CPD-UNFPA
Programme on Population and Sustainable
Development
Paper 5 (Summary)
Recent Shift in Bangladesh's Population
Policy and Programme Strategies:
Prospects and Risks
Mohammed A. Mabud and Rifat Akhter
INTRODUCTION
All successive Governments in Bangladesh
since independence appear to have
demonstrated interest in two areas
with respect to population policy
planning: a concern with regards
to the rapid growth of population
and a political commitment to address
the problems that originate from
it. Despite substantial progress
in terms of fertility decline, increase
in the contraceptive prevalence rate
and life expectancy at birth, accrued
through cumulative efforts of successive
Governments, a number of population
related issues remain unaddressed.
The introduction of the Health and
Population Sector Programme (HPSP)
in 1998 was a major departure in
this respect. This departure entailed
important shifts in emphasis on
population activities from the point
of view of strategic approach to
the population problem. These are:
(i) a shift from door to door services
to one-stop services, (ii) a shift
from a multisectoral to a sectoral
approach, (iii) a shift from a mix
of projects and programme approaches
to single mega programme approach;
(iv) a change from sectoral status
to sub-sectoral status, and (v)
a change from 40/50 project/programme
directors to 28/30 Line Directors.
The objective of the paper is to
discuss those shifts and their prospects
as well as risks. The purpose of
this paper is to see whether the
on-going population programme strategies,
apart from family planning/reproductive
health activities, can attenuate
the adverse consequences of some
of the emerging population problems,
such as demographic momentum, arsenic
problem, HIV/AIDS, deteriorating
nutrition status of growing population,
increasing slums, environmental
degradation and so on.
OBJECTIVES
OF THE STUDY
The
main objectives of the paper are
to-
· Review the population policy
and programme, and, in retrospect,
to highlight the successes and failures.
· Highlight the HPSP with
a view to showing the shifts that
differ from the previous policy
strategies.
· Identify some common ground
between the old and new policy strategies
· Present some risks and
prospects based on the analyses
of the implementation experience
of various stakeholders.
· Articulate some policy
recommendations as to how risks
can be minimised in the current
policy strategies.
Major Features of the HPSP
Essential Service Package (ESP)
One of the key features of new health
and population policies is the introduction
of Essential Service Packages (ESP)
which aim at maximising health benefits
relative to per capita expenditure,
meet the felt needs of the clients,
strengthen service delivery, and
improve system management. The five
major areas, on which the ESP has
focused, are the following:
Reproductive Health Care
These are the services that aim
at safe pregnancy and delivery,
including fertility regulation and
treatment of abortions, avoiding
unwanted pregnancies and postponing
births. It also includes reproductive
morbidity and mortality, including
STD/HIV, and other aspects of sexual
and reproductive health among adults
and adolescents.
Child Health Care
Child health care encompasses basic
preventive and curative care for
infants and children. The Government
of Bangladesh has implemented control
programmes for Acute Respiratory
Infection (ARI), Diarrhoeal Diseases,
Vaccine-Preventable Diseases and
prevention of Vitamin A deficiency
disorders. Hepatitis B immunisation
of infants and Td (Tetanus-diphtheria)
immunisation of school age children
will be considered for inclusion
in the EPI programme. The programme
also takes into account school
health services that include training
of schoolteachers for providing
first aid to the school students
and provision of a First Aid Box
in every school.
Communicable Disease Control
Major interventions will include
prevention and effective management
of communicable diseases with a
severe health impact, e.g. TB, leprosy,
malaria, filarial, intestinal parasites,
STDs/RTIs and other emerging and
re-emerging diseases.
Limited Curative Care
Care for common conditions and injuries
must be provided under the ESP.
And for these services government
resources are needed to provide
basic first aid and treatment of
medical emergencies.
Behavior Change Communication (BCC)
BCC
is a cross cutting intervention
conceptualised to capitalise on
the opportunities of the rapidly
expanding communication networks
in Bangladesh. The emphasis is on
multi-media, multi-channel, inter-sectoral
approaches based on a systematic planning
process to produce innovative communication
and creative strategies. The BCC
component aims at:
· Changing the attitude and
behaviour of people to improve their
health status;
· Building effective community
support for health seeking behaviour;
· Changing attitude and behaviour
of service providers to provide
client centred services;
· Promoting men's respect
for the special situation of women and girls in society.
Some Critical Lapses in HPSP
The
HPSP has had quite a few lapses
due to which the creation of a
suitable environment for achieving
its various objectives has been difficult.
These lapses are: (i) HPSP does
not provide for other sectors' participation
in Population, Health, HIV/ AIDS
and Nutrition etc.; (ii) it underestimates
or excludes measures for minimising
the population momentum effect;
and (iii) the roles of three women's
programmes of BRDB, Social Welfare
and Women Affairs Departments in
Population, Health, HIV/ AIDS etc.
were excluded.
RISKS AND PROSPECTS
Risks
The HPSP has superseded many aspects
of the 5th five-year Health and
Population Plan (1997-2002). For
example, the 5th Five Year Health
and Population Plan envisages the
implementation of HPSP, in phases,
in unions where there are FWCs with
doctors. Based on the implementation
experience, it should be gradually
expanded to other places in congruence
with the progress in human resource
development through training in
the new programme strategy. This basic
approach was undermined. The Government
has rushed into implementing the
programme without creating a core
of well-motivated trained people
to implement the package of services
envisaged in the HPSP. Contrary
to previous practices, the MOHFW
designated 30 (thirty) senior officers
as the line Directors who were vested
with both financial and administrative
power to execute thirty different
components of HPSP. These line-Directors
themselves were not reportedly fully
conversant or oriented with the
programme approach. Such inadequate
preparation has created some confusion
at the national level and further
down. Thus, it has affected the
service delivery programme. It has
been observed that some established
institutions like NIPSOM and NIPORT
which used to draw their annual
allocation from the Ministry of
Finance are now subservient
to the Line Director (training)
who cannot provide them with the
resources they need unless he gets
the approval of the Ministry of
Health and FW and the Ministry of Finance.
Consequently, it has not only limited
their institutional freedom, but
has also affected their training
programmes. The same case holds
for research activities, which are
also subject to similar
limitations. The sector-boundary
is defined within the narrow
confine of the MOHFW barring the participation of other
Ministries. This has extremely limited
the prospects of other Ministries' contribution
towards the achievement of the objectives
of Health and Population Sector.
The MOHFW's shift from "doorstep"
to "one stop" service
involves risk as society is
not yet poised and cultured towards
visits to clinics or hospitals to take F.P. services. The female literacy
rate is still not high enough to
ignite such strong motivation, which
may be needed for one stop service.
It is not the public demand that
workers should not visit them at
home, for motivation, follow up
and supplies. In fact, all these
problems have created a great risk
for the success of population/family
planning service delivery. Some
analysts even doubt that the demographic
and social objectives of the Health
and Population Sector as envisaged
in the 5th Five Year Plan may not
be achieved under the changed circumstances.
Instead whatever progress has been
achieved so far is most likely to
be neutralised owing to lack of
direction and operational stagnation
at the grass root level. Various
reform measures such as (i) hospital
autonomy, (ii) cost sharing in public
hospitals etc. have not yet been
taken. As mentioned earlier inter-sectoral
support for HPSP was not
visualised
as essential and thus, other ministries'
ability to contribute towards the
success of the HPSP was thwarted.
The measures to counter the effect
of demographic momentum are not
built-in the HPSP itself, because
the other sectors' direct involvement
in population and health activities
is excluded. Such an important issue
is highly marginalised. This is
a serious risk.
Prospects
The
HPSP is a new paradigm that postulates
a relationship between rapid improvement
in health care and the adoption of new
reform measures through sector-wide
management. Here the sector has
one programme with many components
and necessary resources will be
injected for each component from
both development and revenue budgets.
It has abridged the multiple planning
processes. Once the programme is
approved, it does not have to come
to the Planning Commission or ECNEC.
Different desk masters can resolve
their problems through the intra-sectoral
arrangement. It is also a time saving
device in the sense that each component
of the HPSP has to have an annual
operational plan with budget breakdowns
for each sub-component and so on.
The designated Line Directors are
the key holders of the HPSP. The
Secretary of the MOHFW is the principal
task Manager and responsible for
overall implementation of the programme.
The HPSP is supposed to ensure economy
of scale at various levels, especially
at the MOHFW, but in reality it
remains as large as before and the
Line Directors, despite their delegated
authority, are still dependent on
the Ministry even for tasks that
they can do. For example, the service
matters of the non-gazetted staff
of the Directorate of the Health
services are still attended by the
MOHFW when, as a matter of fact,
no other Ministries deal with such
matters. If the risk factors are
taken into account from now onward
and addressed properly, the HPSP
may yield expected results. But it
will take longer than one might
expect. If risk factors are undermined
or ignored, the HPSP may have disastrous
consequences. The part of its success
also relies on the trained manpower
at all levels of the Health and Family
Planning programme that is currently
lacking.
POLICY RECOMMENDATIONS
In
a variety of ways, HPSP appears
to be at risk. Therefore, it is
important that the Government should
initiate a mid term review to find
out the extent to which (i) different
ESP elements are in place as envisaged
in HPSP; (ii) whether CPR has increased
and the fertility rate has decreased
further; and (iii) the extent of GOB's efforts in initiating the
various reform measures. In order
to provide inputs in the review
exercise, one quick survey with
the stakeholders and another one
with the general beneficiaries should
be conducted to see the status of
various health and population indicators.
Based on results, the HPSP can be
retained, modified or strengthened.
In the meantime, in appreciation
of the other Ministries' express
desire to participate in population
activities, some more broad-based
multi- and inter-sectoral programmes
can be taken up. Some inter-sectoral
programmes/projects, which are currently
underway with the support of the
UNFPA, should be broad based. It
is important that the ongoing and
emerging problems, which threaten
the existence of the population,
should be inter- and multi-sectoralised.
It is also important that the population
policy institutions have in many
instances been highly dysfunctional.
A public policy, to be regarded
as population policy, must be both
population responsive and population
influencing. It must have a long-term
vision to have a particular size
of population with clearly stated
means to achieve that population.
To obtain the full text of this report
please contact:
Centre
for Policy Dialogue
Dialogue
and Communication Division
House No 40/C, Road No 11,
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GPO Box 2129, Dhaka-1000, Bangladesh
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Pages: 34
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