INTRODUCTION TO THE COUNTRY'S SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS (SRHR) AND DEVELOPMENT CONTEXT
1.1 The Problem
Bangladesh, with an estimated population of 136.7 million in 2004 (1) and a per capita income of US$470 in 2005, (2) has the highest population density in the world (941 people/sq kilometer). (3) About a quarter of the population are adolescents. (4) although poverty declined during the last decade by 1% per year, almost half of the Bangladesh population continue to live below the national poverty line. (5)
The status of women is low (0.524 Gender-Related Development Index or GDI in 2004), (6) which is reflected in an unacceptably high maternal mortality rate (MMR). Every year, in Bangladesh, there are more than three million women (7) who face the violation of their most fundamental right, the right to survive pregnancy and childbirth. While global estimates assume that 15% of pregnant women are likely to develop complications, one-third of which are potentially life-threatening, (8) all three million are at risk of either dying or of being ill for the rest of their lives.
In Bangladesh, women's status and rights as well as the low utilisation of health facilities (due to factors which will be discussed later in the paper) are the major reasons for these high rates of maternal mortality and morbidity. The strong patriarchal structure of society has lowered women's status within the family, in particular, and society, in general. This is reflected in women's limited social mobility, women's low self-esteem, a culture of acceptance of women's low status, early marriage, early pregnancy, unsafe abortion, lack of effective community support structures for women and inappropriate and ineffective allocation and utilisation of resources for women's rights. All this is further aggravated by conservatism and prejudices. It is important to understand that high rates of maternal mortality are not due solely to the shortcomings of the health system alone: they are the product of multifaceted forms of discrimination against women. Its prevalence is indicative of gross neglect and a failure to fulfill women's right to life.
1.2 Relevant International Commitments for Women and Girls
Bangladesh is a signatory to several international treaties, conventions and consensus documents. Therein commitments have been made to respect, protect and fulfill women's rights and ensure women's development. These include the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW); the Convention on the Rights of the Child (CRC); the Optional Protocol to CEDAW; the 1994 International Conference on Population and Development (ICPD) Programme of Action (POA); the 1995 World Summit for Social Development and Copenhagen Declaration; the 1995 Beijing Declaration and Platform for Action (BPfA); and the 2000 United Nations Millennium Declaration with its commitment to fulfill the Millennium Development Goals (MDGs). (9)
The ICPD PoA and the BPfA, especially, embody the international community's commitment to the improvement of SRHR and the advancement of women. The action plan set time-specific targets and commitment to concrete actions in such areas as health, education, decision-making and legal reforms with the ultimate goal of eliminating all forms of discrimination against women in both public and private life. As part of its commitment to the Beijing Declaration, the Government of Bangladesh (GoB) adapted the National Policy for the Advancement of Women (NPAW) in 1997 and its accompanying action plan, the National Action Plan for Women's Advancement, in 1998. The plan's goals include, among others:
* making women's development an integral part of the national development programme;
* establishing women as equal partners in development with equal roles in policy and decision making in the family, community and the nation at large;
* removing, legal economic, political or cultural barriers that prevent exercising equal rights by undertaking policy reforms and strong affirmative actions; and
* raising/creating public awareness about women's differential needs, interests and priorities and increase commitment to bring about improvements in women's position and condition. (10)
It must be noted that although the Bangladeshi government has signed these international treaties and agreements pertaining to women and has put in place national policies and action plans, limited progress has taken place with regard to their actual implementation as evidenced by the situation of Bangladeshi women mentioned above. Moreover, the GoB has made reservations to several articles of CEDAW on the grounds that these conflict with Islamic shariah law. (11) Thus, the existence of these written commitments has had limited meaning. Much more advocacy needs to be done in order for promises and obligations to become a reality.
1.3 Policies on Population and SRHR
The Population Policy that was adopted in 1976, soon after independence, was reflected in the successive 5-year plans and programmes until 1998. This policy sought to place the population and family planning programme as an integral component of overall national development programmes. However, in practice, this policy framed women's health within the narrow lens of the Maternal and Child Health (MCH) programme, which meant women were entitled to receive health services only when they were pregnant. The range of offered services under the MCH programme was also very limited.
After the International Conference on Population and Development (ICPD) in 1994, a major reform was seen in the Bangladeshi health sector. The government, with the support of the World Bank and other donors, introduced the Health and Population Sector Programme (HPSP) in July 1998 in the 5th five-year plan, which was the first time the concept of reproductive health (RH) surfaced in a policy document. The major features of this programme were the following: integration of family planning and health services, which were previously covered by separate wings of the Ministry of Health and Family Welfare; introduction of sector-wide programme management system; decentralisation of services; construction of community clinics which would replace home visits from community health and family planning workers; and measures to improve the quality and coverage of essential health and family planning services (i.e., the Essential Services Package or ESP) particularly for the economically disadvantaged, women and children. (12)
During the HPSP (1998-2003), much effort, time and resources were spent on the structural issues like unification, decentralisation and local-level planning. Evaluation of the programme found there was little improvement in health and family planning (FP) indicators, while some community-based surveys found that use of public health facilities declined and public opinion of government services worsened. (13,14) Putting the blame on the design flaw (15) of HPSP, the government stepped into the second phase of the reform process under the rubric of the Health, Nutrition and Population Sector Program (HNPSP). This phase, i.e., from 2003 to 2006, saw a strategic policy shift that formally separated again health and family planning services from an earlier effort to integrate them. Later, the HNPSP period was revised and extended to 2010, with the formulation of the HNP Strategic Plan July 2003-June 2010 (16) and its accompanying HNPSP Revised Programme Implementation Plan. (17)
HNPSP's priority objectives are the following: reducing MMR; reducing Total Fertility Rate (TFR); reducing malnutrition; reducing infant and under-five mortality; reducing the burden of HIV/AIDS, tuberculosis (TB) and other diseases; and prevention and control of non-communicable diseases including injuries and early screening of cervix, breast and oral cancers. (18) However, the HIV/AIDS component is not prioritised in HNPSP as an integrated programme,19 with AIDS and sexually transmitted infections (STIs) treated as a separate vertical programme--the national AIDS/STD programme--under the Directorate of Health. Given the increasingly sophisticated awareness of the connections between sex and reproduction, the verticality of AIDS funding in the country so far has failed to recognise any linkages between sexual and reproductive health and HIV/AIDS and its impact on women.
HNPSP goals and priorities fit within the framework of the interim Poverty Reduction Strategy Paper (i-PRSP), which the Bangladesh government adopted in 2002. The National Strategy for Economic Growth, Poverty Reduction and Social Development aims to reduce poverty and improve health, particularly reducing mortality rates among infants and children under age five by 65% and eliminating gender disparity in child mortality; reducing the maternal mortality rate by 75%; and ensuring access to reproductive health services of all people. (20)
A new Population Policy was enacted in 2002, (21) wherein the Ministry of Health and Family Welfare (MoHFW) committed to implement the following strategic proposals in cooperation with other concerned Ministries to achieve the policy objectives. Apart from the HNPSP and the i-PRSP, the National Health Policy enacted in 2000 provides the health policy framework in Bangladesh. (22) This policy, as well as policies related to maternal health, and adolescent reproductive health will be discussed in subsequent chapters.
1.4 Medical Staff and Facilities at Different Tiers
Bangladesh has to its advantage a comprehensively designed health infrastructure which permeates different levels. The public health system is structured as a hierarchical pyramid with five tiers: three at the primary, one at the secondary and one at the tertiary level. (23) Health and family planning services comprise two different wings with different staff at each level. At the bottom or village level are 13,500 wards each covering 6,000-7,000 people and where basic primary health care services are provided through home visits (and in Community Clinics where operational). The staff responsible for the services are: one male Health Assistant (HA), one female Family Welfare Assistant (FWA), one Family Planning Assistant (FPA), and one Assistant Health Inspector. On the other hand, Traditional Birth Attendants (TBAs) provide services for safe home deliveries. In the second tier are 4,500 Union-level Health and Family Welfare Centres (HFWC) covering a population of 25,000 to 30,000 people. One Sub-Assistant Community Medical Officer and one Family Welfare Visitor who have 18 months' training on nursing, clinical family planning methods and other reproductive health issues run these HFWCs. Three paramedicals and a pharmacist complement the HFWC staff.
Next to HFWCs are the 413 Upazila Health Complexes (UHC) at the sub-district level, (24) which is the first-level referral centre for the population. Each UHC has about 30-50 beds and covers on the average a population of 250,000 to 300,000 people. On the health side, each UHC has nine doctors of different disciplines, including one dental surgeon, two Medical Assistants, a pharmacist, a radiographer, an Expanded Programme on Immunisation (EPI) technician and five nurses. On the family planning side, there is a Thana Family Planning Officer, a Medical Officer, an Assistant Family Planning Officer, a Senior Family Welfare Visitor and two Family Welfare Visitors. In-patient and out-patient care, FP and MCH services and disease control are provided through these UHCs.
Patients from the HFWCs and the UHCs are referred to the 60 district hospitals, (25) a 50 to 250-bed facility where specialised services are available there. Eleven doctors, including three specialists and 17 nurses, render services catering to a one to two-million population. Besides district hospitals, there are 58 Maternal and Child Welfare Centres (MCWC) staffed by one female Clinic Medical Officer, two female Welfare Visitors and two dai nurses offering antenatal care (ANC), normal deliveries, postnatal care (PNC), immunisation sessions, comprehensive emergency obstetric care (EmOC), child care, family planning services and follow-up care. At the highest level of the public health sector system are the 14 government-supported Medical College hospitals, (26) each of which has 250-1,050 beds and serves a population of 1015 million. Together with other specialist hospitals, they provide tertiary level care.
While the public health sector comprise the main bulk of health service delivery, there are also non-government organisations (NGOs) with clinics at various levels and private health facilities that supplement government services.
1.5 Key National Development Indicators
Selected latest development indicators in Bangladesh and their sources are listed in Table 1 below:
Table 1. Bangladesh Key Development Indicators INDICATORS ESTIMATE SOURCES Total Population (in millions) 130.52 Population (2001) census 2001 (27) 13670 Sample vital (2004) Registration System (SVRS), Bangladesh Bureau of Statistics (BSS) in "Bangladesh Datasheet" (28) Percentage of Young People 22.52 SVRS 2004, BBS in the Population 31.15 in "Bangladesh --10-19 years, 2004 Datasheet" --10-24 years, 2004 Human Development Index 0.53 UNDP Human (HDI) value, 2004 Development Report (HDR) 2006 Gender-Related Development 102 UNDP HDR 2006 Index (GDI) Rank, 2004 GDI value, 2004 0.524 UNDP HDR 2006 Gender Empowerment 67 UNDP HDR 2006 Measure (GEM) Rank GEM value 0.374 UNDP HDR 2006 Crude Birth Rate, 2001-2003 28.7 Bangladesh (per 1,000 population) Demographic and Health Survey (BDHS) 2004 (29) % of Children Who Were 42 BDHS 2004 Exclusively Breastfed for Six Months, 1999-2003 % of Births Attended by Skilled Health Staff, 2004 --Total 13.4 BDHS 2004 --Poorest 20% 3.4 --Richest 20% 39.6 % of Births Done, 2004 --at Home, Total --at Home, Poorest 20% --at Home, Richest 20% --in a Health Facility 89.9 BDHS 2004 (6.1 public, 3.2 67 9 private) 9.0 --in a Health 2.0 Facility, Poorest 30.3 20% --in a Health Facility, Richest 20% Mean Distance to Nearest Health Facility (in km), 2005 --Rural 4.8 Child and Mother --Urban 1.8 Nutrition Survey 2005 --National 4.2 (CMNS 2005) Mean Transport cost to Go to the Nearest Health centre (Taka) --Rural 26 CMNS 2005 --Urban 15 --National 23 Population per Physician, 3,169 Health Information 2005 Unit (MIS), Directorate General of Health Services (DGHS) 200530 Population per Nurse, 2005 6,442 MIS 2005 No. of Persons per Hospital 2,571 MIS 2005 Bed, 2005 Estimated HIV/AIDS Adult <0.1 "Epidemiological Prevalence Rate (% age 15+), Fact Sheets on 2005 HIV AIDS and Sexually Transmitted Infections: Bangladesh December 2006"ae Per capita Gross Domestic 445 Ministry of Finance, Product (GDP) (in US$), in Bangladesh Health 2005 Profile Per capita Income (in US$), 470 Ministry of Finance, 2005 in Bangladesh Health Profile Population Living Below the Household Income Poverty Line and Expenditure --% in the Upper Poverty 40 Survey (HIES) 2005 Line, 2005 World Health --% Living on < US$1 per 36 Organization Day), 2000 (WHO) core Health Indicators (32) Total Expenditure on Health 3.1 WHO Core Health as Percentage of GDP, in %, Statistics 2004 General Government 5.9 WHO Core Health Expenditure on Health as Statistics % of Total Government Expenditure, 2004 External Resources for Health 15.1 Who core Health as % of Total Expenditure on Statistics Health, 2004 General Government 28.1 WHO Core Health Expenditure on Health as Statistics % of Total Expenditure on Health, 2004 Private Expenditure on 71.9 WHO Core Health Health as % of Total Statistics Expenditure on Health, 2004 Out-of-pocket Expenditure 88.30 WHO Core Health as % of Private Expenditure Statistics on Health, 2004 Private Prepaid Plans as % 0.1 WHO Core Health of Private Expenditure on Statistics Health, 2004 Social Security Expenditure 0.0 WHO Core Health on Health as Percentage Statistics of General Government Expenditure on Health, 2004 % of Health Budget from the 6.6 2007-08 Budget, combined Development and Ministry of Non-Development Budget of Finance (33) 796.14 Billion Taka (US$11.67 Billion) % of Health Budget from 9.7 2007-08 Budget, the Development Budget of Ministry of 269.64 Billion Taka (US$3.95 Finance (34) Billion)
1.6 National Gender-Related Indicators
Relevant gender-related indicators in Bangladesh, listing data for women or for both women and men are provided in Table 2 below.
THE BURDEN OF MATERNAL MORTALITY AND THE BARRIERS TO SAFE
2.1 Facts, Figures and Key Issues
Bangladesh has made considerable progress over the years in terms of lowering infant mortality (153 deaths per 1,000 live births in 1975 to 54 deaths in 2005). (39) Even the total fertility rate (TFR, the number of children that an average woman bears in her lifetime) has dropped from 6.3 in 1975 to 3.0 in 2004. This puts Bangladesh's TFR in the middle range among Asian countries. (40)
However, improvements in maternal health have been much slower and uneven among various subgroups. Deaths and disabilities due to pregnancy and childbirth-related in Bangladesh remain unacceptably high, with the maternal mortality ratio of 322 deaths per 100,000 in Bangladesh (41) being one of the highest in South Asia and in the world. Of the 3.8 million women who became pregnant in Bangladesh in 2001, it is estimated that 14,500 died due to pregnancy and childbirth. (42) Other estimates put annual deaths at a much higher 20,000 per year. (43) This means that two women die every hour due to complications related to pregnancy and childbirth. Indeed, United Nations Children's Fund (UNICEF) puts the lifetime risk of dying from pregnancy and childbirth in Bangladesh as one in 59, which is higher than in other South Asian countries (Nepal: one in 24, Pakistan: one in 31, or India: one in 48) or in industrialised countries (one in 4,000). (44)
In addition, disparities exist within various sub-groups, with the highest risk for maternal mortality occurring among the following: in the middle 20% income group (473 compared to 208 among the richest 20%), in Sylhet division (471 compared to 223 in Rajshahi), and among those who have had none or more than five children (511 and 475 respectively, compared to 192 among those who had one prior child). The most common causes of death were ante- and postpartum hemorrhage and eclampsia, followed by obstructed or prolonged labour, and deaths related to induced abortion. (45)
Maternal mortality is strongly linked to infant mortality: it is estimated that 75% of the babies born to women who die from PCRDD also die within the first week of life. (46) The maternal morbidity situation is likewise deplorable, with an estimated 600,000 women expected to develop complications every year. (47) The 2001 BMMS cited that 61% of women experienced at least one complication during pregnancy, delivery and after delivery, the most common being eclampsia and malpresentation or prolonged/obstructed labour.
Various factors conspire to produce these high rates of deaths and disabilities related to pregnancy and childbirth. One of these is women's limited access to and utilisation of health services, including reproductive and maternal health. On the average, the nearest health facility (at the village level, not the district hospitals where comprehensive emergency obstetric services are available) is 4.2 kilometres away and costs an average of 23 taka. (48) Given that 36% of the population are living on less than US$1 a day (68 taka), (49) it is not surprising that utilisation of health services is low. Data from the 2004 BDHS reveals that a high proportion of women received no antenatal care at all (44%). While two in three women received at least two doses of tetanus toxoid, 21% received only one dose and 15% received none. Only one out of 10 births (13.4%) is attended by skilled health staff (among the poorest 20% this is even lower at 3.4% while among the richest 20% it is 29.6%) compared to 63% who were attended by untrained birth assistants. Nine out of ten (89.9%) were done at home (97.6% among the poorest 20% and 67.9% among the richest 20%). More than 80% of those who did not give birth at a health facility did not receive any postnatal care. Moreover, while one out of four births had complications, in only 29% of cases were medically trained providers approached for treatment. Nearly four in 10 women with complications did not seek any care at all. Concern over cost was the primary reason for not seeking medical care, followed by the perception that treatment was not necessary. Transportation and access issues, family opposition, and concerns related to service quality aggravate the problem.
Issues of unwanted pregnancies, contraception and unsafe abortion are also linked to the overall maternal health situation. BDHS 2004 data reveal that despite a rise in the use of contraceptives in the past 30 years (CPR for modern methods is currently at 47%), 11% of women have an unmet need for family planning and three out of 10 births in Bangladesh are either unwanted (14%) or mistimed and wanted later (16%). Perhaps as a result of these, 5% of all pregnancies in Bangladesh end in a miscarriage or abortion and another 5% end in stillbirths and menstrual regulation. (50) It is estimated that 100,300 abortions occur in Bangladesh yearly. While menstrual regulation procedures are conducted in safe and legal circumstances (up to eight weeks from last week of menstruation), abortion beyond eight weeks is illegal. (51) In addition, a large proportion of women go to untrained providers, mainly because of greater familiarity with village practitioners, inadequate information about safer alternatives, perceived low quality of public health services, and concerns over high charges in the government system. (52) As a result, 71,800 women were hospitalised due to abortion-related complications. (53) It is also estimated that 5.4% of all maternal deaths are due to abortion-related complications. (54)
Women's low status in society plays a determining role in women's ill health and the burden of pregnancy and childbirth-related deaths. Women's poor nutritional status whether pregnant or not--as shown by 38.8% of pregnant women and 46% of non-pregnant women having anaemia, (55) and 42.2% of non-pregnant women being malnourished (56)--perhaps illustrates this clearly. Malnutrition, in general, and anaemia, in particular, contributes to increased MMR. Women's reduced power in decision making within the family over crucial matters, including their own health, is highlighted in a recent national survey: in 39.1% of households only the man decides whether the woman goes to a health facility for her own health needs, as compared to 5.6% of households where only the woman decides. (57)
Violence against Women (VAW) is another gender inequality issue which impacts on women's health and maternal health. A 2005 WHO study (58) discovered the following: 40% of ever-married women in Dhaka and 42% in Matlab reported physical violence; 37% in Dhaka and 50% in Matlab reported sexual violence by their husbands. 10% of Dhaka women and 12% of Matlab women were also physically abused when they were pregnant; of these, 37% in Dhaka and 25% in Matlab were punched or kicked in the stomach. Of those who experienced physical or sexual violence by a partner, 19% in Dhaka and 21% in Matlab stated they had poor general health, compared to 13% in Dhaka and 16% in Matlab who never experienced violence. Women who have experienced violence were almost twice as likely to have had induced abortions compared to those who have not experienced violence (Dhaka--19 vs. 9.9, Matlab--3.2 vs. 1.7). This probably points to women in violent relationships lacking power to negotiate for safer sex and/or experiencing forced intercourse and thereby an increased likelihood of having an unwanted pregnancy and having an induced abortion.
Studies by the London School of Hygiene and Tropical Medicine, UK in rural Bangladesh (59) also found a strong link between violence and maternal death. Women's death rates double during pregnancy and for 90 days after birth and more than 35% of all deaths in women aged 15-44 occur during pregnancy. Three out of four of these deaths are directly-related to pregnancy and childbirth, but the rest are from indirect causes including intentional violence and accidental injury. A 2002 United Nations Population Fund (UNFPA) source also estimates that 14% of pregnant women's deaths are associated with injury and violence.
2.2 Policy Environment
In August 2000, the government approved a new National Health Policy, which envisioned the development of a modern, client-responsive, efficient health service involving non-governmental and government providers. The policy aimed to reduce maternal mortality and improve maternal health services. While the policy looks impressive on paper, implementation of the recommendations was limited, and gave rise to a high number of maternal deaths, among other problems. A good physical health infrastructure is available at different tiers, but these are under-utilised strategically. This is partly due to staff absenteeism and other logistic supports supposedly available in these facilities. There is also a lack of accountability among the service providers due to limited monitoring and supervision of activities in public health facilities.
Currently, there is no maternal health policy in Bangladesh. However, a National Maternal Health Strategy was formulated in 2001, which is a comprehensive workplan to ensure safe motherhood for all women throughout the country and is integrated in the HNPSP. It emphasises several elements of maternal health care, including:
* antenatal care;
* safe delivery, including Emergency Obstetric Care (EmOC); postnatal care;
* family planning;
* prevention of unsafe abortion and management of abortion complications; and neonatal care.
It also focuses on the provision of EmOC services and of necessary delivery assistance through skilled birth attendants (SBA) at the grass root level. The specific target goals for 2006 and in the MDGs were to increase the percentage of pregnant women who receive three prenatal care visits to 60% and deliveries conducted by SBAs to 35%. (60)
A National Reproductive Health Strategy was also adopted in 1997, based on the principles set forth in the ICPD PoA. It emphasises a client-centred and lifecycle approach to reproductive health services. The strategy prioritises the following reproductive health issues: safe motherhood, including infant care; family planning; menstrual regulation and care of post-abortion complications; management of reproductive tract infections and STIs; infertility services; and adolescent health care. (61)
Under the Bangladesh penal code, abortion is restricted to saving the life of the mother and can only be performed by a qualified physician in a hospital. However, menstrual regulation is allowed as an interim health measure to establish non-pregnancy up to eight weeks from the last menstrual period by a trained family welfare visitor under a physician's supervision and up to the 10th week by a licensed medical practitioner. It is available in the public health facilities at the district level and below. (62)
2.3 Service Provision
The Health and Nutrition Population Sector Program has the following maternal, child and reproductive health-related targets for 2006-2010: (63)
Maternal and child health and reproductive health services have four main components as per the HPNSP Revised Implementation Plan: safe motherhood services, child health care services, newborn care and adolescent health care. (65) These services are provided through the countrywide public health infrastructure described earlier. The Maternal and Child Welfare Centers (MCWCs) provide the MCH services under the supervision of the Directorate of Family Planning, whereas the district hospitals provide maternity services through an outpatient consultation centre and a labour ward. Between 25-40% of hospital beds are reserved for maternity patients in every hospital. (66)
Considering the high number of maternal deaths in Bangladesh, the government has placed a special emphasis on providing Emergency Obstetric Care (EmOC) services as a main strategy to lower pregnancy and childbirth-related deaths. EmOC has been introduced in phases in selected MCWCs, Upazila Health Complexes (UHCs) and district hospitals. The Review of Availability and Use of Emergency Obstetric Care Services conducted by the Ministry of Health and Family Welfare in 2000 found that the existing comprehensive EmOC facilities (67) are distributed mostly at division and district levels, and basic EmOC facilities at district as well as upazila levels. All 13 Bangladesh government Medical College Hospitals, 59.32% DHs, 27.42% MCWC, about 3% of sampled UHCs are providing comprehensive EmOC services. (bp) Of the institutional deliveries, 64.62% are conducted by government facilities and the rest by private clinics. The private clinics providing comprehensive EmOC services on payment are highly concentrated in the big cities of four divisions: Dhaka, Chittagong, Rajshahi and Khulna.
With support from UNFPA, UNICEF and Averting Maternal Death and Disability (AMDD), the government has increased the number of functioning comprehensive EmOC facilities from 45 in 2000 to 70 in 2002. It has also installed and incorporated life saving equipments, as well as standardise the lists of EmOC equipment and supplies in UHCs and district hospitals on a pilot basis.
A 2002 study to assess the effects of the UN interventions vis-a-vis the UM EmOC process indicators in the Khulna division found significant improvements in the EmOC indicators with the exception of coverage of basic EmOC. The coverage of comprehensive EmOC increased from 0.23 to 1.04 per 500,000 population (UN standard: at least one facility per 500,000 population); the coverage of basic EmOC remained the same at 0.64 basic EmOC facility per 500,000 population (UN standard: at least four facilities per 500,000 population); met need increased from 11.1% to 26.6%; the proportion of births at the EmOC facilities increased from 5.3% to 11.7% (UN standard: at least 15%), and the overall case fatality rate decreased by 51% (UN: <1%). (69)
The HPNSP target is to ultimately provide comprehensive EmOC in all district and medical college hospitals and in selected UHCs, as well as basic EmOC in all UHCs. (70) In addition, 25% of women in need of emergency obstetric care should have access to and be able to use government health facilities for delivery complications management (compared to only about 13% in 2005).
Recommendations for Government Agencies
* Develop a comprehensive SRHR policy/strategy, which incorporates women's health as one of the key components and which uses a rights-based and women-centred approach.
* Increase local and national budgetary allocations for emergency obstetric care and other components of maternal health.
* Develop a stronger strategic stewardship and governance role for the Ministry of Health and Family Welfare to effectively render maternal health and other SRHR services.
* Increase accountability of government health facilities at all levels so that quality maternal health services will be ensured from these facilities.
* Develop programmes to promote gender equality, such as strengthening girls' education and increasing the current school stipend provision for girls up to higher education, stronger enforcement of birth registration and legal age at marriage, enforcing equal pay for equal work, which would in turn have a positive effect on women's decision making and SRHR, including maternal health.
* Implement effective strategies to increase institutional delivery.
* Make available comprehensive EmOC at the Upazila level in all districts; strengthen the number and quality of existing basic and comprehensive EmOC.
* Enable health services to address complications due to violence during pregnancy.
* Involve local non-government organisations and community-based organisations (CBOs) in monitoring the functioning of local health facilities.
* Develop a sound data base to document the current picture of maternal health situation at the local level, which provides disaggregated data (including by age, socio-economic status, educational background and others) and which links it to other issues such as VAW.
Recommendations for NGOs
* Build awareness of the government officials and the media on the need for a women-centred and rights-based approach to maternal health and other SRHR issues, and a comprehensive SRHR policy.
* Build partnerships with government and other relevant organisations working in other issues, including VAW, economic and political empowerment, to create closer and fully operational linkages to establish women health and rights.
* Develop capacity and effective organisational mechanisms for the promotion of SRHR, including to increase government accountability and to improve citizen's voice.
* Increase men's understanding of maternal health issues, including contraception and unwanted pregnancies, and other related issues such as Violence Against Women.
Recommendations for the Media
* Awareness of media practitioners on various SRHR issues, including pregnancy and childbirth-related deaths and disabilities, is urgent.
* Increased collaboration between media and NGOs working in PCRDD and various SRHR issues is critical for successful interventions.
* Media practitioners should write about PCRDD and other SRHR issues on a regular basis to increase public awareness on such issues.
Recommendations for Donors
* Long term uninterrupted funding support on women's health and SRHR issues is critical instead of project funding.
* SRHR funding priority should be an integrated components.
* HIV/AIDS funding should be integrated within HNPSP.
* Donors' coordination is urgent to avoid duplication of services.
2.5 Case Studies
The following case studies taken from Naripokkho and BWHC project sites underscore women's lack of access to appropriate and affordable maternal health services, as well as abuse in patients rights by public health service providers.
EMOC SERVICES: FAR FROM ACCESSIBLE
Twenty-year old Joytsna is in her third trimester of pregnancy. A resident of Chittagong, she went to Kathaltoli union under the Pathorghata Upazilla (subdistrict) to give birth at her in-laws' house. Because Joytsna was not registered in Kathaltoli, no health worker visited her. Family members tried to deliver the baby and only when she started having convulsions was the local traditional birth attendant (TBA) called in. The TBA immediately referred her to the Pathorghata upazilla health complex, which was 5 km. away. There, attending physicians diagnosed her to be suffering from eclampsia and referred her to the Barisal Medical College Hospital. As Barisal was three and a half hours away and transporting her would cost 1,000 to 2,000 taka, the family took some time to decide on whether to take her to the medical college hospital or not. In the meantime, Joytsna and her baby died.
PATIENTS' RIGHTS ABUSED
Asia Begum, 30, wife of a day laborer from Panapur village, Palashbari Upazila (sub-district) of Gaibandha district, was admitted to the district hospital for delivery, which is 22 km from her home through a van. When Asia said she was already feeling labour pains, Nurses Hafiza Begum and Zulekha Khatun said they would not be able to provide the needed medicines (oxytocin). They asked the patient's mother, Moyna Begum, to buy these outside the hospital but the family was poor and could not afford to buy the medicines (it costs 11 taka). As Asia's condition deteriorated and her family could not pay for the medicine, the nurses allegedly drove them out of the hospital. Asia ended up giving birth at the hospital gate.
CHALLENGES TO MEETING YOUNG WOMEN'S HEALTH NEEDS
3.1 Facts, Figures and Key Issues
Bangladesh's population is relatively young. According to the National Census of 2001, as many as 36.3 million Bangladeshis are adolescents (10-19 years of age), constituting 23% of the population. Population Reference Bureau (PRB)'s "World's Youth Datasheet 2006" estimates, on the other hand, that there are 45.7 million youth (age 10-24) in 2006, comprising 32% of the population. This will increase to 52.2 million in 2025 (27% of the population). (71)
Bangladesh stands out internationally in having an extraordinarily early marriage age for girls and with a considerable average age difference between girls and boys for marriage. Although the legal age is 18 for girls and 21 for boys, PRB cites that 48% of girls age 15-19 are married compared to only 3% of boys in the same age group. (72) In the rural areas, there are cases of girls marrying as early as 12 years. BDHS 2004 data reveal that more than half of all women aged 20-49 are married before their 15th birthday. (73)
Early marriage exposes young girls to early and longer childbearing. Indeed, in Bangladesh, one out of three adolescent women aged 15-19 has already begun childbearing. (74) 28% of these teenagers have given birth, while another 5% are pregnant for the first time. Teenage girls in rural areas and in Rajshahi and Khulna divisions are more likely to begin childbearing early compared to urban girls and girls from other divisions. Young women who had completed secondary education were more likely to delay childbearing compared to those with incomplete primary or no education (15.5% vs. 45.8% and 46.5%). Adolescents from lower socio-economic status were also more likely to begin childbearing--four out of 10 adolescents in the poorest 40% of households have begun childbearing compared to three out of ten in the richest 20%. Early childbearing is a major social and health concern, as adolescent girls are more likely to suffer from severe complications during birth, and therefore are at increased risk of suffering from disabilities and of dying from pregnancy and childbirth together with their children. (75) The major pregnancy and childbirth-related causes of death for young women are toxaemia, unsafe abortion and obstructed labour (caused by the immaturity of the birth canal). The WHO states that, worldwide, girls younger than 18 years are up to five times more likely to die in childbirth than women in their 20s.76 Furthermore, early childbearing has severe implications on a young woman's socioeconomic status, cutting short her education and limiting her ability to pursue a career and earn an income.
Contraceptive use is less prevalent among married adolescent girls compared to older married women. Only 34% of girls aged 15-19, compared to 47% among girls aged 20-24, use modern contraception. (77) While unmet need for contraceptives among married adolescent girls has improved slightly over the past years, it is still 23.3% among girls aged 10-14, 15.1% for girls aged 1519 and 12.5% for girls aged 20-24 in 2004. (78) Moreover, 21% of adolescent births in Bangladesh are unplanned. (79) More than one in three births to adolescent girls aged 15-19 occurs after a "too short" interval of less than 24 months (the median birth interval for women in general is 39 months, compared to teenage mothers which is 27 months). (80)
Bangladeshi adolescent girls' poor nutritional status further exacerbates their poor maternal health. The Child and Mother Nutrition Survey 2005 found that 60.2% of adolescent mothers are stunted, leading to an increased risk of having difficulty in pregnancy. On the other hand, the 2004 BDHS cite that 39.6% of teenage mothers aged 15-19 are thin. It also reported that teenage girls suffer from micronutrient deficiency, with only 13.9% of women younger than 20 years receiving a vitamin A dose after delivery and 2.1% reporting night blindness. Anaemia and iodine deficiency are also higher amongst adolescent populations.
While data on the prevalence of sexually transmitted infections and HIV/AIDS among young people is not available, (81) these remain major public health concerns for adolescents. Adolescents run a high risk of contracting STIs including HIV/AIDS, especially adolescent girls having particular biological susceptibility to these infections. Lack of information and knowledge of the symptoms and modes of transmission of STI, and the unavailability of adolescent-friendly health facilities increase their vulnerability to STI/HIV/AIDS. (82)
Given the double burden of women's low status and age, violence is another area of concern for Bangladesh adolescents. The WHO 2005 Multi-Country Study on Women's Health and Domestic Violence Against Women stated that 7% of respondents in Dhaka and 1% in Matlab reported sexual abuse before 15 years of age. Further, the study revealed that of those who had their sexual experience before age 15, 38% in Dhaka and 36% in Matlab said it was forced. (83) Studies by the London School of Hygiene and Tropical Medicine UK, on the other hand, revealed that in rural Bangladesh, among women aged 15-19, the risk of death from intentional and accidental injury is increased nearly threefold during pregnancy. (84)
Adolescents appear to be poorly informed about their sexuality, physical wellbeing, health and their own bodies. In addition, whatever knowledge they have is often incomplete or inaccurate. Low rates of educational attainment (although progress has been made in this area, particularly in addressing gender inequality in education), limited sex education, and a culture with inhibited attitudes toward sex further add to this ignorance. (85) An evaluation study of the Family Planning Association of Bangladesh (FPAB) reported that adolescents and youth, married and unmarried, are not knowledgeable about the following: the underlying cause of menstruation, the consequences of unprotected sexual acts, how a person is infected with HIV/AIDS, menstrual regulation, gonorrhoea, syphilis, causes of nightblindness, and the availability of treatment facilities for sexually transmitted infections. Sex before marriage was reported by 7% of the adolescents (both married and unmarried) and 21% of the unmarried youth, but more than 50% did not use a condom during the first sexual intercourse. A large percentage of married adolescents was also unaware of the need for antenatal check-ups, post-natal care, emergency preparedness and the risks of unsafe abortions. (86)
All these factors add to the vulnerability of adolescent women and expose them to higher risks of maternal mortality. Unfortunately, while data on married adolescents is quite rich, given that all married women are included in demographic and other national surveys, reliable nationally representative data among unmarried adolescents on the above issues is harder if not impossible to locate.
3.2 Policy Environment
The Ministry of Youth and Sports has a youth policy, covering major areas including education, training, health, environment, culture and art. Under this ministry, a very limited and basic school health programme is incorporated.
The concept of adolescent health first surfaced in the fifth five-year plan (1998-2003) of the Bangladesh Health and Population Sector Program (HPSP). After ICPD, the government has given due emphasis on adolescent reproductive health as one of the important components of Reproductive Health Care. Currently, major initiatives on how to address the SRHR issues pertaining to adolescents and youth are being implemented from government and NGO sides. As mentioned earlier, adolescent health care is one of the major components of the MCH and RH services under the HPNSP Revised Implementation Plan. A comprehensive Adolescent Reproductive Health Strategy was also formulated and endorsed by the MOHFW in 2006. This strategy paper covers quality service provision as well as the provision of adolescent-friendly services.
Among the programmatic challenges for adolescent interventions, the most important is to opt for the appropriate way to reach the huge number of adolescents in Bangladesh and to provide them with reproductive health services. Strategies like sex education in school and easy availability of contraceptives still pose a question of acceptability in the socio-cultural setting of Bangladesh.
3.3 Service Provision
Young married adolescent girls are being reached through MCH care and family planning services when they are pregnant, while unmarried adolescents may also access government services. However, the health seeking behaviour of adolescents in Bangladesh indicates that they are more likely to consult non-medical personnel with their health problems. This is partly because existing health facilities are not adolescent/youth friendly, discouraging service-seeking behaviour. Moreover, societal barriers make adolescents reluctant to visit the health facilities.
Availability of adolescent-friendly corners in service facilities is increasingly being promoted by the government. Many NGOs are also rendering adolescent-friendly reproductive health services quite competently and have been proven to be successful.
Recommendations for Government Agencies
* Implement the newly developed Adolescent Reproductive Health Strategy.
* Incorporate the rights-based and women-centred agenda in Adolescent Family Life Education and ensure that the content is accurate, scientific and comprehensive, including information on body functions, menstruation, sex, reproduction, safer sex, contraception, abortion, diverse sexualities and sexual coercion. Build life skills for interpersonal communication and decision-making.
* Provide formal and informal education on sexual and reproductive health to both in-school and out of school adolescent boys and girls.
* Make available appropriate Information, Education and Communication (IEC) materials on sexuality for the adolescents.
* Incorporate adolescent or youth-friendly health service corners in the existing public and private health facilities at all levels.
* Ensure that service providers involved in adolescent health programmes are adolescent-friendly and non-discriminatory and would not violate adolescent rights, including on confidentiality.
* Provide high quality, safe, effective and affordable contraceptive services to reduce the present high rate of teenage pregnancy and unwanted pregnancies.
* Seek better understanding between parents and children by establishing dialogue about the problems of the society.
* Make every effort to obtain and make accessible age-disaggregated information, as well as data on unmarried adolescents, in national demographic and other surveys and studies.
* Introduce vocational education in order to equip boys and girls to enter occupational streams.
* Address poverty and the rural-urban divide, as well as improve girls' educational status, in order to improve girl's sexual and reproductive health status.
Recommendations for NGOs
* Advocate to the various government agencies and institutions on the above recommendations for the government.
* Mass campaign and advocacy to raise knowledge and awareness on the importance of young women's SRSH issues among various community and school gate keepers.
Recommendations for the Media
* Media should come forward to generate public awareness on young women's SRHR issues.
* Media should be involved in the implementation of the Adolescent Reproductive Health strategy.
Recommendations for Donors
* Coordination among donors to avoid programme and service duplication.
ESCAPE FROM DEATH
Roushia is a young woman from Polash Upazilla of Narshindi District, Bangladesh. Her husband is a rickshaw puller. During her first pregnancy at the age of 16, Roushia had her regular check-ups at the BWHC-Polash Center. On her eighth month of pregnancy, she stumbled and fell while collecting water and was hurt badly. The Community Health Volunteer (CHV) of BWHC only found out about Roushia's serious condition during one of her regular household visits in the community, seven to eight days after the accident. The CHV took Roushia to the Sader Hospital of Polash, an upazila-level hospital, but as there was no EmoC facilities there, the doctor in-charge referred them to Narshindi Sader Hospital (district-level). At Narshindi, the on-duty Resident Medical Officer (RMO) provided her two options-either Roushia waits for the hospital's female doctor as this doctor was absent and will be coming back only after thrre days or she could avail services in a private clinic at the cost of 10,00 taka which the RMO will specify. The CHV repeatedly requested for the RMO's assistance for free service but this was not granted so she and Roushia had to return to their village. As Roushia's family could not afford the cost, the CHV attempted to come up with the money from the community. In the meantime, Roushia's condition reached critical levels.
When the CHV has raised enough money, they rushed Roushia to the Dhaka Medical College Hospital where her life was saved but Roushia had a still-birth child. She was later abandoned by her husband.
ASSESSING THE IMPACT OF HEALTH SECTOR REFORMS ON WOMEN'S HEALTH AND RIGHTS
4.1 The Health Sector Reform Process in the Country
The Ministry of Health and Family Welfare (MoHFW) underwent tremendous transformation during the health sector reform in the 5th five-year plan from 1998 to 2003 under the banner of Health and Population Sector Program (HPSP) in Bangladesh. Major initiatives undertaken in this reform were: (87)
* Unification of Vertically Operated Services: Under HPSP, both the Health and Family Planning Directorates were merged into one sector under a single management structure. Resources (revenue and development funds) were put together to support activities to achieve the overall sectoral goals.
* Introduction of a Sector-wide Approach: Instead of project-based planning, there was a shift to sector-wide planning, management and financing. This involved prioritising targeted issues at many levels within the sector, but financial support was directed into overall budget support and less into earmarked components.
* Decentralisation: One of the important milestones of Bangladesh's health sector reform initiatives was the move from centralised planning and management to decentralisation of administration at the sub-district level and below. This was done to strengthen the capacity of the public health sector to deliver high quality curative and preventive services. A decentralised system of local level planning, including procurement of equipment was introduced.
* GO-NGO Collaboration: The collaboration between the government and NGOs has been in place for a long time without any signed agreements between the MoHFW and the NGOs. Through this reform process, rather than just the government being the main health provider, NGOs were contracted out to implement several innovative service delivery programmes (e.g., on HIV/AIDS/ STI prevention, national nutrition programmes, and urban primary health care projects).
* Community Involvement: The rationale for introducing this approach was to ensure community participation at all levels, particularly in setting their priorities and planning the process of health service delivery mechanisms. It was expected that the community would thus understand their well-being and would be able to demand quality of care. Community clinics were established in rural areas and were supposed to be operated through joint management of the government and the local people through the community groups.
* Equity and Pro-poor Service Delivery: Through HPSP, the government introduced the Essential Services Package (ESP), which was supposed to address the health needs of women and disadvantaged members of the population. ESP includes reproductive health care (including safe maternal health, contraceptive services, menstrual regulation, adolescent health and infertility care), child health care, communicable disease control, limited curative care and behavior change communication (BCC).
* Gender Mainstreaming: From having separate women's projects which addressed gender equity, HPSP shifted to a gender mainstreaming approach. (88)
The second phase of health sector reforms in Bangladesh, the Health Nutrition Population Sector Program (HNPSP), was initiated in 2003 and was to be implemented till 2006 but has been recently extended to 2010. HNPSP focuses on modernising health, nutrition and population (HNP) services in Bangladesh and continues with the sector-wide approach used in HPSP, ESP (which is now to be known as Essential Service Delivery or ESD) and improved equity. (89) However, it formally separated again family planning and health services, brought back home-based services, included nutritional aspects of the health of mothers and children in the ESP package and initiated the provision of urban primary health care services. (90)
4.2 Financial Requirements of the HNPSP 2003-2010
The MoHFW estimates that HNPSP will cost 324,503 million Taka (US$4,73.43 Billion) from 2003-2010. In Bangladesh, spending for health, nutrition and population comes from two budgets: revenue, which finances mainly recurrent costs (including salary), and development, which comes from international funding partners and finances both recurrent and investment expenditures. (91) The funding sources and costs are summarised in Table 4 below:
Table 4. Total Cost of HNPSP Financing Pattern APPROVED REVISED IN IN MILLION MILLION FINANCING PATTERN TAKA TAKA (2003-2006) (2003-2006) Government of Bangladesh 14,000 54,297 (GOB) (Development) Project Aid (PA) 32,000 107,935 Sub Total (Dev. Budget) 46,000 162,232 GOB (Revenue) 48,100 162,271 Total (Revenue + 94,100 324,503 Development) Source: HNPSP Revised Implementation Plan, November 2005
Of these total funds, the estimated cost of maternal and child and reproductive health programmes, as well as family planning, are as follows:
It must be noted that a financing gap of about 450 million taka (US$8 million) is missing between the expected development partners' support during the implementation of HNPSP and the estimated development funding availability. The breakdown per year of planned expenditures and resources is summarised in Table 6.
4.3 Budget Expenditure for Health, Particularly MCH and RH
HNPSP spending for the year 2003-04 was 27,861 million taka (US$406 million), representing only 0.83% of the GDP. MoHFW represented only 5.6% of government spending compared to 7.2% in 1995-06, indicating that the health sector has been less prioritised over the years. Funding from international partners has declined since 2002-03 and 2003-04, mainly due to the MoHFW's ill-preparedness to spend the allocated development fund during the previous years. (92) While the HNP allocation in the revised Development Budget for 2003-04 was 18,476 million taka (US$269.56 million), the actual expenditure was 13,383 million taka (US$195.25 million), an achievement of 72.4%. In the Non-Development Budget, the revised allocation was 14,967 million taka (US$218.36 million) but the actual expenditure was 14,478 million taka (US$211.23 million), the achievement being 96.7%. Expenditures in many cases have exceeded the budget provision, while in some cases no expenditure was incurred.
In 2003-04, services of curative care accounted for 1/3 of the total expenditure, followed by health administration at 22%, capital formation at 20%, and MCH and FP and counselling at 17%. Essential Service Delivery accounted for 53% of expenditure, the largest of which is on family planning constituting almost half of the ESD expenditure. Child health comprised 25%, reproductive health (Non-FP) 16%, Limited Curative Care 8%, support service and coordination 2% and BCC 1%. (93)
Only 28.1% of the total health expenditure was financed by the public sector, while 71.9% was financed privately, most of which was out-of-pocket spending by households (88.3%). (94)
It should also be noted that during the first phase of health sector reforms, a substantial amount of project aid (65.58%) was spent for consultancy services.
4.4 Impact on SRHR Service Provision and Access to Services (95)
Health sector reforms under the HPSP apparently looked manageable but did not work out as intended. On the one hand, this is due to the socio-economic and bureaucratic cultural context of government machinery; on the other hand, it is due to a lack of ground work, prior institutional capacity and preparedness for implementing such an important and massive reform in the field. Bipartisan political support for the reforms was also weak, and space for civil society and women's voices was limited during the implementation. (96)
A series of reform initiatives was taken during HPSP but was found to be very short-lived. Little actual decentralisation occurred, while the unification of health and family planning services was halted in 2001 with the change in government. Many community clinics have been constructed but limited health services were provided from these facilities due to lack of proper training and orientation in local level planning. Home-based services were formally brought back again under HNPSP. Organisational changes did not lead to anticipated changes in indicators while some community-based surveys even indicating that use of public health facilities declined and public opinion of government services worsened. (97) HPSP also had limited success in increasing community participation due to various reasons, with groups having been used to mobilise free time and labour, but was not used to strengthen accountability of providers. (98) Having been overly focused on health system restructuring issues, there was less emphasis on tools to ensure the inclusion and tracking of priority indicators of SRHR. No specific comprehensive plan was visible in the area of capacity building.
Other major limitations that have been identified in HPSP are as follows:
* There was recognition of the need for, and commitment in principle, to the importance of gender equity in health sector programmes. But implementation of policies and plans was limited due to weak institutional mechanisms, capacity building initiatives and leadership.
* Overall, public spending on health has remained low and scarcity of resources remained. At the same time, HPSP could not disburse all the funds available. In this regard, delayed World Bank fund disbursement mechanism was acute.
* Development partners' coordination, even though improved, remained too much World Bank-dominated.
* Ineffective unification, long-lasting conflicts between FP and Health cadres, inefficient efforts on management information system (MIS), BCC, procurement of medicine and logistics, hospital improvement initiative, planning process, halting of satellite clinics and home visitation have resulted in curving down the quantity and quality of RH services rendering from different tiers of the health service delivery chain.
* Insufficient attention has been paid to the supply side barriers faced by the vulnerable population. These are: unofficial fees, erratic drug supplies, absenteeism, and negative attitude of the service providers.
* Social marketing initiatives have mainly concentrated on promotion of contraception and condoms, and not on comprehensive maternal health or youth SRH services.
* The weak decentralisation process has severely endangered the local health services. In conservative areas, decentralisation can even be counter-productive.
* It allowed cost recovery by local governments and explored cost-recovery for public services.
Ostensibly, the HNPSP sets out to address these deficiencies, in order to create "a modern, responsive, efficient and equitable HNP sector." (99) A look at the Public Expenditure Review (PER) of HNPSP 2003-04, the first year of HNPSP implementation, reveals that much remains to be done, particularly in terms of equity and gender issues. Allocation of resources across districts is neither based on health needs nor on poverty status. For instance, Kishoreganj, a very poor district, receives 83 taka per capita even though it should get 236 taka per capita when needs are considered. In contrast, Sylhet, a non-poor district, receives 182 taka per capita, when it only needs 29 taka per capita. On average, very poor districts receive 102 taka per capita even though its actual need is 159 taka per capita. Meanwhile, non-poor districts, on an average, receive 103 taka per capita when it should only be getting 70 taka per capita.
The PER also reported that utilisation of public health services remains low, with only 12% of people visiting public facilities for healthcare when they reported sick. Moreover, the economically disadvantaged continues to receive less public resources devoted to health compared to the rich people of the country. The poorest 20% of the population receive only 19.1% of the total public healthcare subsidy (145 taka) while the richest 20% receive approximately 1/3 of the total subsidy (241 taka). For people in rural areas, the per capita subsidy is 161 taka compared to 117 taka.
On the average, a Bangladeshi spends 398 taka annually per capita on health services. While both women and men appear to be sharing healthcare payments equally, there is significant variation when disaggregated by broad age groups. For boys aged less than 14 years old, per capita healthcare expenditures seem to be higher as compared to their girl counterparts. In contrast, in the reproductive age group, expenditure is significantly higher for the female as compared to the male of the same age group. There are also gender differences in receiving health subsidy when disaggregated by class. For example, the per capita subsidy for very poor urban women is 94 taka whereas their male equivalents get 265 taka. Something similar happens in rural areas as well.
* Ensure that gender equity policies and plans are implemented.
* Revise resource allocation so that it is equity-based, with poorer districts receiving more resources.
* It is imperative to introduce an efficient targeting mechanism so that the poor can get more benefits from the limited public resources owed to the health sector.
* Address supply-side barriers particularly experienced by more marginalised populations, such as unofficial fees, erratic drug supplies, and unprofessional attitude of service providers.
* Ensure availability of skilled service providers even at the rural and poorer areas. Moreover, accountability systems need to be strongly in place.
* In any attempt at decentralisation, ensure that maternal and child health services, menstrual regulation and young people's SRH services are compulsory and are exempted from user fees. Implement social insurance schemes and community insurance schemes to cover these kinds of services
* Ensure that elements of ESD/ESP such as services for infertility, pregnancy complications arising out of violence, adolescent and youth sexual and reproductive health services, among others, are really available on the ground.
GENDER, ECONOMIC AND SOCIO-CULTURAL OBSTACLES TO, AND CIVIL AND FACILITATING POLITICAL FACTORS FOR IMPROVING SRHR
5.1 Gender, Economic and Socio-cultural Factors Affecting SRHR
Gender discrimination is deeply rooted in the patriarchal culture and society of Bangladesh. Most of the common health and nutritional problems of poor women and girls can be seen within this wider context of women's disempowerment, which gives a clear picture of the ways in which gender, health and poverty are linked. For instance, maternal malnutrition, a serious health problem, is not only a consequence of income poverty but also of the poor societal valuation of maternal health. There remain glaring gender inequalities in women and men's health status and access to and utilisation of health facilities. This is connected to discriminatory practices which start in homes, including women's lack of bargaining power in the household, low expenditure on the health of women and girls and prioritisation of men and boys over women and girls in the division of food.
Outside of the family, women face considerable constraints in accessing health care: distance to facilities and lack of money for treatment are the two most frequently cited problems. Women face restrictions in travelling unaccompanied, and are economically dependent on men, both of which affect their health care-seeking opportunities. Thus, in 39.1% of households, only the husbands decide whether the wives go to a health facility for their health needs, compared to 5.6% of households where only the women decide. (100) Moreover, the 2003 Third Service Delivery Report revealed that only 35% of women decided about assistance at the delivery compared to 42% of husbands. (101) Widespread reluctance of husbands to spend money on their wives' medical needs is also reported.
Women's health and body remain "taboo" subjects for many and girls and women are socialised not to talk about their reproductive health problems. (102) As a result, most women suffer health problems in silence, not disclosing their health condition even if their lives are at risk. (103) The growing religious fundamentalism in the country poses even more threats to women's SRHR.
Neglect of women's health during pregnancy reflects the low value placed on women's lives. Pregnant adolescent girls represent significant subgroups of pregnant women. There is evidence of numerous barriers to the utilisation of health care by adolescents. This implies that the special vulnerability of adolescents has to be taken into account in the organisation, content and quality of care.
A public utilisation study conducted by the Bangladesh Institute of Development Studies (BIDS) in 2003 revealed that male utilisation rates at public sector facilities for both in-patient and out-patient MOHFW services far exceed those of females, except in MCH services, particularly Family Planning services. Measured in financial terms, benefits from use of MOHFW services accruing to males are likewise higher than those accruing to females. (104)
Women are reluctant to go to male doctors and sometimes families would not allow female members to be treated by male doctors. (105) Many women usually do not have the power to decide over this; mothers-in-law and husbands do. Women are also often not taken in time for emergency obstetric care. There are reported cases of women finally arriving at health service centers and not receiving adequate attention, with no importance seemingly given to save their lives. With the health care providers' general insensitivity to women's health needs, women's reproductive rights are not respected and their reproductive health emergency conditions are often neglected. (106) Women do not enjoy their rights to decide how many children to have, whether or not to have them and when to have them. There is also a general lack of freedom to choose whether to use contraception to prevent pregnancy or to terminate unplanned pregnancies.
5.2 Enabling factors
The 1994 International Conference of Population and Development is a watershed event which has affected population and reproductive health policy-making in Bangladesh. In observance with the recommendations of ICPD, the MOHFW in 1998 has adopted an SRHR framework in its five-year health sector plan. Consequently a major shift is seen in the design and implementation of health programmes pertinent to SRHR. As a result of ICPD, the Ministry of Women and Child Affairs has taken several steps to improve the status of women, integrating women's issues in country's development concerns. A central agency for the elimination of violence against women and children has been established within the ministry.
Investigative reports in the electronic and print media on women's rights issues have raised public awareness and sparked public debate on women's SRHR. Private TV and radio channels have taken proactive initiatives in media campaigns to portray women's situations. Consequently, government-controlled sources of information decreased in credibility and popular interest. An environment that has increasingly brought positive changes in the minds of people and supports women's empowerment has visibly taken shape.
NGOs are identified as an active and growing movement behind women's empowerment and SRHR services provision in both rural and urban Bangladesh. This sector has contributed significant innovations including rendering microcredit programmes to women, providing comprehensive SRHR services to the poor and very poor, introducing cost analysis for efficiency improvements and rendering quality services that helped to establish evidence-based models. Women activist, human rights and legal aid organisations have voiced public concerns on gender issues and have supported different initiatives for the adoption of a rights agenda. These organisations are very active in taking necessary steps for implementing the Convention on the Elimination of All Forms of Discrimination Against Women, either correct or create laws to ensure fulfilment of women's human rights and the participation of women in policy-making.
Together with the NGOs, women's and other United Nations bodies have also actively worked to promote women's SRHR in Bangladesh. UNFPA, UNICEF and WHO, along with the government, have been working on increasing access, availability, quality and utilisation of women's health services through the local government health facilities at different levels. Women-friendly corners (stations specifically catering to women) have been introduced in government hospitals for women victims and survivors of violence. WHO has piloted a safe motherhood initiative with trained skilled birth attendants and after positive evaluation expanded this to 24 districts of the country; the Women's Right to Life and Health (WRLH) a collaborative initiative of the Government of Bangladesh, UNICEF Regional Office for South Asia (ROSA), and AMDD is supporting the government in implementing strategies, actions and measurements for reducing maternal mortality. A comprehensive perspective that includes appropriate management, respect for human rights and life-saving technology has been adopted. In addition, a joint-UN Safe Motherhood Initiative has been undertaken by the United Nations Development Programme (UNDP); the UNICEF; the UNFPA; the WHO; the World Food Programme (WFP); the United Nations Educational, Scientific and Cultural Organization (UNESCO); and Food and Agriculture Organization (FAO). All these agencies have reached consensus for district-based synergistic interventions that will contribute to a broader development sector to enhance women's status and maternal health.
As a signatory to many international treaties including CEDAW, the Bangladesh Government has taken specific steps for eradicating oppression against women. In CEDAW, it has opted to abide by:
* Amendment of existing laws which assist in oppression of women and formulate new laws for establishing the rights of the women;
* Giving special assistance to the oppressed women;
* Eradicate oppression of women and ensure the participation of women in judicial system and at all levels of police force in order to implement laws properly;
* Ensuring that legal procedures against criminal charges such as trafficking, committing crimes against women and girl children are completed within six months;
* Increase women's education, eradicate discrimination in the rate of education between girls and boys and follow active and clear policy in order to integrate women in the mainstream development and take initiative to make education free up to class XII for girls; and
* Incorporate equality perspective of men and women in all curriculum in order to create opportunity to get education throughout life.
The Government has worked to ensure women's political participation at the union and municipal levels. Enactment and amendment of some laws have been undertaken to protect women against violence. Maternity leave has been extended up to four months.
Other factors facilitating improvement of women's SRHR in Bangladesh are the fast bridging of gender inequalities in education and improvements in the country's economy and decline in its levels of poverty. In fact, Bangladesh, together with Sri Lanka are the only South Asian countries, which were reported likely to achieve MDG targets on eliminating gender inequalities.
MOBILISING FOR CHANGE
The government's obligation to ensure laws and policies affirming and supporting women's SRHR and putting women's health issues squarely in the country's socio-economic development agenda need to be always highlighted. Other challenges are not just limited to building countrywide awareness on the do's and don'ts of SRHR issues. They extend much further to mobilising administrative and professional bodies, instigating district based innovation and making sure the health facilities and service providers themselves are able and willing to provide the quality services expected of them. Government policies, strategies, and implementation mechanisms on SRHR issues need to be made public and stakeholder participation need to be ensured so that people can take part in this process and raise their voices with authority.
As a signatory to several international conventions, Bangladesh submits periodical reports to respective UN committees. This mechanism permits both CEDAW and CRC committees to monitor the implementation of the relevant articles and to raise concerns on weak implementation of the recommendations. Increasingly, international standards relating to women's rights in citizenship are being introduced into the Bangladesh government's vocabulary. Both the judiciary and media have created a space for assertion of rights and identifying issues that require interventions for legal and social change. Recently, the Bangladesh government has adopted its interim Poverty Reduction Strategy Paper, where it has highlighted several areas for reform in the country. Central among these are reducing poverty and advocating the promotion of women's health & rights agenda. Now the challenge is how to activate the call for a greater awareness of "Rights and Responsibilities" issues among the community people, which can eventually create pressure on public accountability areas.
Finding out policy and other strategic areas where specific actions are required in the area of youth SRH and maternal health is essential. In the context of Bangladesh, these are: early marriage, early pregnancy, maternal death, dramatic increase of the young population, and limited functioning of the government health facilities in rural areas. Highlighting these, the recommendations are:
* Ensure smoother and stronger implementation of the Birth and Marriage Registration Act as well as the law against early marriage.
* Initiate mechanisms to raise people's knowledge, awareness and capacity to understand SRHR issues so they can analyse their local problems and seek solutions.
* Empower local governments so that they could effectively perform their role in rendering relevant functions.
* Build the capacity of women in politics on the importance of quality affordable and accessible health services at local level.
* Ensure availability and accessibility of referral centres that are adequately equipped and staffed to handle complex maternal health emergencies.
* Adopt adolescent/youth friendly SRHR policies, strategies and programmes.
* Advocate the inclusion of SRHR information in the school curriculum.
* Provide formal and informal SRHR education to both in-school and out-of-school adolescent boys and girls.
* Encourage access of young people to SRHR services by establishing adolescent-friendly health service centres or corners in public and private health facilities at all levels.
* Provide adolescent SRH and life skills education to young people and counseling for parents, teachers and service providers on how to address adolescents SRHR concerns.
* Conduct mass campaigns and advocacy to raise knowledge and awareness on the importance of young people SRHR issues among key stakeholders and decision makers.
(1) Bangladesh Bureau of Statistics. 2007. "Bangladesh Datasheet." Available at http://www.bbs.gov.bd/
(2) Directorate General of Health Services (DGHS). 2006. "Bangladesh Health Profile 2006." Available at http://www.dghs.org.bd/health_profile.asp
(3) Ministry of Finance 2005. Cited in Directorate General of Health Services (DGHS). 2006. "Bangladesh Health Profile 2006." Available at http:// www.dghs.org.bd/health_profile.asp
(4) Bangladesh Bureau of Statistics. 2007. "Bangladesh Datasheet." Available at http://www.bbs.gov.bd/
(5) 49.8% for the period 1990-2003. In UNDP Human Development Report 2006.
(6) United Nations Development Programme (UNDP). 2006. "Bangladesh Statistics." In UNDP. 2006. Human Development Report 2006: Beyond Scarcity: Power, Poverty and the Global Water Crisis. New York: UNDP. Available at http://hdr.undp.org/ hdr2006/statistics/countries/data_sheets/cty_ds_ BGD.html
(7) The United Nations Children's Fund (UNICEF). 2006. The State of the World's Children 2007: Women and Children, the Double Dividend of Gender Equality. New York, USA: UNICEF. 148 pp. Available at http://www.unicef.org/sowc07/
(8) National Institute of Population Research and Training (NIPORT), ORC Macro, Johns Hopkins University and ICDDR,B. 2003. Bangladesh Maternal Health Services and Maternal Mortality Survey (BMMS) 2001. Dhaka, Bangladesh
and Calverton, Maryland (USA): NIPORT, ORC Macro, Johns Hopkins University, and ICDDR,B. Available at http://www.measuredhs.com/pubs/pub_details. cfm?ID=456#dfiles
(9) Center for Reproductive Rights (CRR). 2004. "Bangladesh." In CRR (Ed.). Women of the World: Laws and Policies Affecting Their Reproductive Lives, South Asia. New York, USA: CRR. pp. 29-67.
(10) Government of Bangladesh Ministry of Women and Children's Affairs. "The National Action Plan (NAP) for Women's Advancement." http://www.mwca.gov. bd/cooperation.htm
(11) Center for Reproductive Rights (CRR). 2004. "Bangladesh." In CRR (Ed.). Women of the World: Laws and Policies Affecting Their Reproductive Lives, South Asia. New York, USA: CRR. pp. 29-67.
(12) The elements of the ESP includes the following:
a. reproductive health care--includes: safe motherhood services (antenatal care, safe delivery and obstetric first aid and referral services, post-natal care); family planning services to increase distribution of pills and condoms, emphasising clinical contraception, with particular attention to low-performing areas and under-served groups; prevention and control of RTIs/STDs/AIDS, specially in behavioural change communication and condom promotion; maternal nutrition; adolescent care, emphasising behavioural change messages on proper nutrition and hygienic practices, information regarding puberty, safer sexual behaviour, and avoidance of health risks, including STDs/HIV/AIDS; services that address problems of infertility, particularly if caused by RTIs and STDs, such as sexually transmitted chlamydia infection;
b. child health care--provision of basic and curative care for infants and children for ARI, CDD, vaccine-preventable diseases and Vitamin A; Integrated Management of Childhood Illness (IMCI) as a child survival strategy directed at improved prevention and case management of measles, malaria, malnutrition, diarrhoea, and bacterial pneumonia; services to address malnutrition, especially chronic energy deficiency, protein energy malnutrition, low birth weight, and micronutrient deficiency; school health services, such as first-aid care, and periodic health check-ups of school children;
c. communicable disease control-- services that prevent and manage infectious diseases that have severe health impact (TB, leprosy, malaria, kala-azar, and other emerging and re-emerging diseases).limited curative care--concentrating on first aid for trauma, medical and surgical emergencies, asthma, skin diseases, eye, dental and infectious ear diseases;
d. limited curative care--care of common illnesses and injuries (basic first-aid, treatment of medical emergencies, pain relief and advice, specially for those in poverty); and
e. Behaviour Change Communication--provision of information, education and communication (IEC) services to support access to and use of the ESP and to promote healthy behaviour change. Available at http://www.icddrb.org/images/ wp133_annexure.pdf
(13) Cockcroft, A. et al. 2007. "What did the public think of health services reform in Bangladesh? Three national community-based surveys 1999-2003." Health Research Policy and Systems 2007, 5:1.
(14) It must be noted though that HPSP was not fully implemented--with the coming of a new government in 2001, the integration of health and family planning as well as construction of community clinics halted, and home visits continued. Cited in Cockcroft, 2007.
(15) Order from Director General--Health, MOHFW regarding Family Planning, MCH-RH, November 18, 2003.
(16) Ministry of Health and Family Welfare, Government of the People's Republic of Bangladesh. 2005. HNP Strategic Investment Plan July 2003-June 2010. Available at http://www.hnpinfobangladesh.com/ documentdetail.aspx?di_key=di_69
(17) Government of the People's Republic of Bangladesh Ministry of Health and Family Welfare Planning Wing. 2005. Health, Nutrition and Population Sector Programme Revised Programme Implementation Plan (Original: July 2003-June 2006; July 2003-June 2010). Available at: http://www.hnpinfobangladesh. com/documentdetail.aspx?di_key=di_97
(18) Ministry of Health and Family Welfare, Government of the People's Republic of Bangladesh. 2004. HNPSP Implementation Manual. Available at http://www. hnpinfobangladesh.com/documentdetail.aspx?di_ key=di_97
(19) Reproductive Health Matters, volume 11, number 22, November 2003.
(20) Economic Relations Division, Ministry of Finance, Government of the People's Republic of Bangladesh. 2002. "Bangladesh: A National Strategy for Economic Growth, Poverty Reduction and Social Development." Available at http://www.bdix.net/ sdnbd_org/world_env_day/2001/sdnpweb/sdi/ issues/poverty/BD-prsp/prsp-dec-jan-2002.pdf
(21) In the Population Policy 2002, the Bangladeshi government proposed a set of legal and social measures to enhance the welfare of women and their families, including empowerment of women to promote equity and peace, broadening the scope of their participation in the decision- making process in health and other matters. Some of the policy objectives are:
* Reform laws and procedures and design an implementation strategy to ensure compulsory registration of birth, marriage, death and divorce;
* Pursue implementation strategies with respect to compulsory registration of birth, marriage, death and divorce; ensure the rights of citizenship for every child; prevent marriage of minor girls; and enrol children to schools at appropriate age. Birth registration may be ensured by putting in place the provision of producing a birth certificate at the time of enrolment to schools and registration of marriage. It is expected that compulsory birth registration will help prevent child labour; generate sex disaggregated demographic data for the purpose of planning in such important sectors as education, health and other welfare sectors; and prevent the widespread practice of supplying false information with respect to age.
* As per the existing law, the minimum age of marriage for women is 18 years, and for men 21 years. Registration for marriage is compulsory for all citizens. Prior to marriage registration, the age of the applicant is proposed to be verified as per information in the birth registration certificate.
(22) "Health Policy of Bangladesh." http://www. bangladeshgateway.org/healthpolicy.php
(23) Explanation sourced from HNP Strategic Investment Plan July 2003-June 2010.
(24) Data as of 2006 from DG Health. Bangladesh Bureau of Statistics. 2007. "Bangladesh Datasheet." Available at http://www.bbs.gov.bd/
(25) 2006 data. In "Bangladesh Datasheet."
(27) Bangladesh Bureau of Statistics. 2007. "Bangladesh Datasheet." Available at http://www.bbs.gov.bd/
(29) National Institute of Population Research and Training (NIPORT), Mitra and Associates and ORC MACRO. 2005. Bangladesh Demographic and Health Survey 2004. Dhaka, Bangladesh and Calverton, Maryland, USA: NIPORT, Mitra and Associates, and ORC Macro.343 pp.
(30) Directorate General of Health Services (DGHS). 2006. "Bangladesh Health Profile 2006." Available at http://www.dghs.org.bd/health_profile.asp
(31) World Health Organization (WHO), The United Nations Children's Fund (UNICEF), & Joint United Nations Programme on HIV/AIDS (UNAIDS). 2006. "Epidemiological Fact Sheets on HIV AIDS and Sexually Transmitted Infections: Bangladesh December 2006." Available at http://www.who. int/GlobalAtlas/predefinedReports/EFS2006/EFS_ PDFs/EFS2006_BD.pdf
(32) World Health Organization. Core Health Indicators: The Latest Data from Multiple WHO Sources (Including World Health Statistics 2007). Available at www.who.int/whosis/database/core/core_select_ process.cfm#
(33) Ministry of Finance. "Use of Resources." Available at http://www.mof.gov.bd/budget/inbrief/eng_fig_ II.htm
(34) Ministry of Finance. "Details of Development Expenditure." Available at http://www.mof.gov.bd/ budget/inbrief/eng_fig_V.htm
(35) Bangladesh Bureau of Statistics. 2005. Key Findings of HIES 2005. Available at http://www.bbs.gov.bd/ dataindex/hies_2005.pdf
(36) Helen Keller International (HKI). 2006. "The Burden of Anemia in Rural Bangladesh: The Need for Urgent Action." Nutritional Surveillance Project Bulletin No. 16. Available at http://www.hki.org/research/ nsp_storage/NSP%20Bulletin%2016.pdf
(37) Bangladesh Bureau of Statistics. 2006. "Key Findings of Child and Mother Nutrition Survey of Bangladesh 2005." Available at http://www.bbs.gov.bd/ dataindex/k_child_nutrition.pdf
(38) National Institute of Population Research and Training (NIPORT), ORC Macro, Johns Hopkins University and ICDDR,B. 2003. Bangladesh Maternal Health Services and Maternal Mortality Survey (BMMS) 2001. Dhaka, Bangladesh and Calverton, Maryland (USA): NIPORT, ORC Macro, Johns Hopkins University, and ICDDR,B. Available at http://www.measuredhs.com/pubs/pub_details. cfm?ID=456#dfiles
(39) BDHS 2004
(40) Above India, Indonesia and Vietnam but below Nepal, Cambodia and the Philippines. BDHS 2004
(41) BMMS 2001
(43) World Bank. 2001. World Development Report 2000/2001: Attacking Poverty. Oxford: Oxford University Press. Cited in Rahman, S.A., Parkhurst, J.O. and Normand, C. 2003. "Maternal Health Review Bangladesh. Bangladesh: Policy Research Uniy, Ministry of Health and Family Welfare.
(44) The United Nations Children's Fund (UNICEF). 2006. The State of the World's Children 2007: Women and Children, the Double Dividend of Gender Equality. New York, USA: UNICEF. 148 pp. Available at http://www.unicef.org/sowc07/
(45) BMMS 2001
(46) Research, Training and Management (RTM) International (formerly JSI Bangladesh). "Executive Summary of Bangladesh Country Profile on Reproductive Health. Available at http://www.rtm-international.org/ 04Executive%20Summary%20RH%20Profile UP%20Amin.pdf
(47) Bangladesh Ministry of Health and Family Welfare, 2002. Cited in Rahman, Parkhurst & Normand.
(48) CMNS 2005
(49) World Health Organization. Core Health Indicators: The Latest Data from Multiple WHO Sources (Including World Health Statistics 2007). Available at www.who.int/whosis/database/core/core_select_ process.cfm#
(50) BMMS 2001
(51) CRR Bangladesh
(52) Rahman, S.A., Parkhurst, J.O. and Normand, C.
(53) CRR Bangladesh
(54) Khan, H.K., et al. 2000. "Review of Availability and Use of Emergency Obstetric Care (EOC) Services in Bangladesh." Dhaka, Bangladesh: Associates for Community and Population Research. In Ganatra, Bela. 2006. "Unsafe abortion in South and South-East Asia: a review of evidence," in Warriner, I.K. & Shah, I.H. (eds.). Preventing Unsafe Abortion and Its Consequences: Priorities for Research and Action. New York & Washington: Guttmacher Institute. pp. 151-186.
(55) Helen Keller International (HKI). 2006. "The Burden of Anemia in Rural Bangladesh: The Need for Urgent Action." Nutritional Surveillance Project Bulletin No. 16. Available at http://www.hki.org/research/ nsp_storage/NSP%20Bulletin%2016.pdf
(56) Child and Mother Nutrition Survey 2005
(57) "Key Findings of HIES 2005"
(58) World Health Organization. 2005. "Multi-country Study on Women's Health and Domestic Violence against Women--Bangladesh Country Factsheet." Available at http://www.who.int/gender/violence/ who_multicountry_study/fact_sheets/Bangladesh2. pdf
(59) Khlat, Myriam. "Is Pregnancy Bad for Your Health? Maternal Death Rates in Bangladesh." Available at http://www.id21.org/id21ext/h8cr1g2.html
(60) Government of Bangladesh. National Maternal Health Strategy.
(61) CRR Bangladesh.
(63) Government of the People's Republic of Bangladesh Ministry of Health and Family Welfare Planning Wing. 2005. Health, Nutrition and Population Sector Programme Revised Programme Implementation Plan (Original: July 2003-June 2006; July 2003-June 2010). Available at: http://www.hnpinfobangladesh. com/documentdetail.aspx?di_key=di_97
(64) HNSP Revised Programme Implementation Plan, 2005
(65) According to the HNSP Revised Programme Implementation Plan (2005), the Components of Maternal, Child and Reproductive Health services are the following:
i. Safe Motherhood services including the following: Antenatal care (ANC), Safe delivery (by Skilled Birth Attendants-SBA); Emergency Obstetric Care (EOC) including Obstetrical first Aid, Basic EOC and comprehensive EOC; Prevention of unsafe abortion through safe MR services and provision of post abortion care (PAC); Postnatal Care (PNC) with vitamin A supplementation; Maternal nutrition (through Iron + Folic acid and Vit.- A supplementation); Syndromic management of RTI/STI; Counseling on HIV/AIDS and condom promotion; Prevention of unwanted pregnancy through introduction of Emergency Contraceptive Pill; Potential new areas will be screening for cervical cancer through Visual Inspection of cervix with the help of Acetic acid approach and screening for breast cancer; Services for violence against women and Gender equity; Essential Newborn care
ii. Child Health Care services including the following: Promoting integrated approach to address sick child through IMCI including ARI/Pneumonia, Diarrhoea, malnutrition, fever etc.; Growth monitoring; Providing medication of Deworming; Routine immunization in coordination with EPI Programme and Vit-A supplementation; Ensuring management of drowning, injuries and accident; Limited curative care for Eye, Ear, Skin infection/worm infestation etc.; Expanding vaccination programme of Hepatitis-B in coordination with DGHS.
iii. Newborn Care: Special emphasis will be given on the following domiciliary, UH& FWC and MCWC
services: Health education for mothers on cleanliness, nutrition, danger signs of both mother and baby, Umbilical cord care, Breast feeding, Thermal control, EPI etc; Management of birth asphyxia; Routine eye prophylaxis, and; Special care of pre-term and low birth weight baby
iv. Adolescent Health Care for girls and boys: Development of Adolescent Health Strategy; Counseling and developing awareness for adolescents on personnel hygienic practices, nutrition, puberty, RTI/STI, unprotected sexual activities, night wets, addiction to narcotic drugs, accident, violence and sexual abuse; Provision of family life education through peer group; Deworming and Iron+Folic acid for adolescent girls in non-NNP areas; Management for minor gynecological problems, i.e., Dysmenorrhea, and puberty menorrhagia etc.; Syndromic management of RTI/STI, awareness creation on HIV/AIDS and condom promotion for married adolescents; Providing consultation and treatment for some reproductive health related problems of adolescents; Full immunization of adolescent girls with five dose TT vaccination in coordination with EPI Programme.; Initiation for making all service centres adolescent friendly in phases.
(66) Rahman, S.A et al. 2003. "Maternal Health Review Bangladesh. Bangladesh: Policy Research Unit, Ministry of Health and Family Welfare.
(67) A basic EmOC facility is one that is performing all six of the following functions:
a. Administer parenteral antibiotics
b. Administer parenteral oxytocics
c. Administer parenteral sedatives/ anticonvulsants
d. Perform manual removal of placenta
e. Perform manual removal of retained products
f. Perform assisted vaginal delivery
A comprehensive EmOC facility is one that is performing the followings functions in addition all of to the above:
g. Perform surgery
h. Perform blood transfusion
(68) Khan, M.S.H. et al. 2000. Review of Availability and Use of Emergency Obstetric Care Services in Bangladesh. Bangladesh: Associate for Community and Population Research.
(69) Islam, M.T. et al. 2005. "Improvement of Coverage and Utilisation of EmOC Services in Soutwestern Bangladesh." International Journal of Gynecology and Obstetrics, Vol. 91, pp. 298-305.
(70) HNSP Revised Programme Implementation Plan, 2005
(71) Population Reference Bureau (PRB). 2006. "The world's youth: 2006 data sheet." Washington, DC: PRB. Available at www.prb.org
(73) BDHS 2004
(74) BDHS 2004
(75) BDHS 2004
(76) Barkat, Abul and Majid, Murtaza. 2003. Adolescent and Youth Reproductive Health in Bangladesh: Status Issues, Policies and Programs. Dhaka, Bangladesh: Policy Project.
(77) PRB. The World's Youth 2006 Datasheet.
(78) BDHS 2004
(79) Guttmacher Institute. Teblemaker. Available at www.guttmacher.org/tablemaker/page4.mhtml
(80) BDHS 2004
(81) WHO, UNICEF, & UNAIDS. 2006. "Epidemiological Fact Sheets on HIV AIDS and Sexually Transmitted Infections: Bangladesh December 2006." Available at http://www.who.int/GlobalAtlas/ predefinedReports/EFS2006/EFS_PDFs/EFS2006_ BD.pdf
(82) Kabir, R. 1999. Adolescent Girls in Bangladesh. Dhaka, Bangladesh: United Nations Children's Fund.
(83) World Health Organization. 2005. "Multi-country Study on Women's Health and Domestic Violence against Women--Bangladesh Country Factsheet." Available at http://www.who.int/gender/violence/ who_multicountry_study/fact_sheets/Bangladesh2. pdf
(84) Khlat, Myriam. "Is Pregnancy Bad for Your Health? Maternal Death Rates in Bangladesh." Available at http://www.id21.org/id21ext/h8cr1g2.html
(85) Barkat & Majid 2003
(86) Barkat, A. et al. 2000. "Adolescent Sexual and Reproductive Health in Bangladesh: A Needs Assessment Conducted for the International Planned Parenthood Federation (IPPF) and Family Planning Association in Bangladesh (FPAB)." In Barkat & Majid 2003.
(87) Rob, Ubaidur, et al. 2005. Health Sector Reform: Trends and Lessons Learned. Dhaka, Bangladesh: Population Council. (firstname.lastname@example.org)
(88) Jahan, Rounaq. 2003. "Restructuring the health system: Experiences of advocates for gender equity in Bangladesh." Reproductive Health Matters, Vol. 11 No. 2 (Integration of Sexual and Reproductive Health Services: A Health Sector Priority), pp. 183-191.
(89) HNPSP has its following objectives and strategies outlined in the HNPSP Revised Implementation Plan 2005.
(90) Research, Training and Management International and Associates for Development Services. 2006. Public Expenditure Review (PER) 2003-04 Final Report of the Health, Nutrition and Population Sector Program. Available at http://www. hnpinfobangladesh.com/documentdetail.aspx?di_ key=di_64
(91) HNP Strategic Investment Plan July 2003-June 2010
(92) Research, Training and Management International and Associates for Development Services. 2006. Public Expenditure Review (PER) 2003-04 Final Report of the Health, Nutrition and Population Sector Program. Available at http://www. hnpinfobangladesh.com/documentdetail.aspx?di_ key=di_64
(94) World Health Organization. Core Health Indicators: The Latest Data from Multiple WHO Sources (Including World Health Statistics 2007). Available at www.who.int/whosis/database/core/core_select_ process.cfm#
(95) HNP Strategic Investment Plan July 2003-June 2010
(96) Jahan, Rounaq. 2003. "Restructuring the health system: Experiences of advocates for gender equity in Bangladesh." Reproductive Health Matters, Volume 11 No. 2, pp. 183-191.
(97) Cockcroft, A, et al. 2007. "What did the public think of health services reform in Bangladesh? Three national community-based surveys 1999-2003." Health Research Policy and Systems 2007, 5:1.
(98) id21. 2004. "No say for the poor: The failure of Bangladesh's community health reforms." Id21 communicating development research. Available at: http://www.id21.org/id21ext/s8csm2g1.html
(99) HNPSP Revised Implementation Plan 2005
(100) "Key Findings of HIES 2005"
(101) Cockcroft, A.; Milne, D.; Andersson, N. 2004. Bangladesh Health Population Sector Programme 1998-2003, The Third Service Delivery Survey 2003: Final Report. Dhaka, Bangladesh: Government of the People's Republic of Bangladesh Ministry of Health and Family Welfare. Available at: http:// www.ciet.org/en/documents/projects_library_ docs/200622495850.pdf
(102) Naripokkho. 2002 (2nd ed.). Advocacy Brief on Maternal Mortality: Lives Not Valued, Deaths not Mourned. Dhaka: Naripokkho.
(103) Afsana K, Rashid SF. 2003. "A women-centred analysis of birthing care in a rural health centre in Bangladesh." In Access to Quality Gender-Sensitive Health Services. Kuala Lumpur, Malaysia: ARROW, Malaysia.
(104) Bangladesh Institute of Development Studies (BIDS) and Health Economics Unit (HEU), Ministry of Health and Family Welfare, Govt. of Bangladesh. 2003. Public Health Utilization Study. Cited in the Strategic Investment Plan.
(105) Naripphokho, 2002
(106) Naripokkho. 2003. Report on the Action Research Project "Ensuring Accountability of the Local Health Authorities and Health Service Providers to People, Specially Women in Bangladesh." Dhaka: Bangladesh.
Table 2. Bangladesh Gender-Related Indicators TOTAL VALUE/ BOTH INDICATORS SEXES FEMALE MALE Population (in 136.7 66.6 70.1 million) by Sex, 2004 (SVRS 2004, BBS in Bangladesh Datasheet) Sex Ratio of the 105.2 -- -- Population, 2004 (SVRS 2004, BBS) Age-Sex Composition of Population by Age Group, 2004 (SVRS, BBS) --Ages 10-14 (in %) 12.68 12.65 12.71 --Ages 15-19 (in %) 9.84 9.63 9.63 --Ages 20-24 (in %) 8.63 9.46 9.46 No. of Female- or Male- headed Households (in 15.1 2.93 (10.2%) 25.7 (89.7%) millions, HIES 2005) (35) Poverty Incidence by Sex of Head of Household (HIES 2005) --Upper Poverty Line -- 29.5 40.8 --Lower Poverty Line -- 21.9 25.4 Adult Literacy Rate, 2004 (%, aged 15 years 51.6 45.8 57.2 and above, SVRS, BBS) Literacy Rate, 2004 (SVRS 2004, BBS in Bangladesh Datasheet) --Age 10-14 65.69 68.51 62.9 --Age 15-24 71.86 71.22 72.57 Gross Enrollment Rate for Primary School, -- 102.3 104.8 2004 (SVRS 2004, BBS) School Enrollment Ratio 6-10 Years, 2004 -- 82.6 81.4 (SVRS, BBS) Net Primary School Enrolment Ratio, 2005 (WHO Core Health -- 95 92 Indicators) % of Health Budget 2007-08 from the Development Budget, Budget of 269.64 Billion 9.7 Ministry of 105 Taka (US$3.95 Billion) Finance (36) Primary Dropout Ratio 6-10 Years, 2004 (SVRS, 32.3 30.5 34.0 BBS) Estimated Earned Income (PPP US$), -- 1,170 2,540 2004 (UNDP HDR 2006) Seats in Parliament Held (% of Total), 2006 100 14.8 85.2 (UNDP HDR 2006) % in Government at Ministerial Level, 2005 100 8.3 91.7 (UNDP HDR 2006) % of Legislators, Senior Officials and Managers 100 23 77 (UNDP HDR 2006) % Professional and Technical Workers 100 12 88 (UNDP HDR 2006) Total Fertility Rate (BDHS, 1999-2000) 3.3 -- -- Number of Children Ever born (BDHS, 1999- 2.6 -- -- 2000) Previous birth interval (Median months) 38.8 -- -- Age at first marriage (BDHS, 1999-2000) 15.0 Contraceptive Prevalence Rate (BDHS, 1999-2000), modern 38.6 4.8 -- methods % of Age 20-24 Married -- 98 4.4 by Age 18 (BDHS 2004) % of Age 20-24 Married -- 78.6 5.5 by Age 20 (BDHS 2004) Median Age at First Marriage among Women Aged 20-49 and -- 14.8 24.5 Men Aged 25-54, 2004 (BDHS 2004) Percentage never Never marrieMarried, 200d4 (15-19, BDHS 1999-2000-2004) --Ages 10-14 -- 88.6 No data --Ages 15-19 -- 48.752.1 96.06 --Ages 20-24 -- 15.2 65.6 % of Currently Married Women, 2004 (SVRS, BBS in Bangladesh Datasheet) --Age 15-19, Rural -- 33.29 -- --Age 15-19, Urban -- 24.31 -- --Age 20-24, Rural -- 83.81 -- --Age 20-24, Urban -- 69.65 -- --Age 25-29, Rural -- 93.96 -- --Age 25-29, Urban -- 89.34 -- Median Age at First Birth among Women Aged 20-49, 2004 BDHS -- 18.4 -- (2004) Total Fertility Rate of Women Age 15-49 -- 30 -- (children per woman), 2001-2003 (BDHS 2004) Fertility Rate of Women (No. of births per 1,000 woman, BDHS 2004) --Age 15-19 -- 135 -- --Age 20-24 -- 192 -- Mean Number of Children Ever Born to Women Age 40-49, -- 5.1 -- 2001-2003 (BDHS 2004) Birth Interval, 2004 (Median, in months, -- 39 -- BDHS 2004) Contraceptive Prevalence Rate, %, 2004 (BDHS 2004) -- 58.1 -- --any method -- 47.3 -- --any modern method -- 10.8 -- --any traditional method Percentage never married (15-19, BDHS 48.7 96.0 -- 1999-2000) --Percentage of anaemic mothers (HKI, 2001) 34.0 -- -- % of Unmet Need for 11 (5 for Contraception among -- spacing, 6 -- Currently Married for limiting) Women (BDHS 2004) Percentage % of pregnant women with Anaemia in Rural Bangladesh, 15-49 years, -- 51.038. -- 2004 (HKIHelen Keller Int'l. or HKI, 2001) (36) --% of Non-Pregnant Women with Anaemia -- 46.0 -- in Rural Bangladesh, 15- 49 years, 2004 (HKI) % of Adolescents with Anaemia in Rural -- 39.7 30.9 Bangladesh, 2004 (HKI) Percentage % of Malnourished Non- Pregnant Adult Mothers, -- 45.445.5 -- 2005 (BMI<18.5, BDHS 1999-2000 CMNS 2005) (37) % of Stunted Adolescent Non-Pregnant Mothers -- 60.2 -- (HAZ < -2.00, CMNS 2005) % of Thin Adolescent Non-Pregnant Mothers (< 5th percentile BMI- -- 7.6 -- for-age, CMNS 2005) Percentage% of Pregnant Women with access to Who Received Antenatal Care from a Medically Trained Provider, 2004 (BDHS, 1999-20002004) --Total -- 3748.8 -- --Poorest 20% -- 24.6 -- --Richest 20% -- 81.1.0 -- Percentage of pregnant anemic (HKI, 2001) 51.0 -- -- Percentage of mal- nourished mothers (BMI<18.5, BDHS 45.4 -- -- 1999-2000) Antenatal Care (BDHS, 37.0 -- -- 1999-2000) IMR 76.9 82.2 -- Under five Mortality 11.7 108.3 -- Life Expectancy at Birth in Years, 2004 (SVRS, 65.1 65.7 64.4 BBS) Maternal Mortality Ratio (per 100,000 live births, 1998-2000) (Bangladesh Maternal -- 322 -- Health Services and Maternal Mortality Survey or BMMS) 2001 (38) Maternal Mortality Rate (per 1,000, 1998-2000) -- 0.367 -- (BMMS 2001) Infant Mortality Rate, 1999-2003 (per 1,000 65 64 80 live births, BDHS 2004) Neonatal Mortality Rate, 1999-2003 (per 1,000 live births, BDHS 41 40 52 2004) Under-Five Mortality Rate, 1999-2003 (per 88 91 102 1,000 live births, BDHS 2004) Child Mortality Rate, 1999-2003 (per 1,000 24 29 24 live births, BDHS 2004) Estimated Number of People Living with HIV/AIDS (age 15+), 2005 ("Epidemiological Fact Sheets on HIV 11,000 1,400 9,600 AIDS and Sexually Transmitted Infections: Bangladesh December 2006") Perinatal mortality 57.4 -- -- Institutional delivery 12.1 -- -- Life Expectancy 61.0 years 61.3 years -- Morbidity (per 198 -- -- thousand women, BBS 1997) Percentage in Hardcore poverty 32.6 27.7 -- Total employed aged 15 years and above (BBS, 19.2 80.8 -- 2000) Adult literacy rate (aged 40.8 53.5 -- 15 years and above) Participation in the 5.0 95.0 -- Ministerial level Sex Ratio of women to men in public sector/ 10.8 89.2 -- government service Table 3: HNPSP priority objectives and indicators with benchmarks and targets (64) BENCHMARK HNPSP PRIORITY (WITH REFERENCE OBJECTIVE UNIT OF MEASUREMENT PERIOD AND SOURCE) Reducing Proportion of births attended 15% (2003) Maternal by skilled health personnel Mortality Maternal deaths per 1,000 3.2 (BMMS, 2001) live births Reducing the Lifetime number of births per 3.00 (BDHS 2004) Total woman at current-period age- Fertility Rate specific fertility rates Reducing the HIV prevalence among <4% among Intravenous Burden of HIV/ pregnant women aged Drug Users (IDUs) and AIDS HIV/AIDS 15 to 24 years Commercial Sex Workers (CSWs) (Report of the HIV/ AIDS Control Program) Prevention and Increase screening for Early -- Control of Major Detection of Cancer (Cervix, Non-communicable Breast and Oral Cancer) Diseases through Self-Examination Other Maternal Contraceptive Prevalence Rate 58.1% (BDHS, 2004) and Reproductive Health-related Total Fertility Rate 3.0 (BDHS, 2004) Targets Antenatal Care 15,00,000 (mid-2003) Postnatal Care 5,70,000 (mid-2003) Safe Menstrual Regulation 2,50,000 (mid-2003) (MR)--Number of women who received MR services in a year Safe delivery--Number of 4,65,000 (mid-2003) pregnant women who obtained safe childbirth care both at home and facilities provided by skilled personnel in a year Availability of Obstetric -- first aid at Union HFWCs-- Number of UHFWCs staffed and equipped for safe delivery and Obstetric First Aid in a year PROJECTED TARGETS HNPSP PRIORITY OBJECTIVE UNIT OF MEASUREMENT MID-2006 MID-2010 Reducing Proportion of births attended 25.0% 43% Maternal by skilled health personnel Mortality Maternal deaths per 1,000 2.75 2.4 live births Reducing the Lifetime number of births per 2.8 2.2 Total woman at current-period age- Fertility Rate specific fertility rates Reducing the HIV prevalence among Burden of HIV/ pregnant women aged <2% <0.5% AIDS HIV/AIDS 15 to 24 years Prevention and Increase screening for Early 15% of the 30% of Control of Major Detection of Cancer (Cervix, eligible the Non-communicable Breast and Oral Cancer) women eligible Diseases through Self-Examination women Other Maternal Contraceptive Prevalence Rate -- 70-72% and Reproductive Health-related Total Fertility Rate -- 2.2 Targets Antenatal Care 18,00,000 22,00,000 Postnatal Care 9,00,000 13,00,000 Safe Menstrual Regulation 3,50,000 5,00,000 (MR)--Number of women who received MR services in a year Safe delivery--Number of 7,50,000 9,50,000 pregnant women who obtained safe childbirth care both at home and facilities provided by skilled personnel in a year Availability of Obstetric 860 1500 first aid at Union HFWCs-- Number of UHFWCs staffed and equipped for safe delivery and Obstetric First Aid in a year Table 5. Estimated Cost of FP and MCH and RH Programmes under HNPSP APPROVED NAME OF OPERATIONAL PLAN ALLOCATION FOR 2003-2006 GOB PA Total Clinical Contraception Services Delivery, 962 569 1,531 Directorate General of Family Planning (DGFP) Family Planning Field Services Delivery 1,350 9,805 111,155 Maternal, Child and Reproductive Health 420 1,215 1,635 Services Delivery, DGFP Information, Education and Communication 100 204 304 (FP), DGFP MIS--Services and Personnel (FP), DGFP 40 56 96 Training, Research and Development (FP), 74 142 216 NIPORT Procurement, Storage and Supply 558 15 573 Management, DGFP NAME OF OPERATIONAL PLAN EXPENDITURE DURING 2003-2005 GOB PA Total Clinical Contraception Services Delivery, 474 61 535 Directorate General of Family Planning (DGFP) Family Planning Field Services Delivery 1,088 4,406 5,494 Maternal, Child and Reproductive Health 198 136 334 Services Delivery, DGFP Information, Education and Communication 55 0 55 (FP), DGFP MIS--Services and Personnel (FP), DGFP 14 0 14 Training, Research and Development (FP), 23 0 23 NIPORT Procurement, Storage and Supply 89 0 89 Management, DGFP NAME OF OPERATIONAL PLAN REVISED PROPOSAL FOR 2003-2010 GOB PA Total Clinical Contraception Services Delivery, 2,258 2,633 4,891 Directorate General of Family Planning (DGFP) Family Planning Field Services Delivery 2,185 16,595 18,780 Maternal, Child and Reproductive Health 925 4,459 5,385 Services Delivery, DGFP Information, Education and Communication 342 776 1,118 (FP), DGFP MIS--Services and Personnel (FP), DGFP 117 90 207 Training, Research and Development (FP), 46 1,027 1,073 NIPORT Procurement, Storage and Supply 975 56 1,031 Management, DGFP Source: HNPSP Revised Implementation Plan, November 2005 Table 6. HNPSP Expenditure Plans and Resources (Indicative) AREA 2003-04 04-05 05-06 06-07 Revenue 14967 16521 20446 22899 Development (Core services) 9368 20255 16377 18549 Accelerated services 1254 1459 New Investment 926 1577 TOTAL 24335 36775 39003 44484 GOB contribution 18363 22103 25468 28415 Expected DPs Support 5973 14672 13535 16069 AREA 07-08 08-09 09-10 G. TOTAL Revenue 25647 28725 32172 161379 Development (Core services) 20941 23644 26700 135834 Accelerated services 1459 1520 1851 7578 New Investment 2349 2992 3053 10898 TOTAL 50432 56881 63775 315686 GOB contribution 31991 36020 40561 202921 Expected DPs Support 18441 20861 23214 112765 Source: HNP Strategic Investment Plan
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|Date:||Jan 1, 2008|
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