Bangladesh Health Sector Profile 2010



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68885



Bangladesh Health Sector Profile 2010

Final Version


Disclaimer

This volume is a product of the staff of the International Bank for Reconstruction and Development/The World Bank and HLSP/Mott McDonald Ltd, in collaboration with the World Health Organization and with inputs from staff of the Ministry of Health and Family Welfare and members of the Health Nutrition and Population Consortium in Bangladesh. Their work was carried out from 2009 to 2010. The findings, interpretations, and conclusions expressed in this paper do not necessarily reflect the views of the Executive Directors of the World Bank or the governments they represent, HLSP/Mott McDonald, or any of the agencies that contributed to this volume.

The World Bank, HLSP/Matt McDonald and the collaborating agencies do not guarantee the accuracy of the data included in this work. The boundaries, colours, denominations, and other information shown on any map in this work do not imply any judgment on the part of the World Bank or collaborating concerning the legal status of any territory or the endorsement or acceptance of such boundaries.



Contents

Executive summary 6

1. Socio-economic and demographic overview 29

1.1 Geography and demographics 29

1.2 Socio-economic profile 31

1.3 National development and policy framework 33



2. Health status (and trends) 37

2.1 Progress against the health MDGs and key health outcomes 37

2.2 Status in key health areas 38

43

2.3 Summary of principle causes of mortality and morbidity in Bangladesh 54



3. Health sector organisation 56

3.1 Historical background—development of the health sector 56

3.2 Organisational arrangements of MOHFW 56

3.3 Other government ministries and agencies involved in the health sector 63

3.4 Roles of the private sector and NGOs 64

3.5 Public health, and research and development 64

3.6 MOHFW governance arrangements 69

3.7 Formal regulatory structures 70

3.8 Community empowerment in the HNP sector of Bangladesh—regulation through information 72

3.9 Gender mainstreaming in the health sector 74



4. Health services 79

4.1 Utilisation of health care services 79

4.2 Overview of the health services network 82

4.3 Public sector health services 83

4.4 Non-state health services delivery 90

4.5 Health services for special populations 96



5. Human resources for health 98

5.1 Human resource policy and strategic planning 98

5.2 Workforce estimates 99

5.3 Estimating the health workforce gap 102

5.4 Public sector health workforce 104

5.5 Production of the health workforce 110

5.6 Professional regulation and professional development 112

6. Health information, monitoring, and evaluation systems 113

6.1 Information flows in the heath sector 113

6.2 Monitoring and evaluation systems under the SWAp 120

6.3 Information systems development 125

6.4 Information communications and technology 127

7. Health financing and expenditures 128

7.1 Funding flows 128

7.2 Health financing trends in Bangladesh 129

7.3 Alternative financing mechanisms 134

7.4 Resource allocation: Planning and budgeting processes 140

7.5 Financing flows at the upazila level 145



8. Procurement and supply of medicines 149

8.1 Overview 149

8.2 Procurement in the public sector 149

8.3 Logistics and supply chain for medicines in the public sector 154

8.4 Pharmaceuticals regulation 155

8.5 Pharmaceuticals manufacturing 158

8.6 Pharmacies and drug retail outlets 160

9. Sector response 162

9.1 Background and rationale for reform 162

9.2 Donor coordination 166

9.3 Draft National Health Policy 2010 168



10. Conclusion 172

References 174

Annex: Persons consulted 184

List of figures



Figure 1.1 Map of Bangladesh 29

Figure 1.2 Estimated Bangladesh population by end of 21st century (in millions) 30

Figure 1.3 Sectoral composition of the national economy 31

Figure 2.1 Map of Bangladesh showing MDG composite index by upazila 38

Figure 2.2 Trends in under-five mortality rates, 1989–2007 (per 1,000 live births) 39

Figure 2.3 Trends in under-five mortality rates by residence, 1993–2007 (per 1,000 live births) 39

Figure 2.4 Trend in national vaccination coverage among children 12–23 months, 1991–2009 (%) 40

Figure 2.5 Trend in infant mortality rate, 1989–2007 (per 1,000 live births) 41

Figure 2.6 Infant mortality rates by wealth quintile, 2004 and 2007 (per 1,000 live births) 41

Figure 2.7 Trend in deliveries attended by a skilled attendant/health care professional, 1993–2007 (%) 42

Figure 2.8 Prevalence of underweight children under five in Bangladesh and selected countries 42

Figure 2.9 Trends in Bangladesh of underweight children under five, 1990–2007 43

Figure 2.10 Contraceptive prevalence rates, 1975–2007 (%) 45

Figure 2.11 Trends in fertility rate among women aged 15–49, 1975–2007 (average number of children) 45

Figure 2.12 Non-communicable disease mortality over time in rural Bangladesh 48

Figure 2.13 Leading causes of death and DALYs, 2004 55

Figure 3.1 MOHFW senior management structure 57

Figure 3.2 Administrative levels (numbers) and average population 60

Figure 3.3 Functional organisation of the directorate general health services, MOHFW 60

Figure 3.4 Functional organisation of the top level of DGFP, MOHFW 62

Figure 3.5 Management arrangements for delivery of essential services in urban areas 64

Figure 4.1 Institutional deliveries by income group 79

Figure 4.2 Antenatal care by income quintile 79

Figure 4.3 Rich-poor differences in access to family planning methods 79

Figure 4.4 Means of meeting medical expense 80

Figure 4.5 Private expenditure on health by income group 81

Figure 4.6 Expenditure by type of provider: Where is the money spent? 81

Figure 4.7 Breakdown by contacts by source of treatment 82

Figure 4.8 Schematic of the health service delivery networks in Bangladesh 83

Figure 4.9 Structure of the health service delivery system in the public sector 84

Figure 5.1 Density of providers per 10,000 population 100

Figure 5.2 Schematic comparing the proportion of qualified and unqualified health care providers 102

Figure 5.3 Proportion of health care providers by location by type 102

Figure 5.4 Distribution of physician, nurse and dentist per 10,000 population by division 102

Figure 5.5 Schematic outlining process and responsibilities for creation of a new post 106

Figure 5.6 Schematic illustrating process for filling a vacant post 107

Figure 7.1 Map of funding flows 128

Figure 7.2 Total health expenditure by funding source (constant Tk billion) 129

Figure 7.3 Health expenditure by type of provider (constant Tk billion) 130

Figure 7.4 Per capita expenditure on health in selected countries in Asia (PPP $) 131

Figure 7.5 Allocation of the revenue budget, 2009/10 132

Figure 7.6 External partner funding by channel, 2003–7 (taka million) 132

Figure 7.7 Private expenditure on health by income group 133

Figure 7.8 Distribution of household expenditures on health by type of provider 134

Figure 7.9 Place of care for those who sought services for selected interventions 134

Figure 7.10 Fund flows for Maternal Health Voucher scheme 136

Figure 7.11 Schematic illustrating principles of a health insurance function 137

Figure 7.12 Payment arrangements for drug purchases by type of provider 139

Figure 7.13 Funding sources for the Revised Programme Implementation Plan,
July 2003–June 2011 140

Figure 7.14 Government funds release process 144

Figure 7.15 Multi-Donor Trust Fund release process 144

Figure 7.16 Overview of funds allocation and reporting flows at upazila level 146

Figure 8.1 Source of medicines for patients seeking care 160

Figure 9.1 Key milestones of the health and population sector policy and plans 162


List of tables



Table 1 Health indicators at a glance 8

Table 2 The leading causes of mortality and morbidity 11

Table 2.1 Recent progress against key health MDGs 37

Table 2.2 Trend in inequality in prevalence of malnutrition, 1996–1997 and 2004 (%) 43

Table 2.3 Leading causes of mortality and morbidity, 2004 54

Table 3.1 Proposed roles and responsibilities in MOHFW, late 1990s 59

Table 3.2 Health managers, institution heads, and supervisory staff, DGHS 61

Table 3.3 Health managers, institution heads and supervisory staff, DGFP 62

Table 3.4 List of leading agencies for public health, and research and development 65

Table 3.5 Main regulatory authorities in the health sector in Bangladesh 70

Table 3.6 Issues identified in the Gender Equity Strategy of 2001 75

Table 4.1 Summary of range of facility-based health services by referral level 86

Table 4.2 Summary of staff mix for public sector health services at upazila level and below 87

Table 4.3 Listing of total bed complement of hospitals in the public sector by type of hospital 87

Table 4.4 Summary of key roles in construction and maintenance management 89

Table 5.1 Health workforce ratios per 10,000 population, 2001–2005 99

Table 5.2 MOHFW present staff position and future projection 100

Table 5.3 Scope of services and staffing in other government ministries and agencies 101

Table 5.4 Bangladesh estimated health workforce density per 10,000, 2006 103

Table 5.5 Estimation of gap for doctors and nurses, 2007 103

Table 5.6 Projected workforce ratios per 10,000 population based on 2007 data 103

Table 5.7 Vacancies in different posts of DGHS, DGFP, and DNS, June 2008 105

Table 5.8 Public service cadres in the health sector 105

Table 5.9 Yearly production capacity of different categories of HRH inclusive of the private sector as of 2008 111

Table 5.10 Overview of regulatory functions by professional category 112

Table 6.1 HNPSP results framework 122

Table 7.1 Overview of the MOHFW budget 131

Table 7.2 Maternal Health Voucher scheme reimbursement rates 135

Table 7.3 Key financing characteristics of selected NGO programmes on health financing 138

Table 7.4 Summary of budget cycle 141

Table 7.5 Summary of planning and monitoring cycle 142

Table 9.1 List of HNPSP operational plans 163

Table 9.2 HNPSP performance against six core performance indicators 164

List of boxes



Box 1.1 National Strategy for Accelerated Poverty Reduction strategies 34

Box 1.2 Summary of MDG Progress Report for Bangladesh, 2008 36

Box 3.1 Role of the Secretariat of MOHFW 59

Box 5.1 Planning for nurse development 103

Box 9.1 Summary observations on the HNPSP Independent Review Team, APR 2009 165

Box 9.2 Draft National Health Policy 2010 168

Box 9.3 Remaining challenges outlined in the draft National Health Policy 169

Box 9.4 Key features of the draft National Health Policy 169


Acronyms


ADB

Asian Development Bank

ADP

Annual Development Programme

AIDS

Acquired Immune Deficiency Syndrome

ANC

Antenatal Care

APR

Annual Programme Review

APIR

Annual Programme Implementation Report

ARI

Acute Respiratory Infection

BBS

Bangladesh Bureau of Statistics

BCC

Behaviour Change Communication

BDHS

Bangladesh Demographic and Health Survey

BHW

Bangladesh Health Watch

BINP

Bangladesh Integrated Nutrition Project

BMDC

Bangladesh Medical and Dental Council

BNC

Bangladesh Nursing Council

BPC

Bangladesh Pharmacy Council

BRAC

Bangladesh Rural Advancement Committee

CAO

Chief Accounts Officer

CGA

Controller General of Accounts

CMMU

Construction Management and Maintenance Unit

CMSD

Central Medical Stores Depot

DALY

Disability-adjusted Life Year

DDO

Drawing and Disbursement Officer

DFID

Department for International Development (United Kingdom)

DGFP

Directorate General of Family Planning

DGHS

Directorate General of Health Services

DMCH

Dhaka Medical College Hospital

DMIS

Data Management Information System

DNS

Directorate of Nursing Services

DOTS

Directly Observed Treatment Short Course (TB)

DSF

Demand-Side Financing

EPI

Expanded Programme for Immunisation

FP

Family Planning

FWC

Family Welfare Centre

GAVI

Global Alliance for Vaccines and Immunisation

GTZ

Gesellschaft für Technische Zusammenarbeit (German Technical Cooperation)

HFWC

Health and Family Welfare Centre

HIES

Household Income and Expenditure Survey

HIV

Human Immuno-deficiency Virus

HNP

Health Nutrition and Population

HNPSP

Health Nutrition and Population Sector Programme

HPSP

Health and Population Sector Programme

HRH

Human Resources for Health

HRM

Human Resource Management

ICDDR,B

International Centre for Diarrhoeal Research, Bangladesh

ICT

Information Communication Technology

IEC

Information, Education and Communication

IEDCR

Institute of Epidemiology and Disease Control & Research

IT

Information Technology

JICA

Japan International Cooperation Agency

KfW

Kreditanstalt für Wiederaufbau (German Development Bank)

LMIS

Logistics Management Information System

MACS

Management Accounting Consolidation System

MCH

Maternal and Child Health

MCWC

Maternal and Child Welfare Centre

MDG

Millennium Development Goal

M&E

Monitoring and Evaluation

MIS

Management Information System

MOHFW

Ministry of Health and Family Welfare

MOLGRD

Ministry of Local Government, Rural Development and Cooperatives

MSA

Management Support Agency

MTBF

Medium-Term Budget Framework

MTR

Mid-Term Review

NASP

National AIDS/STD Programme

NCD

Non-Communicable Disease

NEMEW

National Electro-Medical Equipment Workshop

NGO

Non-Governmental Organisation

NIPORT

National Institute of Population Research and Training

NIPSOM

National Institute of Preventive and Social Medicine

NNP

National Nutrition Project/Programme

NSAPR

National Strategy for Accelerated Poverty Reduction

NTCP

National Tuberculosis Control Programme

PCB

Pharmacy Council of Bangladesh

PIP

Programme Implementation Plan

PLMC

Procurement and Logistic Monitoring Cell

PNC

Postnatal Care

PWD

Public Works Department

SMC

Social Marketing Company

STD

Sexually Transmitted Disease

SWAp

Sector-Wide Approach

Sida

Swedish International Development Cooperation Agency

TB

Tuberculosis

Tk

Taka

UHC

Upazila Health Complex

UHFWC

Union Health and Family Welfare Centre

UNDP

United Nations Development Programme

UNFPA

United Nations Population Fund

UNICEF

United Nations Children’s Fund

UPHCP

Urban Primary Health Care Project

USAID

United States Agency for International Development

WHO

World Health Organization





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