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The challenge

In 2012, approximately 30% of Bangladesh’s total popula-

tion of 160 million lived in one of the rapidly expanding

cities and towns. This urban population was expected to

increase at an annual rate of 6% as millions of people left

rural areas in search of work. By the end of 2014, approx.

55 million people would live in cities and towns and thus

increase their demands for urban public health services.

In Bangladesh, the delivery of public health services

is the responsibility of two ministries. The Ministry of

Local Government Rural Development and Cooperatives

(MoLGRD&C) is predominantly responsible for Primary

Health Care in urban settings, whereas the Ministry of

Health and Family Welfare (MoHFW) ensures Primary

Health Care in rural areas, health service provision through

hospital care, and is also in charge of health educational

institutions.

As is the case in other City Corporations, the administrative

and technical boundaries between the City Corporations

of Sylhet (SCC), Rajshahi (RCC) and Narayanganj (NCC)

Health Departments under MoLGRD&C and various health

authorities under MoHFW and other stakeholders are not

clearly defined. This has led to fragmentation, duplication,

and inefficiency in Sylhet’s, Rajshahi’s and Narayanganj’s

health systems. Hence, mechanisms need to be in place to

coordinate the activities amongst all involved.

Although significant progress has been made in the

Bangladeshi health sector during recent years, substan-

tial shortfalls, and other inequities still exist in the area of

sexual and reproductive health (SRH) services. Acknowledg-

ing the success of an overall reduction of the total fertility

rate (TFR) from 3,4 in 1993 to 2,2 in 2011 the rate of modern

contraceptive use remains low, and discontinuation rates

are high. Only one-third of all births are attended by skilled

professionals, delivery complications occur frequently, and

staff are often not prepared and/or equipped to provide

professional care.

Addressing Bangladesh’s Demographic Challenges

Photo: © Thomas Kelly / GIZ BD

Project name Addressing Bangladesh’s Demographic Challenges (ABCD)

Commissioned by

German Federal Ministry for Economic Cooperation and Development (BMZ)

Project region Bangladesh

Lead executing agency

The Ministry of Local Government, Rural Develop-ment and Cooperatives (MLGRDC), the Ministry of Health and Family Welfare (MOHFW)

Duration 2012 to 2015

Buzzing traffic in Dhaka.

In cooperation with:

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Midwifery student providing postnatal care to a young mother and her newborn.

2

These problems are particularly acute in urban centres in

the eastern regions of Bangladesh where access to and

the availability of SRH services is limited as reflected by

poor indicators relative to other regions of Bangladesh. It

is particularly acute in

� Sylhet Division, where the contraceptive prevalence

rate is only 45% compared to 61% nationwide (Bang-

ladesh Demographic Health Survey, BDHS 2011), only

24% of deliveries are attended by skilled birth attend-

ants compared to 31% nationwide (BDHS 2011); and

� Rajshahi Division, with the second (to Sylhet) highest

mortality rates for early childhood mortality indica-

tors [Neonatal Mortality: 39; Post-Natal Mortality: 13;

Infant Mortality: 51, Child Mortality: 13 and Under-5

Mortality: 63] (BDHS 2011)

In addition, qualified midwives are considered a new

health profession in Bangladesh. Recently a 3-year

diploma programme in midwifery education has been

accredited and was launched in a number of nursing col-

leges and institutes countrywide, including the ones in

Sylhet and Rajshahi.

Our approach

In this context, the Federal Ministry for Economic

Cooperation and Development (BMZ) is supporting the

relevant health authorities and ministries operating in

Sylhet City, Rajshahi City and Narayanganj City through

both financial and technical cooperation. Technical

cooperation, implemented by Deutsche Gesellschaft für

Internationale Zusammenarbeit (GIZ) GmbH focuses on

the improvement of SRH services in an urban setting.

The GIZ supported project “Addressing Bangladesh’s

Demographic Challenges” (ABDC) deals with institutional

and organizational development of the health system in

the following areas:

� Governance with special focus on quality manage-

ment and inter-ministerial coordination,

� Health information systems,

� Service delivery, ranging from the improvement of

obstetrics emergency care and the referral system to

health promotion especially addressing adolescents

and consumer rights,

� Human resources for health

The overall objective of the project is to identify the

gaps in health service provision in the urban setting and

strengthen SCC’s, RCC’s, NCC’s and MoHFW’s capacity

in health systems governance in order to close these gaps

to improve service delivery, especially for the neglected

population living in urban slums.

GIZ is cooperating with KFW Development Bank which

is giving financial cooperation in the area of family

planning.

Photo: © Thomas Kelly / GIZ BD

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Peer educator giving a training session on sexual and reproductive health in an adolescent friendly corner in an urban slum.

Photo: © Thomas Kelly / GIZ BD 3

Success factors

In order to address the fragmentation of responsibili-

ties in the health sector, GIZ supports partners at the

national, divisional and municipal level to coordinate

activities more efficiently, both within their own institu-

tions as well as among local stakeholders and between

national and international organisations. The intended

outcome is a more harmonized governance of the health

system where resources are invested in a more coordi-

nated and rational manner.

Governance in health

Under the framework of strengthening governance,

quality management is identified as a crucial area that

requires improvement. In order to provide a reliable

standard of healthcare services, GIZ supports the respec-

tive health departments to adopt a uniform quality

management (QM) system for improving their health ser-

vices by different service providers within the city. This

includes capacity building to use and promote the use of

QM standards, assessment tools, which were developed

under the previous phase of GIZ support to the SCC

health system as well as existing Standard Operating

Procedures (SOPs) and guidelines.

Health Information Systems

Primary Health Care in Sylhet, Rajshahi and Narayanganj

is provided by a range of public and private providers that

have no common set of standards for reporting of health

services provided (data variables, reporting formats,

definitions, etc.). This makes it difficult for the city corpo-

ration to get a clear overview of the health sector. GIZ

provides technical cooperation to strengthen the health

information system by developing standard variables and

reporting formats, strengthening existing legal frame-

work to make routine reporting mandatory and also sup-

porting the customization and implementation of a free

and open source health management information system.

This comprehensive system serves as a cost effective

platform for collecting routine health information from

the various public and private service providers in the

city, and assists to devise, execute and measure appropri-

ate health interventions.

Service delivery

Various service providers in Sylhet, Rajshahi and Naray-

anganj i.e. public, and both private for profit and not for

profit, funded by the government and different develop-

ment partners, are providing different services to differ-

ent target groups under different financing mechanisms.

Therefore ABDC is supporting SCC, RCC and NCC to

conduct a comprehensive mapping of the health sector

combined with health seeking behaviour surveys. This

allows the city corporations to have a complete overview

of the current situation and to plan for improvements more

comprehensively. Based on the findings of these two analy-

ses, ABDC is assisting SCC, RCC and NCC in areas such as

strengthening the referral system, improving emergency

obstetric care and health promotion of the population,

especially adolescents. In this context, GIZ works together

with the respective health departments to empower their

citizens by making updated information regularly and easily

available through various communication channels. By

doing so, citizens know their rights and options when seek-

ing health services.

Human resources for health

A major area of cooperation is the support to the imple-

mentation of a new 3-year direct entry midwifery diploma

education programme. This is considered a contribution

to build up the first ever skilled midwifery workforce in

Bangladesh and to overcome the lack of qualified staff

during deliveries.

Based on the findings of the mapping exercise that includes

the identification of training needs, a specific in-service

training programme will be offered. In additional to medi-

cal trainings in Emergency Obstetric and neonatal Care

(EmONC) and QM, a major focus will be on public health

related managerial knowledge and skills.

Published by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH Registered offices Bonn and Eschborn, Germany

Addressing Bangladesh’s Demographic Challenges (ABDC) House 10/B, Road 90, Gulshan 2 Dhaka, 1212, Bangladesh T +880 966670 1000 F +88 02 8823 099 giz-bangladesh@giz.de www.giz.de/bangladesh

Author(s) Eva Schöning

Layout Big Blue Communications

Printed by Portonics Limited

As at November 2014

GIZ is responsible for the content of this publication.

In cooperation with

On behalf of Federal Ministry for Economic Cooperation and Development (BMZ)

Addresses of the BMZ Bonn BMZ Berlin BMZ offices Dahlmannstraße 4 Stresemannstraße 94 53113 Bonn, Germany 10963 Berlin, Germany T +49 228 99 535 - 0 T +49 30 18 535 - 0 F +49 228 99 535 - 3500 F +49 30 18 535 - 2501

poststelle@bmz.bund.de www.bmz.de

Photo: © Thomas Kelly / GIZ BD

Midwifery students participating in a classroom lecture on midwifery.

Contact person

Eva Schoeningeva.schoening@giz.de