell (PPC); developing the national results framework and Health Management Information System (HMIS); streamlining procurement; and developing a national BCC strategy. Increased resources under GHI will make Mission Dhaka a major non-pooled funder and offers the opportunity to better integrate its investments and strengthen coordination with GOB and key donors. It also will provide an opportunity for the USG to deepen its support to the national program and increase use of host country systems in keeping with the spirit of the Paris Declaration, Quadrennial Diplomacy and Development Review and USAID Forward. GHI/B will build on existing investments, identify new ones, improve aid effectiveness and promote policy leadership and program integration. GHI/B will also foster country ownership through increased engagement with other stakeholders, such as civil society organizations (including NGOs and the private sector), the locally elected leaders, and religious and other community leaders.

2. Bangladesh’s Development Challenges, Country Priorities and Context^[2]

Development Challenges: Bangladesh has approximately 160 million people, making it the seventh-largest population in the world. It is a densely-populated country (> 1,000 people per km2), with a land mass roughly the size of the state of Iowa. Over the past 10 years, Bangladesh has made considerable progress to curb population growth: the average Bangladeshi woman now bears fewer than three children in her lifetime, down from more than six in the 1970s. Nonetheless, projections forecast more than 50% growth in Bangladesh’s population, to approximately 250 million over the next four decades. This poses massive challenges for the government in terms of employment and the delivery of social services. Further, between 20-30% of the country is normally flooded each year and the country suffers from frequent natural disasters. Dhaka City is poised to become fastest growing megacity by 2025. It began with a manageable population of 2.2 million in 1975 which reached 12.3 million in 2000. There is no city in the world that has experienced such a high growth rate in population during this period. Due to the current growth rate of 2.7, Dhaka will be 4^th on the list of world’s megacities. This rapid growth of Dhaka City is not commensurate with its industrial development, with about one-third of the city’s population living in slums.

More than 45% of the population lives in abject poverty and 35 million live in extreme poverty. Bangladesh ranks 67th out of 84 countries in the Global Hunger Index 2009 and over 10 million children under the age of 5 suffer from malnutrition, which contributes to two in three child deaths. A weak public health system hampers delivery of care. The maternal mortality rate is one of the highest in the region but recently witnessed a 40% decrease to 194 deaths per 100,000 live births. Forty-nine percent of children under 5 and forty-six percent of women are anemic. Inequalities and challenges for women and girls are not adequately addressed, and improvement in this area is especially important given their role as gatekeepers of the country’s social capital. Further, Tuberculosis is still the major cause of adult mortality as Bangladesh has the fifth highest level of TB cases in the world. Fortunately, HIV/AIDS is well below 1% and our efforts will focus on maintaining that level.[3]

Table 1. Key Health and Population Indicators in Bangladesh

The overarching structural challenge is addressing the politically sensitive issue of forging close coordination between the two most powerful Directorates in the Ministry of Health and Family Welfare (MOHFW). The Directorate of Health (DG/HS) and Directorate of Family Planning (DG/FP) work autonomously, lack coordination and implement two vertical systems of health and family planning services which compromise efficiency in delivering primary health care at all levels. USG will provide the GOB with critical extensive technical assistance and support in order to develop an effective, sustainable health care system that reaches the population. Finally, the most challenging aspects of GHI for the USG Bangladesh team will be to focus on key priorities that can show short-term impact as well as achieving long-term sustainable health outcomes. Fostering sustainability for the Bangladesh health sector so that it delivers quality services to all citizens is a key development challenge for the GOB and its partners.

Despite the grim picture portrayed by the country’s constraints, Bangladesh is, in fact, on a positive socio-economic development trajectory. The under-five mortality rate has declined by more than 50% since 1993, a key accomplishment which received special recognition at the Millennium Development Goals (MDGs) Summit in September 2010 in New York. Eighty-eight percent of children (6-59) months) receive vitamin A supplementation twice a year through successful campaigns led by the GOB. The government is also placing an emphasis on mainstreaming nutrition in their new five year health sector program, currently being development. Given adequate policy measures, however, the government can transform these challenges into opportunities to sustainably develop human capital to contribute to further growth of the economy beyond the impressive 5% to 6% witnessed over the past decade.

3. Bangladesh Health Sector Program

The GOB Program: The GOB’s vision for the health sector “is to see the people healthier, happier and economically productive to make Bangladesh a middle income country by 2021, the golden jubilee year of Bangladesh’s independence”. The GOB is committed to fulfilling its election mandate of restarting 18,000 community clinics to provide essential services throughout the country. Continued success in addressing policy reforms in the next five years is critical. Revitalizing services is a core focus and may offer the GOB a tangible way to deliver on its political mandate, rebuild the health system at the community and district level, improve access to services to the most disadvantaged, including women, and increase governance, accountability and credibility, in addressing the country’s remaining health challenges. The GOB is on track in achieving MDGs for child health, Human Immune Virus/Acquired Immune Deficiency Syndrome (HIV/AIDs) and TB by 2015. However, much more targeted efforts are needed to tackle the MDGs for newborn and maternal health and in order to achieve family planning goals.

The current GOB 5-year Population, Health & Nutrition Sector Strategic Program is supported by 16 donors, including UN agencies, ends in June, 2011 and is one of the largest sector wide programs in the world. Well-funded, the GOB finances 70% of the $4.2 billion program with pooled and parallel funders contributing the remaining 30% (including 15% in loans financed by the World Bank). The GOB is currently preparing its next sector program covering 2011-2016 which is anticipated to be another $3-$4 billion investment over the next five years^[5]. The US is a major donor in the sector but is not a pool-funder. USG programs directly link and support to the GOB’s health sector strategy through parallel funded programs. However, Mission Dhaka has provided critical technical leadership to develop the GOB’s sector-wide Results Framework for the new program (See Annex 3). This Framework is forming the road map for major investments for all donors in an attempt to streamline development assistance. Since GOB funding for the program is significant, it is truly a country-led program. Bilateral agencies have a secondary role; most multilaterals, with the exception of the World Bank (WB), play a minimum role in funding the sector.^[6]

Leveraging Multilateral/Bilateral Alliances and Partnerships: The United States Agency for International Development (USAID) will continue its work with other members of the Donor Consortium to leverage investments and strategically support on-going technical assistance to the MOHFW DG/HS and DG/FP to help achieve a common set of health, population and nutrition goals. USAID is in the process of forming development alliances with United Nations Children’s Fund (UNICEF) to promote low cost technology for community based newborn resuscitation, as well as reviving behavioral change communication (BCC) in health and combating malnutrition. In addition, USAID is rolling out Global Alliances with: (1) Australian Aid (AusAid), the Department for International Development (Dfid), and the Bill & Melinda Gates Foundation to promote reproductive health; (2) Japan’s new “EMBRACE” Initiative focusing on maternal and neonatal health; and (3) corporate development alliances on hand washing, hygiene and sanitation campaigns with Unilever. Discussions are underway with the World Health Organization to collaborate on human resources strengthening and capacity building for health workers at the community and district levels. USAID is also working with the United Nations Fund for Population Activities (UNFPA) to revitalize family planning and support the GOB BCC efforts for FP and population. USAID will also coordinate with the WB and German Technical Cooperation (GTZ) to establish an effective monitoring and evaluation system to support GOB in tracking progress of the MDGs for the next sector program.

4. The USG Health Program in Bangladesh[7]

USAID has worked for over 30 years in the health sector, has significant experience working in NGO service delivery at the primary care and community level, and has invested over $700 million in health to date.[8] Historically, USAID flagship investments include the 28 NGO service delivery (“ Smiling Sun”) franchise network with 325 clinics, 6,200 community health workers and 8,000 outreach satellite clinics reaching over 20 million health contacts each year. The second major investment is the Social Marketing Company (SMC) which is the largest in the world with over 167,000 pharmacy outlets selling health products and contraceptives at subsidized prices throughout Bangladesh. The SMC contributes up to 35% of modern contraceptive use in the country. The USG national surveys are used by the GOB and the development community alike to track progress and monitor trends in the health sector. In addition the Department of Defense (DOD) provides targeted primary and curative care services during civilian-military outreach campaigns and supports capacity building in curative medical, dentistry and eye service care with its military counterparts. The Centers for Disease Control (CDC) support surveillance stations throughout Bangladesh and provides valuable inputs to lab capacity for undertaking investigations and improving the quality of disease detection and diagnosis. USAID support and CDC’s in- depth training of local scientists over the years has resulted in creating Bangladesh’s premiere research institute, the International Center for Diarrheal Disease and Research/Bangladesh (ICDDRB). It is known regionally and internationally for tracking infectious diseases outbreaks and for its work in oral rehydration therapy (ORT) which is saving millions of lives worldwide.

USAID’s recent election to the Global Fund/Country Coordination Mechanism (GF/CCM) provides an entry point for expanding policy dialogue to improve country performance in HIV/AIDS, TB and Malaria, and to enhance financial management. Over the past 18 months, the USG undertook several analyses, conducted site visits and held extensive GHI consultations with hundreds of key partners and stakeholders both within the sector and beyond.[9] GHI/B will work in a new ways, with specific attention to gender, strategic coordination among agencies, and alignment with GOB priorities to further Mission Dhaka foreign policy objectives in Bangladesh’s health sector.

5. Country Led GHI/Bangladesh Strategic Objective and Results

The USG’s GHI/B Strategic Objective “Increased Equitable Use of Evidence-based, High Impact Population Health and Nutrition (HPN) Services“ contributes to the subsequent achievement of the GHI/B goal, to Stabilize Population and Improve Health & Nutrition in Bangladesh. In line with the Paris Declaration on Aid Effectiveness, the GHI/B strategy also ensures national ownership and will also directly contribute to the GOB’s 2011-2016 Health, Population, and Nutrition Sector Strategic Program and is aligned to contribute to the GOB Program’s goal to “Ensure Quality and Equitable Health Care for the Citizens of Bangladesh” and the Intermediate Results (IR).[10] This GHI FY2011 – 2015 strategy will be the first phase of a ten year effort in helping Bangladesh achieve its Vision 2021 of becoming a middle income country, including improved health status for its citizens.[11]

The USG’s GHI/B strategy builds on its evidence-based experience, successes and on-going PHN programs. Women, Girls, and Gender Equality will be a crosscutting theme. GHI Program activities will build on the recommendations of USAID/Bangladesh Gender Assessment[12] which underscore research showing how gender discrimination disproportionately impacts women and girls, maternal and child health, social status and livelihood, and limits effective participation in the economy. The USG will address women’s and girls’ empowerment and gender equality, including addressing gender based violence (acid attacks and rape). It will support GOB efforts to improve women’s and girls’ access to health information and services, create advocacy through partnerships with male leaders and mothers in-law; and increase the contribution of women and girls to Bangladesh’s long term development goals.

Global Health Initiative/Bangladesh Results Framework» (See page 9)

GHI principles embody USG’s commitment to regain and advance technical leadership, influence policy dialogue, leverage new funding, and increase private sector participation in the health sector. See Annex 5 for mandatory template on USG Bangladesh Priority Activities under GHI. The following section describes GHI/B illustrative Results framework.[13]

5.1. Intermediate Result 1: Increased Use of Effective Family Planning & Reproductive Health Services

Bangladesh’s successful family planning program has substantially contributed to a reduction in unintended pregnancies and the significant decline in maternal mortality in the past nine years. The recent stagnating trend in the family planning program is cause for concern because it is likely to impact not only the health of women, their families, and their communities, but will also impede the Government of Bangladesh’s effort in achieving Vision 2021. The 56% growth in population size requires great attention to family planning as a multi-sectoral development intervention affecting urbanization (and urban slums), poverty, education, food, and employment – all of which affect civil and political stability. Thus, the USG will help the MOHFW conduct advocacy with other ministries to revitalize family planning, and address women’s health by reducing unintended pregnancies and unmet need for family planning among women and men as a cross cutting issue impacting all other development sectors and civil and political stability. Under Intermediate Result 1, GHI/B will focus on: Increased policy advocacy to reposition family planning as a development priority; increased access to quality family planning and reproductive health services; and increased information of FP and RH services through behavior change communication to enable couples to make informed choices according to their needs.

Sub-Intermediate Result 1.1 Increased Policy Advocacy to Reposition Family Planning as a Development Priority: GHI/B will support GOB efforts to revitalize its national population policy and develop a multi-sector approach that empowers girls, women and families to make informed decisions about their reproductive health needs. This will include attention on girls’ education, with focus on delaying the age of marriage and early pregnancy, which has implications for the health of women and their children. The GHI/B will support the following activities in support of the GOB’s national population policy.

Illustrative Activities:

Strategic Coordination & Integration:

• GHI/B will create linkages with USG Democracy & Governance civil society groups to address gender-based violence and human rights and create a demand for family planning.
• The USG’s modest Education program will be used for advocacy and policy dialogue to leverage the multi-billion dollar sector program with the Ministry of Education to focus more attention on girls’ education, and delaying the age of marriage and early pregnancy.

Sub-Intermediate Result 1.2 Increased Access to Quality Family Planning (FP) and Reproductive Health Services: For two decades, USAID has worked vigorously with the government to support its family planning program resulting in reducing unintended pregnancies and bringing modern contraceptive use to 56%. In the last decade, the program has stagnated and FP workers are reaching retirement age. Family Planning counseling and contraceptive services will be made widely available through public, private partnerships. GHI/B will support the following GOB efforts to increase the availability and utilization of voluntary FP services, including long acting methods. Efforts will be made to improve efficiencies within existing programs, and identify new interventions and networks to revitalize family planning use.

Illustrative Activities:

• Intensify work with the central ministry to ensure availability of family planning with other primary care services.
• Support MOHFW integration efforts at all service points to ensure “no missed opportunities” and increase availability and quality of FP/RH services. For example, this will include integrating family planning/child spacing counseling during antenatal visits and post-natal visits to ensure that couples have easy access to information and services.
• Also support MOHFW efforts to help ensure that FP information and services, including referrals for clinical methods, are widely available through all health workers from Directorates for HS and FP[14].
• Ensure integration of family planning and reproductive services within the resuscitated community clinics which GHI/B will test model in partnering with its NGO network staff.
• Redesign the NGO franchise program and support to the GOB to accelerate access to and use of clinical contraceptive methods, including voluntary sterilization, implants, IUDs along with pills and injectables among new cohorts of acceptors.
• Support GOB’s desire to: expand choice of contraceptive methods; shift method mix according to couples’ reproductive needs; and expand access to and use of voluntary long-term and permanent methods.
• Support interventions to reduce discontinuation rates; delay age of marriage and first birth; increase birth spacing.
• Provide support to revitalize the National Institute of Population Research & Training and its sub-centers to train the next generation of FP workers.
• Strategically position USG’s successful social marketing program to further increase contraceptive prevalence by reaching more clients through its extensive pharmacy network and use of mobile technology.
• Identify new and innovative partnerships with the garment industry, transporters and port workers to reach the urban poor and pilot existing and future technologies to reach these mobile workers to respond to their unmet need for FP and RH services.

Strategic Coordination & Integration: USAID is the only USG agency currently identified to provide assistance to the GOB in this area.

Sub-Intermediate Result 1.3 Increased Information of FP & RH Services through Behavior Change Communication (BCC): Sixty-two percent of couples in Bangladesh want no more children, but only 7% use long-acting or permanent methods.[15] It is estimated that one in three women terminate their pregnancies each year meaning that one million have unintended pregnancies, and 17% of women of reproductive age have unmet needs for family planning. Trends of early marriage, young age at first birth, and lack of birth spacing have demonstrable negative impacts on the health of women and girls, and their offspring.

Illustrative Activities:

• Support the GOB in developing a national BCC strategy for targeted, age and gender appropriate messages to support individuals and couples’ need for child spacing, family planning and reproductive health services.
• Design new messages to respond to women’s and married adolescents’ currently unmet need for family planning.
• Design targeted messages to improve demand for clinical methods by both men and women.
• Train new workers in counseling in FP and RH services with renewed focus on BCC to support new community norms for FP.
• Support “FP Champions” to reach a new cohort of youth, including men, to support women’s ability to practice FP.
• Ensure greater attention to motivate men in the use of clinical male methods through stronger advocacy and mobilizing local FP “Champions” and community leaders.
• Train journalists to stimulate use of media outlets, raise awareness and report on critical issues related to family planning.
• Use of national multi-sectoral organizations to disseminate FP/RH messages.
• Use new phone technologies to reach the next generation of FP clients with FP/RH messages.
• Design messages which reach mobile populations including the urban poor.

Strategic Coordination & Integration:

• The Embassy’s Public Affairs Office (PAO) and Voice of America (VOA) will engage the media to improve responsible reporting on FP and population related health issues and in mobilizing women’s advocacy and civil society groups in support of gender equality in health and family planning.
• USAID will initiate policy advocacy to promote family planning through new multisectoral partnerships, leveraging USAID programming in education, agriculture, economic growth, and disaster and humanitarian assistance.

5.2 Intermediate Result 2: Increased Use of Integrated Population, Health and Nutrition (PHN) Services

The GOB has an election mandate of phased decentralization to restart 18,000 community clinics and expand access to quality health care services at the grassroots level. Currently, there are 13,500 community clinics at different stages of operation. Given women’s limited mobility and access to services in many regions of Bangladesh, GHI/B will help the GOB bring integrated, quality services closer to the people at the primary care level (upazilla, union, and community), with links to the district level.[16] In addition to building on investments in the USG NGO network and Social Marketing Program, GHI will initiate new networks of providers through alliances with partners such BRAC which has approximately 80,000 community health workers. A grassroots service delivery approach will be utilized to provide a package of critical primary health care services. Under Result 2, the sub-intermediate results are: increased access to integrated, quality PHN services; improved service delivery through effective public/private partnerships and increased healthy behavior through improved BCC.

Sub-Intermediate Result 2.1 Increased Access to Integrated Quality PHN Services: The USG will support delivery of the GOB’s basic Essential Services Package (ESP) including: family planning, maternal health services (including ante-natal, delivery and post-natal), essential newborn care (including newborn resuscitation and infection management), and child health, diarrheal disease control, safe water, immunization and infectious diseases (TB, HIV). Despite economic growth rates of 5-7% over the past eight years, Bangladesh has some of the highest malnutrition rates in the region and is making insufficient progress towards the MDG 1. Over 8 million children in Bangladesh suffer from under nutrition, which contributes to two in three child deaths. Persistent levels of chronic under-nutrition in Bangladesh perpetuate ‘Cycles of Malnutrition” fueled by poverty and poor health.

10 Essential Services Package (ESP)» (See page 13)

The Cycle of Malnutrition in Bangladesh» (See page 13)

Caloric intake is 70% rice and the diet lacks diversity and protein. This results in poor nutritional status, especially among Bangladeshi women who are often anemic, leading to lower birth weight babies, who in turn have a higher probability of child malnutrition, and thus continue the cycle of malnutrition throughout life. Health results will not be successful unless acute levels of chronic under-nutrition and stunting in children are addressed. Improving nutrition in the critical 1,000 day window from pregnancy through the first two years of a child’s life can reduce mortality and morbidity, increase cognitive development, and improve productivity and reduce poverty in later years. CDC will address the prevention and treatment of parasitic diseases such Leishmaniasis that disproportionately affect rural poor women.

Illustrative Activities:

• Support the Government’s 2009 Policy Directive to provide a “one stop shopping’ for first line access to essential health services in partnership with key donors.
• Integrate nutrition into essential service package.
• Integrate post-partum family planning in public and private sectors.
• Technical assistance and training to strengthen public sector capacity in providing health services in low performing areas, to target adolescent mothers and improve safe motherhood and newborn care through better management and care of obstetric complications.
• Support facility and community based Integrated Management of Childhood Illness and community management of acute malnutrition and train and support community workers to integrate nutrition with other health services.
• Scaling up Nutrition (SUN) approaches to mainstream nutrition and integrating 7 Essential Nutrition Actions[17] for pregnant women and young children.
• Implement research on a lipid-based nutrient supplement (LNS) to prevent chronic malnutrition in Bangladesh.
• Technical assistance and training to sustain GOB MDG achievements in TB and HIV/AIDS.
• Broaden focus to include smear-negative cases and extra-pulmonary cases, as well as ensure that proper diagnostic procedures are applied to all smear-negative suspects.
• Utilize the opportunity for revitalization of community clinics to strengthen referral of TB suspects and DOT.

Strategic Coordination and Integration:

• Capitalizing on USG investments by integrating school health, nutrition and sanitation components into education programming to maximize synergies between both sectors. ^[18]
• DOD will provide targeted primary and curative care services during civilian-military outreach campaigns and support capacity building in curative medical, dentistry and eye service care with its military counterparts.
• CDC will support disease surveillance stations throughout Bangladesh to build laboratory capacity in undertaking investigations and improving the quality of disease detection and diagnosis.
• FTF is expected to improve food availability and accessibility for 45% of households that suffer from persistent poverty and food insecurity by producing high-value nutritious foods. GHI/B will promote food utilization and healthy eating behaviors to address under-nutrition in FTF areas.
• Food for Peace activities will reinforce community-based health and nutrition services (including food rations) for pregnant women and children under two. In addition, the USG’s non-emergency food programs will focus on effective safety net programs and appropriate technologies to increase food production. This will help improve nutrition and incomes of the poor, extreme poor and the landless. GHI/B will strategically capitalize on these investments to improve exclusive breastfeeding and enhanced nutrition and dietary habits that lead to better health outcomes.
• GHI/B will work closely with the new USAID/W centrally funded Nutrition Project to determine investments in human health and nutrition; policies to achieve large scale and sustainable improvements in nutrition outcomes; infant and young child feeding practices; and national and community capacity building to combat malnutrition.

Sub-Intermediate Result 2.2 Improved Service Delivery through Effective Public/Private Partnerships (PPP): The USG has a long history and a comparative advantage of working with the private sector (both for-profit and non-profit) and NGOs in Bangladesh. Given the limitations of the public health system, the massive needs for goods, services and information, the growing commercial private sector, and the established roles of NGOs in service delivery, GHI/B will broker public private partnerships among the GOB, NGOs, and private providers to foster collaborative relationships and build expertise in providing a package of integrated services.

Illustrative Activities:

• Strengthen existing partnerships with Chevron, Unilever and Laerdal [19]as well as local firms to provide quality PHN services, information and products
• Target selected Upazillas to promote new partnership models to scale up ESP services which give special attention to infants, girls and women.
• Broker partnerships between MOHFW, NGOs and private sector to expand health services.
• Provide leadership and influence the GOB to more actively engage NGOs and private entities to accelerate access to quality, integrated health services.
• GHI/B will test models of partnering its NGO network staff with up to 6,000 of the 18,000 public sector community clinics to be resuscitated by the MOHFW by 2015.
• Scale up government’s efforts by brokering partnerships with other community care providers such as BRAC, to improve service coverage.
• Accelerate relationships with new local partners; build the management and financial capacity of NGOs in underserved areas; and market low cost maternal, child health and nutrition products through the USG’s social marketing program.
• Initiate programs to include other private sector health providers to respond to a growing preference for the private sector for treatment of childhood illness and obstetric care.
• Develop USG Global Alliances and mobilize private sector resources to promote hand-washing and newborn resuscitation; reposition maternal neonatal health and FP; and expand PPP to increase corporate engagement in Bangladesh’s health sector.
• Within the private sector – engage with private health care providers, pharmacists and drug sellers, non-medical graduate doctors, professional associations, hospitals, for improved case finding, treatment, and retention, as well as strengthened referral networks and consistent reporting back to the National Tuberculosis Program (NTP).
• Support NTP activities with the private sector on the rational use of drugs and the proper use of newer diagnostic tools, including support for accreditation and regulatory functions by GOB in their interface with the private sector.

Strategic Coordination and Integration:

• If Peace Corps is reestablished in Bangladesh, it can play a catalytic role under GHI by providing long-term capacity development for NGOs with a particular focus on community based organization and programs.
• GHI/B and FTF will broker partnerships with the Gates Foundation-funded “Alive and Thrive” Nutrition Project and BRAC to roll out evidence-based nutrition interventions for children 0-24 months in 100 districts.

Sub-Intermediate Result 2.3 Increased Healthy Behaviors through Improved BCC: To improve awareness and healthy behavior, GHI/B will strengthen its behavior change communication. First, GHI/B will support the national effort by developing uniform and consistent MCH, nutrition and FP messages. The USG will re-establish efforts to support the MOHFW in resuscitating the national BCC policy. USG/B will assess the current the BCC activities, identify missed opportunities, gaps, duplication and increase consensus around messages for different target groups. Second, GHI/B will orient, mobilize and engage influential community leaders to raise awareness on healthy behavior practices. Also data will be analyzed and used to raise awareness on health issues and support advocacy on healthy behavior with policy makers and civil society.

Illustrative Activities:

• Promote the “1000 days” model of improving nutrition from pregnancy to the first two years of a child’s life with the Feed the Future and Food for Peace Programs.
• Promoting nutrition counseling, exclusive breastfeeding and growth monitoring to breaking the “Cycle of Malnutrition”.
• Promote hand washing to reduce infections.
• Improve new born health by promoting clean umbilical cord care, delayed bathing, and immediate wrapping and drying.
• Create an evidence based advocacy strategy for increased attention and government support of nutrition. [20]
• Deepen social and behavior change communication in maternal and child nutrition for greater impact by: completing pilot implementation of peer-to-peer breastfeeding support; adolescent peer education; and training religious leaders in nutrition.
• Mobilize the private sector to support the GOB’s “Digital Bangladesh” initiative by promoting USG’s Mobiles for Health Program (M4H) to improve knowledge, behavior and health outcomes.
• Utilize mobile phones to deliver life- saving messages to pregnant women and new mothers on MCH and FP. With GHI/B leadership, M4H will catalyze the formation of a public private coalition to use mobile phones.
• Increase the impact of ACSM activities by disseminating the ACSM strategy and SOPs to all implementing partners.
• Support the coordination and joint planning of implementing partners.
• Collaborate with communities and local authorities on ACSM planning and implementation.

Strategic Coordination and Integration:

• The Embassy’s Public Affairs Office (PAO) and Voice of America (VOA) will engage the media to improve responsible reporting and mobilize civil society groups to increase awareness of improved healthy behaviors.
• Initiate policy advocacy to promote health through new multi-sectoral partnerships, leveraging USAID programming in education, agriculture, economic growth, and disaster and humanitarian assistance.
• Support the Department of State’s partnership with the Organization of the Islamic Conference (OIC), as part of Global Engagement, to promote advocacy by religious leaders in addressing maternal and child health. GHI/B will build on USAID’s successful “Leaders of Influence” Program in mobilizing civil society and religious leaders’ networks to advocate for improvements in maternal and children health.

5.3 Intermediate Result 3: Strengthened Health Systems Governance

Upazilla Health Systems Strengthening Pyramid» (See page 16)

Success in revitalizing FP (Result 1) and delivery of essential services (Result 2) requires strengthened MOHFW leadership, governance and health systems. Therefore, GHI/B will support the GOB’s new health sector program by accelerating family planning use, integrated service delivery, strengthening health systems from the central to district and sub district levels; and supporting MOHFW leadership and governance as it decentralizes selected components of its health system. USAID currently works through its NGO partners to provide essential health and family planning services at the local level in rural districts and selected urban and peri urban slums.

Under GHI, greater emphasis will be given to support GOB systems strengthening in order to deliver family planning and the Essential Service Package. The diagram of Upazilla Primary Health Care Systems Strengthening Pyramid[21] is at the heart of USG’s support to GOB. Under Result 3, GHI/B will focus on 3 sub-intermediate results: improved leadership and management; improved health support systems; and improved M&E systems.

Sub-Intermediate Result 3.1 Improved Leadership and Management of the Health Sector: The GOB has been successful in the past in obtaining “quick wins” by implementing vertical interventions such as family planning, immunizations, and provision of oral rehydration therapy (ORT). However, strategic leadership and smart integration is critical to tackling the more complicated health problems that remain—such as treatment for acute respiratory infections, newborn care and emergency obstetric care-- that require reliable service delivery systems in order to meet MDGs for maternal and child health. Currently, there is strong political will within MOHFW, and relations among the USG, the GOB and donors have reached new heights under GHI. This is a critical moment for the USG to quickly help the GOB transform the health sector and improve leadership to advance health outcomes in the next five years.

Illustrative Activities:

• Support GOB stewardship in health governance structures and sector policy dialogue.
• Promote women’s and girls’ health through supporting MOHFW Gender Equality Strategy and reforms to promote equity, gender and citizen’s voice.
• Policy dialogue with the Directorates of HS and FP to increase coordination, improve efficiency and promote “one stop shopping” for integrated health services.
• Strengthen decentralization, local level planning and budgeting; partnerships and coordination including management of the sector program; aid effectiveness; financial management, and joint technical cooperation among donors.
• Build MOHFW capacity to strategically use data for planning and management and target interventions that have the highest public health impact.
• Support GOB’s desire to resuscitate community health services, strengthen linkages and referrals networks to district health facilities and provide management and technical assistance.
• Support GOB in developing national BCC strategy to reinvigorate health promotion, especially repositioning family planning, addressing maternal and neonatal health and nutrition; and ensuring gender is incorporated into BCC activities and programs.
• Support reforms in the GOB’s management of the Global Fund to ensure efficient use of USG financial resources.
• Provide technical assistance to Global Fund and CCM to bring innovation and learning during reviews of country proposals, ensuring best practices while supporting GOB stewardship.
• Strengthen the NTP in its ability to manage financial systems, including those which relate to release of GFATM funds for procurement of first and second line TB drugs.
• Assist the NTP to develop accreditation and regulatory functions for the use and scale-up of new diagnostic tools, particularly in the private sector.

Strategic Coordination:

• The Embassy will advocate for policy and health governance reforms at the highest level with MOHFW, Ministry of Finance, Ministry of Local and Rural Development (MOLRD), Ministry of Establishments (MOE) and other key ministries.
• GHI/B will facilitate South/South learning exchanges with the other missions to promote advocacy and policy dialogue among host country counterparts and advance GHI priorities.

Sub-Intermediate Result 3.2 Improved Health Support Systems for Efficient Service Delivery: GHI/B offers Mission Dhaka an opportunity to support systems improvement in the ministries of MOHFW and MOLRD. For the first time, the USG will work with both ministries in order have a direct impact on improving family planning and increasing service utilization to improve maternal and new born health and nutrition outcomes. GHI/B will support strengthened management, planning, and budgeting at the district and sub-district levels, quality improvement including community clinics, support local government in responding to community demands for quality health care.

Illustrative Activities:

• Support the MOLRD in local level planning and management to provide critical health services in rural areas.
• Initiate new partnerships with municipal and city corporations responsible for providing services to Bangladeshi’s rapidly growing urban slums.
• Work with MOHFW to increase in-service and pre-service training to increase the number of qualified female healthcare providers and administrators.
• Strengthen HR capacity to improve management and supervision functions of the workforce; revive scholarships for the next generation of Public Health Specialists; and build on and establish new linkages between local and US Universities and academic medical centers.[22]
• Advocate with MOE to develop more effective hiring practices, especially for women, and incentives for hardship postings for health workers;
• Improve MOHFW procurement, logistics and supply chain management systems; place technical advisors in key units of the ministry to help streamline decision making; identify existing inefficiencies and bottlenecks; and propose new approaches, e.g. multi-year contracting for routine drugs and supplies;
• Ensure contraceptive security and build on existing technical assistance to install web-based tracking systems to reduce bottlenecks and streamline procurement, mitigate misuse of resources, increase efficiencies and transparency, and ensure commodity availability at all levels.
• Build on the existing web based logistics management information systems (MIS) for family planning and expand to essential health commodities and supplies; provide assistance to install e-procurement systems to enable MOHFW to reform the solicitation process, increase transparency, and reduce transaction costs.
• Strengthen the laboratory network, including the National TB Reference Lab and the Regional Reference laboratories
• Support the introduction and scale-up of new diagnostic tools and services, including the procurement, maintenance and use of microscopy, line probe assays, and other technologies as they become available

Strategic Coordination and Integration:

• CDC will support activities that build GOB systems for field epidemiology, surveillance, and training programs to improve careers and management practices within the government public health system.
• USAID and CDC will promote access to clean water, sanitation and improved hygiene practices to improve health outcomes among newborns and children.
• DOD will collaborate with USAID on military-to-civilian outreach and seek input from USAID in shaping future events that support improvements in national systems.

Sub-Intermediate Result 3.3 Improved Monitoring & Evaluation Systems for Reporting & Decision Making: The Health Information System (HIS) is one of the weakest components of the GOB’s Monitoring and Evaluation Systems (M&E). Data is often incomplete and unreliable, and systems for compiling and aggregating information are weak, and capacity and processes to analyze, report and use data is limited. GHI/B will help the MOHFW to establish effective M&E systems that would produce reliable and timely information on a routine basis that policy makers and program managers can use for program design, monitoring, management and refinement.

Illustrative Activities:

• Develop Results Framework for Bangladesh’s new health sector program; identify indicators and sources of information for monitoring performance; and coordinate support of various donors to strengthen national M&E systems.
• Improve the quality, reliability and timeliness of data; establish effective M&E tools; and build the GOB’s institutional and technical capacity for performance monitoring and evaluation in collaboration with the WB and GTZ.
• Improve data collection, processing and analysis from the census, surveys, surveillance, GIS, and health information systems to build capacity to analyze and use information for decision making.
• Support MOHFW in establishing a Program Coordination and Monitoring Unit for data management and analysis and tracking performance to ensure achievement of MDGs for the next sector program.
• Support innovation in mobile health technologies, electronic data capture and reporting, and approaches that align with “Digital Bangladesh” initiatives
• Support the wider use of electronic data reporting through the implementation of country wide electronic compilation of reports at district level

Strategic Coordination:

• CDC will support activities that build GOB systems strengthening M&E surveillance in the health sector.

6. Improving Monitoring, Evaluation, Research and Innovation

GHI/B will improve and strengthen overall M&E and monitor the adoption of GHI principles and its impacts through the following:

GHI Results Framework (RF): The GHI/B RF is closely aligned with Bangladesh’s next Health Sector Program’s draft RF and focuses on the three intermediate results to revitalize family planning, improving health services, and systems and governance.[23] The RF and indicators are country specific and will contribute GHI targets globally. The success of GHI is based on a number of critical assumptions as presented in the RF. This alignment of GHI/B and GOB RF will decrease duplication and increase efficiency in data collection and reporting and enable production of timely and reliable information. Improved metrics for monitoring will also strengthen GHI/B ability to improve program effectiveness and rapidly integrate findings for program impact and scale-up.

GHI Indicators & Targets: GHI/B has developed preliminary indicators and targets based on our expected contribution to the national program. These will be refined upon approval of the strategy, guidance from Washington, and finalization of GOB indicators. It is anticipated that GHI will have the greatest contribution in 6 of the 7 target areas, excluding malaria. USAID will work with MOHFW and key donors to refine indicators and targets. The targets for the indicators are based on a review of available baseline information from a nationally representative sample; performance trends over a period of time; the next health sector program targets; and program interventions that will contribute to progress on the performance indicators by 2015.

Metrics and HIS for GHI/B Supported Programs: GHI/B will improve metrics and establish well-functioning health information systems to monitor program performance. It will disaggregate and analyze data by age, gender, geographic region, and, wherever feasible, by economic status to assess equity in use of services and information. Programs will collect qualitative data to show whether women centered approaches are on track and improve gender equality and health outcomes. Both quantitative and qualitative data will be reviewed and analyzed quarterly by implementing partners and USG agencies to monitor program performance. Performance reviews will also include analysis of quantitative and qualitative data such as success stories and case studies. The information will be used to identify inputs for formulating the Learning Agenda, complement the BEST Action Plan[24], and scale up successful interventions to accelerate health outcomes under GHI.

Independent Evaluations: All bilateral programs with total estimated cost of over $25 million (awaiting official guidance on M&E) will be subject to independent evaluations to measure performance outcomes/impacts using baseline-end line surveys; surveillance; national data platforms, and other tools. Data will be disaggregated by gender, age and economic status to assess whether program strategies are reaching the core priority groups – the women, adolescent girls, children and the poor. National surveys like the Bangladesh Demographic Health Surveys, HIV Sero Surveillance and other national surveys will also provide information on GHI/B program performance.

Mid Term Assessment: All bilateral programs with a time frame of at least 4 years will be subject to mid-term management and performance assessments by a third party. Information will be used to refine program strategies.

Research and Learning Agenda: One challenge facing USG is to better align existing research investments and better coordinate the 85 research activities currently taking place in Bangladesh. These include studies by: USDA (3); CDC (33); NIH (19); and USAID (30).[25] In line with GHI Principles, the Embassy will ensure that all USG agencies disseminate and share their findings and that future research contributes to the GHI/B Learning Agenda and GOB priorities. GHI/B will design a Learning Agenda that tests innovative program and policy interventions for scale up, and conducts research to refine program strategies linked to the 3 intermediate results. Topics for USG’s implementation research will be determined annually through a consultative process to foster country ownership and commitment. See Annex 7 for illustrative Research and Learning Agenda.

The Research Learning Agenda will address:

• Intermediate Result 1 – Analyses showcasing family planning as a critical development issue for Bangladesh; testing interventions and communication strategies to improve contraceptive use in eastern regions of Bangladesh where women’s mobility is relatively limited; and surveys to identify barriers to using long-term and permanent methods of contraception.
• Intermediate Result 2 – Studies on promoting service integration in a bifurcated health system (DG/FP and DG/Health); assessing impact of task shifting among staff for synergies; and training and incentives for providers to address immediate shortage of community workers.
• Intermediate Result 3- Studies on interventions to increase mix of partnerships, twinning NGOs with MOHFW clinics; public sector contracting out to NGOs and/or the private sector; experimenting with pay for performance to improve health services; and use of mobile technology to improve health information flows.

Research findings will be widely disseminated. Policy analysis of implementation research, situational analysis, and synthesis of information on what works and what doesn’t will be undertaken. Different communication strategies will be used to effectively reach different audiences to advance the learning agenda. Key target groups will include policy makers, program managers, researchers, media, journalists, leaders of influence, and other beneficiaries.

New Research Mechanism: In collaboration with Washington, USAID has designed a new program, TRACTION (Translating Research into Action) to support (i) evaluation and implementation research, (ii) capacity building in M&E and (iii) advancing the learning agenda. The program is expected to start in the few months. In light of GHI principles, a priority activity of this program will be to create a platform for stakeholders to include the GOB, NGOs, the private sector, development partners, researchers, and beneficiaries to dialogue on priority research needs and implications of implementation research.

7. GHI Strategy Management, Coordination and Communication

GHI/B provides an opportunity to enhance the effectiveness of USG programming, planning, and evaluation across all agencies. The components of this strategy have been developed by the GHI/B Interagency team. Once this strategy is approved and following guidance from Washington, each agency will take responsibility for its respective leadership areas as identified in the GHI Guidance and ensure that an inclusive process is followed for planning and implementing programmatic priorities. The agencies together will be responsible for collecting and reporting on all results.

The Ambassador and Mission Director will provide overall management and policy guidance to the GHI team and represent GHI at the most senior levels with the GOB. The GHI Field Deputy from USAID, designated as a planning lead, will utilize existing weekly Country Team Meetings with the Ambassador and Mission Dhaka Heads of Units to report on the progress of GHI/B and hold periodic planning and coordination meetings with GHI implementing agencies. GHI/B will closely coordinate with the existing Embassy mechanisms such as bi-weekly working group meetings, as well as periodic digital video conferencing and telephone calls with Washington to strengthen USG interagency reporting, coordination and monitoring of activities. Currently, USAID holds monthly reviews with all its implementing partners in health and education, periodic meetings with the donor consortium, and six month reviews with the GOB. Similar approaches will be initiated with key stakeholders in the health sector and across other Presidential Initiatives to ensure greater collaboration to accelerate achievements on expected outcomes from GHI and GOB.

The Embassy’s PA Office will support the GHI public outreach efforts and its policy reform agenda which also advance USG foreign policy objectives for health in Bangladesh. In addition to standard press office activities, joint events will be organized with PA and VOA to train journalists on health advocacy and promote GOB accountability; increase outreach to media contacts reporting on GHI initiatives and outcomes; and use social media resources such as Facebook to raise awareness and elicit public buy-in. PAO is also planning a year-long schedule of events for 2011 in relation to the 40^th anniversary of Bangladesh’s independence. There are tremendous opportunities through PAO to introduce programming that supports GHI/B efforts.

Annex 1: Development Challenges in Population, Health and Nutrition Sector

Population Size and Density: With a current estimate of over 150 million population, demographic projection estimates Bangladesh’s population to reach 243 million by 2050 (UN Population Division). Except for a handful of small countries (i.e. Singapore, Hong Kong), Bangladesh is by far the densely populated country in the world, with over 2,600 persons per square mile. The population density is more than double than that of India and China. In spite of the widely recognized successes of Bangladesh family planning program, the population doubled within the last three decades. The sheer enormity of the population, if left unchecked, has the potential to threaten the peace and security of the entire region.

Rapid Urbanization: Bangladesh is experiencing substantial urbanization, creating increasing demands for services within these crowded and often slum areas where people live and work. In 2005, approximately 25% of the population was urban and 75% rural. Thirty-five percent of the population in six large cities lives in city slums, where appalling living conditions reflect extreme crowding- 520,000 persons per square mile. By 2015, the population may reach or exceed 180 million, with the urban population projected to expand from around 38 million in 2005 to about 54 million- accounting for 30% of the national population (UN Statistical Data Base, 2007). This high rate of urbanization poses a huge burden on the urban health care, and water and sanitation system.

Reduced Fertility and Family Planning: In the HNPSDP (2011-2016), the Government of Bangladesh plans to expand access to family planning services to increase contraceptive prevalence to 72 percent (all methods) and to reduce total fertility rate to 2.0 by 2016. Although the use of modern contraceptive methods has been increasing in Bangladesh, the contraceptive choice of the families is predominantly in favor of short-term methods (oral pill). A major concern of the Bangladesh family planning program is that while a majority of the women (59%) want no more children, only 7.2% of these women are using a long-term method, and among them, only 5.8 percent use voluntary sterilization. Moreover, on average, Bangladeshi women finish child bearing by age 26, and thus require effective contraception for more than 20 years after childbearing is complete (OPHNE Program Sustainability Assessment, 2006). Preponderance of short-term methods in contraceptive use threatens unwanted pregnancy and poses vulnerability on family planning service delivery.

High Maternal and Newborn Mortality: Although the child mortality rates have fallen significantly in recent years, the rate of decline in infant mortality has slowed due to stagnation of the neonatal death rate. The newborn deaths now account for two-thirds of all infant deaths (52 per 1000 live births). Although maternal deaths continue to decline steadily, the maternal mortality ratio is still very high at about 320 per 100,000 live births.

While overall antenatal care has improved, most deliveries (85%) still take place at home. Only 15% of births receive any trained assistance and only 19% of mothers and children receive postnatal care from a trained provider within 2 days of delivery, and only 21% receive postnatal care from a trained provider within 42 days of delivery. The majority (55%) of pregnancy related deaths are due to post-partum hemorrhage and eclampsia, which are preventable through available technologies.

As most deliveries take place at home, low use of skilled birth attendants remains as the primary challenge for reducing the high maternal and neonatal deaths. Improving the care-seeking practices by the families and availability of skilled service providers may bring a substantial effect on furthering the development health of mothers and children.

Malnutrition: Malnutrition is an underlying condition for the high morbidity and mortality in the population of Bangladesh. Protein energy malnutrition still causes high infant and under-five morbidity and mortality. Iron deficiency anemia has been prevalent among 53% of children within 6-59 months age group. Nutrition status of Bangladesh women is equally alarming. Although declined by 27% from 1996-97 status, about 38% (in 2004) of women of reproductive age with under-five children have a Body Mass Index (BMI) of 18.5, indicative of chronic energy deficiency.

High prevalence of malnutrition among women has significantly contributed to high incidence of births (about 30-50%) with less than 2500 gm of weight. Low-birth-weight (LBW) babies grow as malnourished children and adolescent girls who eventually will bear LBW babies. Other micronutrient deficiencies are also eminent in the vulnerable groups.

Malnutrition in children remains high. The 2007 DHS reported that 46% of children under five were underweight (the composite term, which is a good measure of a population’s nutritional health). In the past three years stunting (the term which reflects chronic malnutrition) among children has declined noticeably (from 43% to 36%) while wasting (the term which reflects acute short-term malnutrition) among children has seen a slight increase (from 13% to 16%). Exclusive breastfeeding up to 6 months is still low (42%) and stagnant.

Threat of HIV/AIDS Epidemic: Injecting drug use primarily drives the Bangladesh HIV epidemic. Other at-risk groups are commercial sex workers, men who have sex with men (MSM), and migrant workers. Subsequent interaction between HIV-infected injecting drug users (IDUs) and other key populations will contribute to a rapid rise in the number of infections and to development of a “critical mass” of HIV in Bangladesh among the most-at-risk groups. Although HIV prevalence is low in the general population, the knowledge on transmission of HIV is low. Only half of the men and a fifth of the women know about the use of condoms and faithfulness to prevent HIV. The high rates of syphilis (12% among prostitutes) and other STDs, and the presence of other risky sexual behaviors may easily facilitate the spread of the HIV infection. Although the HIV/AIDS prevalence rate in Bangladesh is less than 1 percent, in a population of over 150 million, a mere 1 percent rise would mean an addition of more than a million to the number of HIV positive people. There are 7,500 HIV positive people as of 2005.

High Burden of Tuberculosis: Tuberculosis is still the major cause of adult mortality. More than 319,000 new cases and 70,000 TB related deaths occur annually. Bangladesh has the fifth highest burden of TB cases in the world. The Annual Risk of Tuberculosis Infection (ARTI) was estimated to be 2.2 percent in 1997, with 300,000 new cases annually. TB incidence appears higher in densely populated urban areas. Although detection of smear positive cases has improved (70%) in past three years, stigma around care seeking for tuberculosis persists and there are significant shortcomings in the program. Non-compliance and treatment failure leads to multi-drug resistant TB (MDR TB); the incidence of MDR TB increases to 14% and ranks Bangladesh 9^th in terms of estimated burden of MDR TB worldwide. Diagnosis and treatment of sputum negative TB is also a challenge the program needs to address in addition to the expansion and sustenance of quality of the directly observed treatment short course.

Eradication of Poliomyelitis: Wild polio transmission is continuing in the South East Asia region including Bangladesh. Bangladesh committed to eradicate poliomyelitis as a co-signatory of a 1988 World Health Assembly Resolution for global polio eradication and conducted extensive supplementary immunization programs from 1995 - 2004. Because of the accelerated and intensified activities, Bangladesh interrupted wild poliovirus transmission in 2000.

However, after being polio free for more than 5 years Bangladesh detected 18 wild polio cases in 2006 in 12 districts of the country. Genetic sequencing of the virus at the Global Reference Laboratory at Mumbai confirms the outbreak from Western Uttar Pradesh (UP) in India, which is still a reservoir of wild poliovirus in the Southeast Asia region. There is a need for strong vigilance to continue until WHO declares the disease eradicated completely. There is also inadequacy in access, use and quality of immunization services, particularly in urban areas.

Threat of Avian Influenza Pandemic: Avian Influenza has struck the poultry in Bangladesh. Despite massive culling by authorities to control the outbreak, the highly pathogenic H5N1 strain of bird flu continues spreading among the poultry in Bangladesh. This avian flu virus has affected 47 districts out of 64, and more than 50 percent of the poultry farms have been closed. This virus strain is regarded to be the most likely to transmit to human and cause of the next human flu pandemic.

Influenza pandemics are natural, recurring events. They are somewhat rare but, like other natural phenomena, happen from time to time. A pandemic occurs on a much greater scale, spreading around the world and affecting people across many countries. Based on the experience, experts fear that the H5N1 strain of avian influenza A could trigger the next pandemic for a number of reasons. H5N1 is a severe highly pathogenic form of bird flu, which has been affecting poultry flocks and other birds across the world since 2003. However, the virus is not simply confined to birds. It has already demonstrated an ability to infect people and cause severe disease, one of the key characteristics of a pandemic strain.

Since it first emerged, 366 people have been infected who have had close and direct contact with infected birds. However, the consequences of an H5N1 pandemic could be much worse because it is so lethal, if that strain did cause a pandemic, it could be very worse. In the 1918, pandemic 50 million people died worldwide from a population on the planet of just over one billion people. The virus also has the ability to mutate and acquire genes from viruses infecting other species. Experts are worried that the virus could either adapt, giving it greater affinity for humans, or exchange genes with a human flu virus, thereby producing a completely new virus strain capable of spreading easily among people, and causing a pandemic.

According to the World Health Organization, the world is currently at a phase that a new influenza virus subtype is causing disease in humans, but is not yet spreading efficiently among humans. We do not know when the next pandemic will begin, how long it will last, how severe it will be, or which flu virus will cause it. Nevertheless, the knowledge of its coming warrants immediate attention for appropriate interventions to prevent. In a densely populated country like Bangladesh, the death toll and the burden due to the disease could be enormous once the pandemic outbreaks in the population.

Issues in Addressing the Challenges

Geographic Disparity in Service Coverage and Use: Although family planning and much of child health services have reached a significant national coverage, there remains a high inequality in service coverage and use between different groups and geographic regions. It is now highly imperative to address the inequality in supply and use of services to pull up the national achievements further.

Access to Services by the Poor: Poverty and other factors limit access to health services by the poor. Enhancing access to health and family planning services for the poor has a profound effect on reducing morbidity and mortality. While access by the poor to many preventive services has increased, overall access of the poor for critical life-saving interventions such as maternity care, treatment of serious childhood illnesses and treatment of chronic diseases of adults needs further improvement.

Contraceptive Procurement and Security: The continuity of affordable products in the public and private sector is the key to contraceptive use. The GOB is unable to ensure continuous availability of contraceptives. Management of contraceptive supply chain must be dealt with as a priority to meet the TFR goal.

Early Marriage of Girls: The cultural practice of girls marrying at an early age (under 18 years) exposes them to the risks of poor maternal outcome and a long period of child bearing. Delaying marriage of girls warrants a comprehensive multi-sector coordinated effort to advance many social development indicators, including fertility.

Strengthening the Health System: Despite past efforts, the health system fails to meet the level of quality and coverage required to meet the needs of the country. A good health system needs to implement key interventions to improve maternal health, skilled attendance at birth, appropriate postpartum care, and other reproductive health services.

Recurring Disasters (floods and cyclones): The frequency of floods, tornados, and cyclones exacerbates the health situation in the country. Disaster management initiatives and public health programs must be orchestrated and synchronized to deal with the effect of disasters on health.

Governance and Health Sector Management: Many weaknesses in the health system including weak policies and governance and lack of gender-sensitive approaches, exist that impede the achievement of health development goals. The country needs to adopt appropriate goal-oriented policies to enable supportive environment for implementation of the health development activities.

Health System - Decentralization, MOHFW Stewardship, Human resources (HR): The Bangladesh health system is highly centralized. A systematic approach is needed to initiate decentralized planning and budgeting, and delegation of authority to lower levels of public health system. In the context of a huge shortage of health workforce, a strategic approach to human resource planning is necessary to further the health sector goals.

Public Awareness and Demand for Public Health Services: While public awareness for some child health services, e.g., immunization and ORT use, is high, similar awareness is not notable for many other services, e.g., birthing at a facility, adoption of long-term family planning methods, care seeking for childhood illnesses, etc. Public health projects should emphasize awareness raising and demand creation for services as integral components.

Annex 2: GHI Data Call and List of Supporting Assessments and Reports^[26]
 

• Bangladesh AIDS Program Assessment, Nov. 2008 (Hard copy in OPHNE)
• Behavior Change Assessment Report, Nov. 2008 (Hard copy in OPHNE)
• Health Systems Assessment Report, Nov. 2008 (Hard copy in OPHNE)
• Commodities Security Review, Nov. 2008 (Hard copy in OPHNE)
• Global Health MCH Team Assessment Report, March/April 2009
• GOB/World Bank HNPSP Annual Review Report April 2009,
• Joint EGAT/GH Food Security and Nutrition Assessment Report, June 2009
• Global Health Nutrition Team Assessment Report, L. Birx, June/July
• Behavior Communication & Change Summary Notes, E. Fox, October, 2009
• Global Health Tuberculosis Assessment Report, C. Powell, October, 2009
• PHNE Semi-Annual Portfolio Review (SAPR) Review, November 2009
• Smiling Sun Mid Term Assessment, April 2010, Pending GH Tech final edits.
• Family Planning and Population Assessment Report, May, 2010, Pending GH Tech final edits.
• USAID GHI Visioning and Strategic Planning Report, June, 2010, Pending GH Tech final edits.
• Global Health Mobiles for Health Presentation to Ambassador, September, 2010. Available from Sandhya Rao.
• USG GHI Launch Team Trip Report, September, 2010. Available from K. Cavanaugh,

Annex 3: Results Framework for HPNSSP 2011-2016 (DRAFT as of November, 2010)

Annex 4: Key Existing and New Investments under GHI

Annex 6: GHI Bangladesh Results Framework & Links to GOB Framework» (See page 42)

Annex 7: USG Bangladesh Illustrative Learning Agenda

Nationwide Revitalized Family and Repositioning Population as a Development Issue

• What are the most effective strategies to increase family planning?
• What are the most effective strategies to increase attention to population and family planning and mobilize support by non-health advocates?
• What structural barriers need to be addressed for increasing long acting and family planning use given that 62% women want no more children, yet only 7% are using long term methods?
• Why do the fertility rates vary so much across geographic areas?
• How to rally “champions” from other sectors to be advocates for addressing population across key sector?
• How can new technologies, assist in meeting unmet demand for longer term contraceptives for both men and women?

Integrated Service Delivery at the Community Level

• How do we measure the impact of the integration of services in a meaningful way?
• Can increased collaboration between the DG and FP directorates result in improved delivery of a basic package of care and improved health outcomes?
• How can you increase integration of nutrition as core part of integrated packaged?
• Can the effectiveness of proven categorical interventions be maintained but offered in an integrated model?
• Are there unintended negative health impacts due to integration of services?

Health System Strengthening & Governance

• How can systems be strengthened at a decentralized level when the entire system is so centralized?
• What incentive systems work to support enhanced work performance?
• How can local level planning and budgeting capacity be strengthened and sustained?
• What is the most effective way to involve other key Ministries e.g. Local Government, Education, to strengthen management skills at district and sub district level?
• What models can be explored to create partnerships/ collaborative arrangements/contracting out to private sector in training selected cadre of health providers?
• What models can be explored to create partnerships/collaborative arrangements/contracting out to NGOs to support systems strengthening at district and sub district level?
• How can new health financing mechanisms at the community level be identified, e.g. demand side financing, users fees, health insurance, be used to sustain health system?
• How can the public sector partner with the private/corporate sector to mobilize financial resources for health?

Annex 8: Approaches in Bangladesh that Demonstrate GHI Principles