Country Case Study: Bangladesh

Civil Society Budget Advocacy for Sexual and Reproductive Health

Dr. Sujit Ghosh Tapati Saha

December 2011

Country Case Study: Bangladesh

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05 December 2011

Civil Society Budget Advocacy for Sexual and Reproductive Health

December 2011

Dr. Sujit Ghosh Tapati Saha

HLSP, 10 Fleet Place, London EC4M 7RB, United Kingdom T +44 (0)20 7651 0302 F +44 (0)20 7651 0310, W www.hlsp.org

Country Case Study: Bangladesh

This document is issued for the party which commissioned it and for specific purposes connected with the above-captioned project only. It should not be relied upon by any other party or used for any other purpose.

We accept no responsibility for the consequences of this document being relied upon by any other party, or being used for any other purpose, or containing any error or omission which is due to an error or omission in data supplied to us by other parties. This document contains confidential information and proprietary intellectual property. It should not be shown to other parties without consent from us and from the party which commissioned it.

HLSP, 10 Fleet Place, London EC4M 7RB, United Kingdom T +44 (0)20 7651 0302 F +44 (0)20 7651 0310, W www.hlsp.org

Country Case Study: Bangladesh

Content
Chapter 1. 2. 3.
3.1 3.2 3.2.1 3.2.2 3.2.3 3.3

Title Acknowledgements Introduction Country Context

Page 2 3 4
4 4 5 6 7 7

Demographic profile _________________________________________________________________ Sexual and reproductive health in Bangladesh _____________________________________________ Maternal mortality and reproductive health in women ________________________________________ Family planning and contraception ______________________________________________________ Sexual rights and HIV ________________________________________________________________ The role of non-governmental organizations and civil society in Bangladesh ______________________

4.
4.1 4.2 4.3

Political, institutional and policy environment in the health sector

Gender dimensions __________________________________________________________________ 9 Governance and institutional factors _____________________________________________________ 9 Citizens voice and social accountability _________________________________________________ 12

5.
5.1 5.2 5.3 5.3.1 5.3.2 5.4 5.4.1 5.4.2

AHEAD Project Findings

Project Partners ___________________________________________________________________ Evaluation principles and methods _____________________________________________________ Activities and interim outputs _________________________________________________________ Capacity and tools development _______________________________________________________ Strategy and knowledge development __________________________________________________ Project Outcomes __________________________________________________________________ Participation and ownership __________________________________________________________ Transparency and accountability ______________________________________________________

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14 14 15 15 16 17 17 17

6.
Annex 1: Annex 2: Annex 3: Annex 4:

Conclusion and lessons learned

MDG Progress Score Card _____________________________________________________________ Strategy decisions lessons learned ______________________________________________________ List of Interviewees____________________________________________________________________ Documents reviewed __________________________________________________________________

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20 21 22 23

Figures
Figure 3.1: Figure 3.2: Figure 4.1: Figure A.1: Inequities in maternal and reproductive health services ______________________________________ 5 Contraceptive method use by married women in Bangladesh (from WHO, SEARO) ________________ 7 Bangladesh Progress Targets_________________________________________________________ 11 MDG progress score card ____________________________________________________________ 20

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1. Acknowledgements
First and foremost, we thank 'AHEAD', lead implementing agency, the Bangladesh Centre for Communication Programme (BCCP) for helping with coordination and providing the assistance and support we needed for the case study. We also thank all the interviewees for their time and valuable insights, without which this case study could not have been developed (please see Annex 3 for list of interviewees), Clare Dickinson (HLSP) for reviewing the document and providing critical inputs and Gemma Nicholas (HLSP) for editing and formatting. The case study was funded by the World Health Organisation, Geneva. We acknowledge that the case study has limitations in what it covers; nevertheless, we hope that stakeholders will find the case study useful and that the document can contribute to the work on budget advocacy on sexual and reproductive health in Bangladesh.

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2. Introduction
The international aid environment has undergone considerable change in recent years and partnerships between governments, donors, private sector and civil society are flagged as key principles of development cooperation. In some countries, civil society has achieved success in navigating the aid architecture and advocating effectively on behalf of sexual and reproductive health (SRH). In other countries, interacting and participating in key development processes has been more challenging due to a lack of sufficient data or evidence to make a strong advocacy case and weak understanding of terminology and processes, making 1 access and influence difficult . For the past two years, WHO has supported the AHEAD project (completed in January 2011) implemented through the German Foundation for World Population (DSW). DSW has provided financial and technical support to civil society organisations (CSO) for developing and implementing locally devised advocacy action plans to raise levels of government funding for SRH in Bangladesh, the Philippines and Uganda. This report is a case study from the AHEAD project in Bangladesh. The case study starts with a description of the socio political context in which the AHEAD project was implemented. The section on context provides an account of civil society movements in Bangladesh, a situation analysis of sexual and reproductive health and rights in the country and background to the policy environment. The next section outlines evaluation findings whilst highlighting achievements and some of the challenges faced. The last section lists lessons learnt with concluding comments. In addition, the case study makes comparisons where relevant with findings from an evaluation of the AHEAD project in Philippines to learn what the similarities and dissimilarities are when implementing the same project in two different countries.

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3. Country Context
3.1 Demographic profile

Bangladesh is one of the most densely populated countries in the world. The country is spread over 147, 1 570 square kilometres and is home to 142.3 million people with a population density of 966 people per square kilometre. Bangladeshs Population includes 71.2 million males and 71.0 million females, which yields a sex ratio of 100.3 indicating equal numbers of men and women in the country. Approximately, 90 per cent of Bangladeshs population are Muslims, 9 per cent are Hindus and other religious denominations constitute about 1 per cent. The dominant sector of the economy is agriculture, occupying 80 per cent of the total work force and contributing to 25 per cent of gross domestic product (GDP). Bangladesh achieved independence in 1971 after a bitter liberation war. The demand for independence from Pakistan gained momentum following a popular language movement which started in 1950s and was against the suppression of Bangla language and culture by West Pakistan. Bangladesh has a parliamentary form of Government headed by a Prime Minister. The Parliament has 300 directly elected members with 64 women Parliamentarians. The country is administratively divided into 6 divisions consisting of 64 districts, 467 Upazilas (sub-districts) and 4,480 Union Parishads. Districts are the main administrative units and civil servants carry out executive responsibilities of these administrative units. The lowest unit of local Government is the Union Parishad run by elected representatives. Laws and the legal system were mostly inherited from the British since colonial times. In Bangladesh, nearly half of the population of 135 million live below the poverty lineas measured by income, consumption and ability to meet basic human needsmaking Bangladesh one of the poorest 2 countries in the world. There has been some progress in reducing poverty and improving the lives of people in the last two decades, and the country seems to be on track to reach its poverty reduction MDG targets. Despite the progress, the government fears that the MDG target for hunger, one of the indicators, 3 may not be achieved due to current challenges of food security in the country. 3.2 Sexual and reproductive health in Bangladesh

Bangladeshs commitment to Millennium Development Goals (MDGs) 4, 5 & 6 and its Health, Nutrition & Population Sector Programme (HNPSP) has helped the government set development and health related targets for 2015. Reports suggest that significant progress has been made in relation to gender and health related indicators like gender parity in education, lowering of under-five mortality rates and reduction in communicable diseases. Bangladeshs progress on child survival has been remarkable. It is one of the best performing countries in the developing world. The Millennium Countdown Report Countdown to 2015 (UNICEF 2008), places Bangladesh among 16 countries in the world that are on track to achieve MDG 4 targets on child mortality. Successful immunizations, control of diarrheal diseases and programmes for vitamin-A supplementation have been significant contributors to the decline in child and infant deaths.

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Bangladesh Bureau of Statistics (2011), Population and Housing census (preliminary results), Government of Bangladesh http://www.worldbank.org.bd Planning Commission (2009), General Economics Division, The Millennium Development Goals: Bangladesh Progress Report

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3.2.1

Maternal mortality and reproductive health in women

In Bangladesh, maternal mortality remains high despite the significant reduction of Maternal Mortality Ratio (MMR) that took place from 1990 to 2005. During this period there was 40% reduction in MMR - from 574/100,000 live births to 391/100,000 live births. However, since 2005, there has been no further reduction and the MMR has plateaued to 350/100,000 live births. The setback is attributed to the political 4 upheaval that took place in the last decade including the imposition of military dictatorship. As a result, it is unlikely that Bangladesh will achieve its MDG target to reduce MMR to 143/100,000 live births by 2015. The most common causes for pregnancy related deaths in Bangladesh are post-partum hemorrhaging, 5 eclampsia, obstructed labour and unsafe abortion. Furthermore, the difference in maternal mortality between urban and rural areas is wide. The MMR in rural areas averages 393/100,000 live births; this is 6 nearly double the ratio in urban areas (242/100,000 live births). The differences in uptake of maternal and reproductive health services between the rich and poor are also quite striking (figure below).

Figure 3.1:

Inequities in maternal and reproductive health services

Source:

BDHS 2007

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To note: a similar setback to SRH of women took place when there was dictatorship in the Philippines in the 80s. Bangladesh Maternal Mortality and Morbidity Survey 2001, Government of Bangladesh 6 Bangladesh Bureau of Statistics, Sample Vital Registration System 2008, Government of Bangladesh 293466///F/2 5 December 2011

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Obstetric care in Bangladesh is inadequate. There are few skilled National maternal health programmes in professionals in the country and the Bangladesh quality of maternal and reproductive health services is poor.14 babies under 1. Emergency Obstetric Care Programme (EOC) one month of age die every hour and 7 120,000 every year. Women have to 2. Maternal and neonatal health programme (MNH) rely mostly on untrained personnel for delivery of babies. In 2009, over 58% of 3. Training of manpower births were assisted by non-trained birth 4. Cervical and breast cancer screening programme attendants and 14.5% by relatives, friends or neighbours. Trained providers 8 5. Tetanus Toxoid for women of child bearing age assisted only 24.4% deliveries and institutional deliveries remained low, accounting for a mere 15% of all births. Moreover, the BDHS 2007 report reveals disappointingly low rates of essential newborn care practices. Survey findings highlighted that following delivery only in 6% of cases drying and in 2% of cases wrapping took place as per guidelines. Not surprisingly, the major cause of neonatal deaths is related to infection (sepsis, ARI and diarrhea). Despite the challenges, the uptake of antenatal care (ANC) has improved, with the proportion of women making four or more antenatal visits before delivery having increased. 3.2.2 Family planning and contraception

The increase in uptake of contraception by women in Bangladesh has been significant since the 1950s. Statistics show that the contraception prevalence rate (CPR) has increased from 40% in 1991 to 60% in 9 2008 whilst the total fertility rate (TFR) has decreased from 6.3 births in 1970-75 to a current rate of 3.3. In Bangladesh, 10.4% couples use traditional methods whilst 43.6% use modern methods. This is the reverse of that seen in Philippines, though in both countries conservative religious institutions similarly influence cultural and social norms. Of the modern methods, most women seem to prefer the pill. Injectables and female sterilization are the other popular forms of modern contraception and the government has promoted these methods through financial incentives. However, in Bangladesh childbearing begins early and the majority of women have a child by the age of 18. This is not surprising as 80% of women marry during adolescence. The negative fallout of early marriage and child bearing is reflected in the countrys neonatal mortality rate. The neonatal mortality rate 10 (NMR) in Bangladesh is 55 per 1,000 live births and higher among younger mothers (<20 years of age). Neonatal deaths account for 57% of all under-five deaths and 70% of infant deaths. Nationally, the unmet need for family planning has not seen enough reduction. In the poorest, there continues to be a high discontinuation rate for family planning methods and contraceptive prevalence seems to have declined. Also, there are significant disparities in services women receive according to rural/urban residence, education levels, household wealth and geographic location.

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UNICEF, 2010 Bangladesh Bureau of Statistics, Multiple Indicator Cluster Survey 2009, Government of Bangladesh Bangladesh and family planning: An overview , WHO fact sheet, SEARO Bangladesh Demographic and Health Survey 2007 5 December 2011

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Figure 3.2:

Contraceptive method use by married women in Bangladesh (from WHO, SEARO)

Source:

Bangladesh DHS, 1999/2000

3.2.3

Sexual rights and HIV

As in other South Asian countries, there is an environment of sexual conservatism in Bangladesh. Yet, nonnormative genders, such as, Hijras (transgenders) are part of the social fabric, albeit marginalised and subject to discrimination. Nationally, the heterosexual discourse of marriage and reproduction dominates the cultural norm and there is little space or tolerance for other sexualities and same sex orientation. Since 2000, however, some underground groups of gay men have been active socially, mainly relying on the 11 internet to meet others, though remaining closeted from family, friends and in the work place. It is feared that the conservative milieu and suppression of sexual rights has contributed to the disproportionate affection of some groups with HIV. Whilst overall HIV prevalence rate in the population is still low 12 (<.01%) , the rates are higher and increasing in risk groups like sex workers, injecting drug users and men who have sex with men. For example, in injecting drug users in Central Bangladesh, HIV prevalence rates have jumped from 1.4% to 4% to 8.9% over a three-year period. 3.3 The role of non-governmental organizations and civil society in Bangladesh

Civil society action in Bangladesh has a relatively recent history. A popular language movement which started in 1952, struggle for independence against Pakistan in 1971 and community emergency relief responses to a series of natural disasters are historical landmarks for civil society in the country. In th comparison, in the Philippines the roots of todays civil society trace back to the 18 century. Indeed, much of the discourse on civil society in Bangladesh emerged in the 1990s originating predominantly from the 13 agendas of international donor agencies and there continues to be ambivalence around the use of the term civil society organisations. For that matter, locally the construct of civil society organisation is debated and is contentious. Whereas, in the Philippines, the use of the term civil society organisations has gained currency and is pervasive. On the other hand, NGO is well accepted, understood by all and has

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Creating a public space and dialogue on sexuality and rights: a case study from Bangladesh, Sabina F Rashid et al, Health Research Policy and Systems, 2011 UNAIDS Global Report, 2010 13 On the difficulty of studying civil society: Reflections on NGOs, state and democracy in Bangladesh, David Lewes, SAGE Publications, 2004
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even been transliterated in the local language. Following the increased proliferation and status of the NGO sector, the government set up an NGO Affairs Bureau in 1990, which is housed in the Prime Ministers Office and is one of its key departments. The departments purpose is to regulate the activities of 15 civil society organisations; in other words, NGOs that receive foreign funds. The other form of civil society organisation is the mass organisation like the Bangladesh Mohila Parishad, a womans network organization. These organisiations do not come under the purview of the NGO Affairs Bureau and many of the mass organisations had their origins in the left movement of the 1970s and 80s. NGOs in Bangladesh have a reputation for providing extensive and innovative community services to the poorest. However, the role of NGOs can be ambiguous because they often overlap with the Governments. The NGO sector seems to have taken greater responsibility for public service provision and to run essential 16 public services. Also, many Bangladeshi NGOs engage in market-based activities, the experience of which has led to operational efficiency and increased professionalism in these NGOs and in the sector. No wonder donors have favoured NGOs as entry points into the country. Indeed, since independence, the economic and political conditions created by weak government service provision and readily available foreign donor funding has allowed NGOs to flourish in Bangladesh. Activists and development academics are unhappy that preoccupation with service provision and its associated lucrativeness has distracted Bangladeshi NGOs from a pivotal role that of advocate and independent watchdog. Constrained by restrictions that come with foreign funds, NGOs refrain from inputting or representing citizen voice into policy processes or to hold the state accountable for graft and corruption. NGOs also perceive government to be powerful and authoritative and avoid confrontation. The belief in the sector is that as long as NGOs carry out poverty alleviation and development oriented services without getting engaged in political matters, NGOs will be tolerated. As anticipated, any indication of political interest or engagement has attracted harsh measures. The recent government admonishment of Grameen Bank is given as an example. The dilution of voice and demand for accountability raises questions on the extent to which the sector has impact on health and development determinants. Researchers Anna T. Scurmann et al claim, Using social exclusion analyses we have concluded that whilst civil society (read NGOs) has potential to positively affect health equity in Bangladesh, there are many factors that curb its ability to affect change and be inclusive, and it is difficult to conclude that civil society activity is a likely determinant of health equity. Weak capacity, complex internal politics, unclear official status, intermittent funding, and general lack of awareness all undermine participatory civil society17 based efforts in health.

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Note: In West Bengal, India, where Bangla is also spoken, there is a separate term for NGO, which has the same meaning as in English. 15 The case study will use the term NGOs to represent civil society organisations as locally the terms NGO and CSO is used interchangeably and indeed distinctions are burred. 16 On the difficulty of studying civil society: Reflections on NGOs, state and democracy in Bangladesh, David Lewes, SAGE Publications, 2004 17 Civil society, health and social exclusion in Bangladesh, Anna T. Schurmann et al, J health Population Nutrition, 2009 293466///F/2 5 December 2011
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4. Political, institutional and policy environment in the health sector

4.1 Gender dimensions The Government of Bangladesh has taken womens health seriously and considers the health and wellbeing of women to be a key index for human development in the country. The governments plans to bring improvement in womens health and nutrition spans reduction of maternal and child mortality, primary health care services, reproductive health care services, mens responsibility in reproductive health, adolescent girls reproductive health, breast feeding, safe drinking water, ageing womens health and human resource development amongst others. Public expenditure for health in the country is equal for males and females albeit with acknowledgement that women and girls are more vulnerable to death and diseases compared to their male counterparts and require greater investment. In contrast, the private 18 sector expenditure on health greatly favours men. There are several formal avenues for the advancement of women in Bangladesh. The Ministry of Women and Children Affairs (MoWCA) has cross-sector responsibility to lead and coordinate governmental efforts towards women's emancipation with authority to safeguard the rights of women in the country. The National Policy for Women's Advancement, 2011 underpins government initiatives on gender equality and the Law Commission reviews all laws related to protection of women's rights and to provide recommendations to the government wherever required. Such public investment in women has shown results. The male to female population ratio has significantly improved from 106.1 in 1991 to 100.3 in 2011 and womens life 19 expectancy has increased from 58 years (1997) to 66.7 (2007). Moreover, awareness of gender equity has resulted in improvements in womens and girls literacy, life expectancy, political participation, schooling and in paid employment. 4.2 Governance and institutional factors

The Government of Bangladesh was a signatory of the health for all commitment in 1978, following which several endeavours were made to expand primary health care services in the country. However, Bangladeshs health care service structure remains predominantly elite-biased, urban-focused and curative-care-oriented. The curative-care approach is evident in budget planning and the way allocations for public health are made. The health budget is based on facility considerations, that is, allocations to a district are based on the number of beds in existing hospitals and health centres. As a result, investment in public health is disproportionately higher for hospital and health centre infrastructure and procurement of modern medical equipment with little attention paid to primary prevention and health education. Added, decisions related to health care investment and expansion is driven by populist politics. Furthermore, the resources for infrastructure investment are made available at the expense of the Essential Services Package, in turn affecting a range of maternal and child health services.

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Civil society, health and social exclusion in Bangladesh, Anna T. Schurmann et al, J health Population Nutrition, 2009 Sixth Five Year Plan, FY 2011-FY 2015, Planning Commission, Ministry of Planning, Government of the Peoples Republic of Bangladesh. 5 December 2011

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The public health care system in Bangladesh operates within a complex political administrative environment. The 20 There are no synergies administrative system is highly centralized and the between the budgetary and organizational structure of the health service mirrors that of the implementing arms of the public administrative set up in the country, which is pyramidal. government. Moreover, the system is lumbered with the legacy of a preSenior Officer, MOHFW independence and archaic health delivery model. In the public health system the Ministry of Health and Family Welfare (MOHFW) is the highest government institution headed by a Cabinet Minister. It is the second largest ministry in the country in terms of its manpower. A large cadre of civil servants assists the Health Secretary, a senior bureaucrat who is the administrative head of the ministry. The secretary has responsibility for implementation oversight, and the management, coordination and regulation of national health and family planning programs and policies. Within the ministry and under the Secretary there are two separate wings, a directorate for Health and a directorate for Family Planning. The Directorate for Health is the primary agency that takes responsibility for the implementation of national health policies and programs. The Director General of Health Services (DGHS) who heads this wing is in charge of a wide range of activities including procurement of material and manpower to supervision of medical schools. Nine functional Directors assist the Director General and under each of them there are several Deputy and Assistant Directors. The Directorate of Family Planning has a similar pyramidal structure. Functionally, these two wings run vertically with their own cadre of workers from the top to the grassroots. In addition to the two wings there are the secondary directorates of Nursing Services and Drug Administration attached to the Health Wing of MOHFW. All Directorates have their own office, separate workforce and are assigned to perform various health care related activities. The directorates tend to work in silos and there is little coordination to monitor public health activities.

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Key issues to health governance in Bangladesh, Fardaus Ara, Rajshahi University, 2008 5 December 2011

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Figure 4.1:

Bangladesh Progress Targets

Source:

Bangladesh Progress Report 2009, General Economics Division, Planning Commission, Government of Bangladesh

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4.3

Citizens voice and social accountability

In Bangladesh, funds of the Ministry of Health and Family Welfare are almost equally spent for the poor 21 and non-poor. However, large expenditure by other ministries, particularly the Ministry of Defense on hospitals and clinics is directed towards rich and urban areas. As a result, rural residents (approximately 80% of the population) receive less than half the public spending on health and merely 12% of the rural 22 population has access to any kind of public health service . The situation is made worse for the poor in rural areas by high levels of doctor absenteeism in government clinics and illegal user-fees. Despite attempts at health sector reform, citizens perceptions and usage of the health system has declined. Unmet 23 need increased from 3% to 9% of households. The responsibility for health planning lies with the central government. The Ministry of Health controls the health care system and there is devolution of limited powers to the local We are often asked by administration in districts and Upajillas. The Ministry in Dhaka government staff, Who are you allocates resources, sets targets and plans activities. Whilst to ask about government there are internal systems to ensure quality of care and finances? Who has given you the authority to do so? accountability, these are largely non-functional. Civil society engagement in planning is nominal or tokenistic. Yet, the DORP field worker Health, Nutrition and Population Sector Plan (HNPSP) 20032010 of the Ministry of Health and Family Welfare, Government of Bangladesh clearly states that civil society should be engaged to advocate and support the needs of the consumers. A limiting factor to citizen engagement may also be that high levels of poverty and low levels of education limit capacity and confidence to challenge state actions. Poor people in Bangladesh may not have the level of institutional 24 literacy or ability that is required to critically engage with the state. Added, there are prejudices about illiteracy and poverty. Policy-makers presume that the poor are ignorant of their health needs and are better guided by the opinion of experts. More recently, ministries have initiated consultation and sharing of information forums for NGOs. However, these forums are generally non-functional. For example, at the district level, the local administration has to organise monthly GO-NGO health coordination meetings. Yet, the local District Commissioner rarely calls these meetings and it is often NGOs who to their own interest have to take initiative and organise meetings on behalf of the administration. In the meetings government officials are mostly high-handed and the discussions are one sided, that is, NGOs have to report on their activities and not vice versa. There is rarely room for NGOs to question officials on public spend or performance. It is evident that citizens voices remain unheard in the administration or is simply too weak to have any influence and there are no mechanisms or ways to redress this. In contrast, the 1987 constitution and the Local Government Code in the Philippines act as a safeguard for citizen voice. There are no such legal frameworks in Bangladesh. Also, the institutional arrangement for implementing health programmes in the country seriously suffers from the absence of effective information flow. Lack of coordination within units of the Ministry of Health, lack of coordination between different ministries, lack of up to date and reliable data in the public domain and inadequate use of health information at the policy level have been added barriers to participatory

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Civil society, health and social exclusion in Bangladesh, Anna T. Schurmann et al, J health Population Nutrition, 2009 Civil society, health and social exclusion in Bangladesh, Anna T. Schurmann et al, J health Population Nutrition, 2009 What did the public think of health services reform in Bangladesh? Three national community-based surveys 19992003 Anne Cockcroft et al, Health Res Policy Syst. 2007 24 Literacy in Bangladesh: the need for a new vision, Education Watch, 2002 293466///F/2 5 December 2011

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governance. The recent passage of the Right to Information Act is an interesting development and should be a step towards greater state accountability. In Bangladesh, larger service provider NGOs despite significant reach and operations of scale have for the most part refrained from social accountability initiatives. The reason may be that the larger and influential NGOs rely on foreign funding and the accountability of these NGOs is towards the donor rather than the communities they work with. Nonetheless, there has been some engagement by NGOs in governmental budgeting mechanisms. The activities are mostly at the grassroots level by including local communities. For example, Transparency International and Development Organisation for the Rural Poor (DORP) are NGOs that have mobilised local communities to form local budget clubs. Bangladesh Budget Watch (BBW) oversees national level budget processes and tracks implementation with the help of an online platform.

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5. AHEAD Project Findings

5.1 Project Partners
25

The AHEAD project in Bangladesh was implemented by five local NGOs led by the Bangladesh Center for Communication Programme (BCCP). BCCP, which was set up by the John Hopkins University Centre for Communication specialises in social sector communication and has developed several health and nonhealth related national campaigns for the Government and NGOs. The other implementing NGOs in the AHEAD project were 1. Bangladesh Rural Advancement Committee (BRAC): www.brac.net 2. DRISTY: a Chittagong based multi-sectoral NGO, which has recently initiated a project to raise awareness on the Right to Information Act in communities. http//dristyctg.topcities.com 3. GHASHFUL: a Chittagong based organisation that works in education and micro-finance. www.ghashful-bd.org 4. Marie Stopes Clinic Society Bangladesh: http://mariestopes-bd.org/ The AHEAD implementing NGOs have considerable experience in service delivery provision mainly in the sectors of health, education, microfinance and community development. The levels of exposure to sexual and reproductive health activities in these NGOs vary. At the minimum, the organisations have been 26 implementing awareness-raising activities for the GFATMs HIV/AIDS programme in Bangladesh. Marie Stopes, on the other hand, primarily works on the improvement of sexual and reproductive health and wellbeing of women and men and adolescents in Bangladesh. 5.2 Evaluation principles and methods

The AHEAD project in Bangladesh was evaluated in September 2011. The evaluation aimed to assess the contribution of the project to sexual and reproductive health budget advocacy in Bangladesh and highlight identifying factors that support or hinder success in such an endeavour. The evaluation was guided by a 27 results framework , which sets out a logical chain that links inputs, intermediary outputs and outcomes at the country level. The inputs and project activities were based on an advocacy plan developed by AHEAD organisations at a workshop in Kathmandu in 2010. As the timeline for the project was brief, measurement of change at the impact level was not planned in the evaluation. However, recognising that budget advocacy can be influenced significantly by contextual factors, the evaluation exhaustively considered the aspects of external environment that could have bearing on the projects success. Sections 2 & 3 of this report provide that contextual background. The approach to field work was qualitative by design. Semi-structured interviews were conducted with a variety of stakeholders - project implementers, project target audience including media personnel and public administrators, and champions active in the field of sexual and reproductive health and rights. Please see Annex 3 for a full list of interviewees. The interviews were based on sets of open-ended questions. The question sets covered four areas. These were contextual factors that influenced the project; project results and outcomes; challenges and lessons learned from implementation of activities; and

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In the case study AHEAD organisations refers jointly to these five implementing organisations. The Global Fund to fight AIDS, Tuberculosis and Malaria WHO advocacy project evaluation framework, HLSP, 2011 5 December 2011

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Key AHEAD activities in Bangladesh A core budget advocacy team is formed. The core team meet at regular intervals to establish a platform to actively advocate for increased resources for SRH in Bangladesh. A working group of SRH champions is identified. The working group is comprised of senior SRH experts, NGO activists, former bureaucrats and media personnel. One on one meetings with senior officials in the Ministry of Health and Family Welfare. A position paper on public allocation and expenditure on SRH is developed. The paper is disseminated at a stakeholders workshop. The key note speaker for the workshop is a leading health economist in Bangladesh. A round table meeting is organised. The round table is attended by officials from several ministries, donor representatives, NGO activists and media personnel. A set of recommendations is presented at the round table. The round table gets wide media coverage from national dailies.

recommendations for next steps. In addition, project documentation and existing literature on topics, such as, SRH, civil society and social accountability in Bangladesh was reviewed. During field work it was apparent that there would be considerable constraint to the use of an evaluation framework based on a results chain. The reason being the results chain was underpinned by a time bound activity based advocacy action plan. Initially, the AHEAD organisations had drawn up an eighteen month advocacy plan; however, the grant available for the project was for 12 months and due to delays in receiving government permission to implement the project, activities could be carried out only for eight months. As a result several activities proposed in the action plan were modified or dropped. 5.3 5.3.1 Activities and interim outputs Capacity and tools development

When budgets were announced, I would not pay as much attentionnow I do. I realise that even at our own level (community) we can advocate on budgets!

Implementing NGOs in Bangladesh became aware of the capacity needs for policy engagement at a national level. The three-country AHEAD project relied upon the capacity of local civil society organisations to advocate and engage in policy with the national government. In the Philippines, the core work areas and objective of the majority of AHEAD organisations is advocacy and policy engagement with A power point presentation is the federal government. However, in Bangladesh, developed for the round table selected AHEAD organisations focus on service meeting. This becomes a tool for delivery and IEC (information, education, budget advocacy. communication) whilst engaging in national policy work nominally. During the evaluation it was not evident what criteria were used to select the NGOs. Irrespective of criteria and process, NGOs in Bangladesh as highlighted in section 3 indeed do not commonly engage in national level advocacy and policy. The advocacy that NGOs carry out is downstream and relates to community mobilisation for demand creation and utilisation of services at the grassroots. In comparison, in the Philippines, there has been a long history of reproductive health advocacy by CSOs with the federal government. For that matter, most CSOs working on SRH in the Philippines focus on national level advocacy and policy engagement.

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The AHEAD project introduced budget advocacy on sexual and reproductive health to leading national and regional NGOs in Bangladesh. The project not only drew to attention the topics of budget advocacy and social accountability but also to the growing importance of advocacy and policy engagement by NGOs in the countrys changing development and economic scenario. As a result of the project, AHEAD organisations had gained insights into the countrys budgetary processes and learn about budgetary mechanisms. The organisations acknowledged that more could have been done but felt confident that policy initiatives and budget advocacy could be taken forward through their existing portfolio of work. BCCP created a national forum for budget advocacy on sexual and reproductive health for the first time in the country by organising two high-level stakeholder meetings. In the meetings, valuable exchange of concepts, knowledge and experience took place. Senior government bureaucrats explained the budgeting process in government departments; health economists highlighted the gaps in national and local planning processes; and, SRH service providers identified challenges in grassroots implementation. Additionally, media personnel participated actively in the meetings and provided wide coverage to social accountability and budget advocacy issues on SRH in the press. Many of the experts who participated in the meetings were keen for follow-up and to provide momentum for budget advocacy and social accountability initiatives in the country. DSW and AHEAD organisations may want to consider how to support these expert individuals and organisations in the future. BCCP commissioned a background paper and developed power points on sexual and reproductive health budgetary processes and issues. These are useful awareness raising tools, which explain fiscal matters in relation to government policy and can be used in the future. However, there appears to be significant knowledge gaps on sexual and reproductive health and rights issues linked to public finances and there is need for further policy research and analysis in this area. 5.3.2 Strategy and knowledge development The budget advocacy forums led to an informal network comprising of AHEAD organisations, peer NGOs, subject experts, media personnel and government officials. The informal network has the potential to act as resource pool on SRH budget advocacy in future initiatives. Participants who attended the stakeholder meetings now know who to approach for expertise on advocacy and sexual and reproductive health policy matters. The AHEAD project in Bangladesh successfully linked with Development Organisation of the Rural Poor (DORP), an organisation active in local budget advocacy. Interaction with DORP helped AHEAD organisations learn about entry points and AHEAD has influenced our strategic approaches to dealing with local administrators thought process this may on budget issues especially at the Upajilla level. seem a small outcome but is critically important for us as an BCCP has identified two key strategic directions that the organisation! project could have taken to overcome challenges faced CEO, BCCP during implementation of the project. These are a) Civil society participation in national sexual and reproductive health policy development is novel and nascent in Bangladesh. For effective
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engagement to take place it is important for the government to learn and be aware of concepts of participation and accountability alongside NGOs. The government should have been included as an AHEAD project partner. This would have critically helped with awareness raising and knowledge building in relevant government departments. b) An advocacy plan need not be linear in its approach. The AHEAD organisations in Bangladesh conceived the advocacy action plan as a set of activities to be implemented sequentially phase-byphase. As a result, several key activities that could have taken place concurrently during the project period albeit shortened were not carried out. It would have helped to identify the critical interdependencies between various activities in the plan and to explore how such activities could have been implemented side by side, if needed. On hindsight, the AHEAD organisations could have also built links with other social accountability initiatives that were not identified in the advocacy action plan such as those by Transparency International or the CIDA funded PLAGE project. There could have been important learning from the experience of these initiatives for the SRH sector. PLAGE, which works directly with the Government of Bangladesh, has been successful in building capacity of various ministries in gender responsive budgeting. 5.4 5.4.1 Project Outcomes Participation and ownership

In the AHEAD project in Bangladesh, BCCCP as lead organisation implemented and managed all activities. The other NGOs participated in activities on invitation from BCCP. Shared responsibility and division of labour as seen in the project in the Philippines was not evident. The relatively small size of the grant and composition of the group of implementing organisations were allegedly restricting factors to joint responsibility and proactive engagement. The other barrier may have been that AHEAD organisations in Bangladesh do not share common agendas in relation to sexual and reproductive health, gender or womens issues. Unlike in the Philippines, a consortium model did not emerge nor was a partnership approach evident. Another significant gap in the project was the absence of capacity and national level experience in SRH advocacy and policy engagement with budgetary expertise amongst the implementing NGOs. In Bangladesh, there are several networks of NGOs yet few examples of single-issue coalitions or NGO collaborations. Whereas, in the Philippines such coalitions and consortium are plenty and widespread. It can be speculated that if a coalition model as seen in AHEAD in the Philippines had emerged, the dynamic within the group and outcomes for AHEAD in Bangladesh may have been different. Furthermore, the sustainability of the project without future funding support is doubtful. In the context of Bangladeshs civil society, it is premature to expect outcomes related to participation and ownership in a year-long project. Realistically, the AHEAD project should be viewed as an initial preparatory phase or setting the ground for future social accountability programmes. To that effect, AHEAD has successfully raised awareness on national and local budgetary processes with a range of strategic stakeholders in the country. 5.4.2 Transparency and accountability

At the national level engaging with government on transparency and accountability is a challenge because of its highly centralised and pyramidal administrative structure as described earlier (please see section 3.2). Government departments may organise consultation meetings to which NGOs are invited, however, these
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meetings tend to be ad hoc. On the other hand, it is common for NGOs to invite senior government officials to workshops and stakeholder meetings. The purpose of such workshops often is to showcase the NGOs activities and to attract media attention. Also, there are several attitudinal barriers to accountability. Accountability in government quarters is perceived to be always upwards i.e. to the Minister and foremost to the Prime Minister but not down to the community and the citizen. Amidst such challenges, a key contributor to AHEAD, the Development Organisation of the Rural Poor (DORP) has successfully engaged with local government officials to track budgets in Upajjilas (subdivision) and Unions (in contrast, the ABI in Philippines with which AHEAD organisations had collaborated focuses on macro and national level budgetary processes). DORP set up a Health and Family Planning Budget Club programme to directly involve communities in budget participation and transparency with local government officials. Community elders were recruited to form Budget Clubs and trained on budget tracking tools developed by DORP. As DORP focusses on the poorest section of societies in rural and semi-urban areas, simple tools and methods were developed by the organisation to help explain budgets in lay terms and for which literacy is not a requirement. The local clubs meet regularly on a quarterly basis with local health officials and elected representatives to discuss utilisation of budgets. This has helped DORP monitor how much of the resources allocated to Upajjilas and Unions have been spent directly for the poor. In Bangladesh, the government has committed that 65% of public resources allocated in the Essential Services Package should go the poorest. Based on the information it receives from the community, DORP has published annual reports since 2006 on levels of spend, the gaps and the solutions proposed by communities to help better utilisation of public funds. Linking with DORP has allowed the AHEAD organisations to learn of different avenues and entry points for budget tracking. The NGOs now have the learning to explore at grassroots how the community groups (for example womens groups) they support can fruitfully engage with the administration on allocation and proper utilisation of public funds.

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6. Conclusion and lessons learned

Funders need to invest in capacity building before embarking on outcome oriented budget advocacy initiatives. It cannot be assumed that there will be pre-existing local capacity on SRH policy engagement and budgetary expertise in project countries. In Bangladesh, where SRH policy work is nascent, it would have been key for the participating organisations to be provided ongoing technical and strategic input through the project period. The AHEAD organisations had limited experience of working in coalitions on policy and the project organisations felt challenged to carry out advocacy in a new area. There were no models to draw upon. Also, the assumptions that local implementing organisations will be motivated to engage with government on policy can be mistaken. NGOs can view advocacy with government to be confrontational. In Bangladesh, the AHEAD NGOs have focussed on service delivery and are mainly resourced by foreign funds. The organisations do not necessarily feel there is need to create spaces and engage with government on policy. The immediate and greater need often is for improved utilisation and strategic allocation of public funds as opposed to increase in the total envelope of financial resources for SRH activities. In Bangladesh and in the Philippines, the issue or concern was not that of inadequate resources. In both countries, there was underutilisation of public funds allocated in the health and planning budgets. Also, allocations were often ad hoc, politically motivated and not strategically thought through. Civil society organisations in the SRH sector have to be strategic and need to strengthen their financial analysis acumen and learn how to track utilisation and rational allocation of funds apropos to public health needs. Once such capacity is enhanced, local CSOs are in a better position to identify where the shortfalls are and to advocate for increased resources or reprioritisation of resources. Measuring results in advocacy projects is challenging. Using standardised and high-level results frameworks has limitations. Whilst having an evaluation framework helps with structured assessment, it needs to be calibrated according to context and local project realities. Context is key in advocacy and policy initiatives and rigorous contextual analysis should be undertaken prior to embarking on such initiatives. Robust contextual analysis will ensure that project targets, purpose and goal are relevant and realistic. Local level budget advocacy has to be linked to issues that are self-evident and can be addressed practically. Local governments better engage with CSOs when genuine concerns of the community which can be easily linked and addressed through provisions made in governmental policy, protocols and budgets are raised. The AHEAD evaluation in Bangladesh gives rise to several questions in relation to the overarching concept of participation and ownership and its link with accountability. These questions warrant further exploration and inquiry. The evaluation has also highlighted how the socio-cultural and religious dynamic in a country, the origins of civil society organisations and movements, and history of civil society engagement with government can impact advocacy work. Comparisons of outputs and outcomes with the AHEAD project in Philippines has highlighted significant differences, the reasons for which may be attributed to differences in context, the way the programme was developed in the two countries and preparedness of the AHEAD organisations.

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Annex 1: MDG Progress Score Card

Figure A.1: MDG progress score card

Source: Planning Commission, Government of Bangladesh

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Annex 2: Strategy decisions lessons learned

Strategy SRH Budget advocacy is in synch with organisation objectives What worked What may or did not work Organisations have RH focus. When SRH issues are not core to the organisation and budget advocacy becomes a standalone project Core business is service provision. Service provider organisations are often adept at downstream advocacy with communities to enhance uptake. However, upstream advocacy requires a different set of skills and resource. If approach is to outsource. Not having carried out adequate research and analysis on issues. Not having the ability to identify and highlight a key issue, which resonates with government and impacts the SRH rights of people. Vertical and silo activities; project implementers do not have the right skills, competencies and experiences. Project works in isolation and not collaboratively. Does not draw upon strengths that already exist. In an autocratic and feudalistic system when access to lawmakers is challenging. Inviting media to only showcase own profile and activity not about issue and how it affects citizens. Token and superficial engagement with senior government officials Not having a legal basis for making a case

Build on existing advocacy capacity Organisation (selection) Acquire budget related skills & competencies Underpin initiative with research and analysis

Advocacy and policy engagement with government is core business. Philippines CSOs have significant experience of advocating for RH Bill with government.

Learning through doing (engaging in ABI) Policy research mainstay of work. (e.g. budget analysis strengths of PLCPD and Social Watch) Reproductive and contraceptive rights for the poor RH Bill in Philippines

The issue (identification)

Critical, felt and need based

Core project group

Consortium approach, bringing in complementarity of strengths

Coalitions and partnerships (being strategic) Strategic alliances e.g. with Social Watch in Philippines

Targeting champions (ensuring leverage)

Lawmakers

Mapping champions and opponents of the issue. Using media to highlight issue providing human interest stories, data

Media

Administrators Engagement with government

Understanding and gaining insight on the complexities of a government system Advocacy and policy engagement embedded in legal provision (constitution, right to information act, other laws and international commitments)

Laws and policies

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Annex 3: List of Interviewees

Name of the Informants 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Mohammad Shahjahan Yasmin Khan Dr. Nazrul Haque Tawfique Jahan Ganesh Chandra Sarker Md.Muniruzzaman Helal Uddin Mahbub Anjuman Banu lima Towhidul Bari Selina Parveen Dr. Tahmina Mirza Mohammad Zobair Hasan Quazi Suraiya Sultana Dr. Salauddin Ahmed Dr.Humaira Begum Iftekher Polash Tarik Hasan Shahriar Jewel Mostafiz Dr. Jahir Uddin Ahmed Mohammad Zobair Hasan Md. Amir Khasro Dr. M. A. Sabur M.M. Reza A. K. M Nurun Nabi Ayesha Khanam Dr. Long Chhun Md. Hafizur Rahman Ranjan Karmaker Ubaidur Rob A. K. M Zafarullah Organization/Designation CEO,BCCP Director, BCCP Deputy Director, BCCP Consultant, BCCP Director IEM, Family Planning Directorate Marie Stopes/ Project partner Dristy/ Project partner Ghashful/ Project partner CWFD/ Project partner HASAB/ HIV alliance Plan Bangladesh DORP RH STEPS Social Marketing Company RTMS FPAB Daily Sun/ Media Kaler Khantho/ Media Consultant/ Former Director DGFP DORP DORP Consultant Consultant/ former secretary Ministry of Health Professor & Project Director, Department of Population Science President, Bangladesh Mohila Parishad Medical officer, Reproductive Health-WHO Deputy Chief, Health Economics Unit, MoH& FW Executive Director, Steps Towards Development Country Director, Population Council Consultant, Population Council

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Annex 4: Documents reviewed

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. ADB (Aug 2008), Overview of NGOs and civil society: Bangladesh, Civil Society briefs. AHEAD (2011), Final report guidelines, DSW. AHEAD (Jan 2011), Report, Stakeholders meeting, Dhaka. AHEAD (Jan 2011), List of participants, stakeholders meeting, Dhaka. AHEAD (Feb 2011), List of participants, round table discussion, Dhaka. AHEAD (Feb 2011), Programme schedule, round table discussion, Dhaka. AHEAD (Jan 2011), Programme schedule, stakeholders meeting, Dhaka. AHEAD (Feb 2011), Report, Roundtable, Dhaka. AHEAD (Feb 2011), Presentation, Roundtable, Dhaka. AHEAD (Feb 2011), Situation Analysis, Roundtable, presentation, Dhaka. Anna T. Schurmann and Simeen Mahmud (Aug 2009), Civil Society, Health, and Social Exclusion in Bangladesh, J HEALTH POPUL NUTR. Anne Cockcroft et al 2007, What did the public think of health services reform in Bangladesh? Three national community-based surveys 19992003, Health Res Policy Syst Bangladesh Bureau of Statistics, Bangladesh Maternal Mortality and Morbidity Survey 2001, Government of Bangladesh Bangladesh Bureau of Statistics, Sample Vital Registration System 2008, Government of Bangladesh Bangladesh Bureau of Statistics, Multiple Indicator Cluster Survey 2009, Government of Bangladesh Bangladesh Bureau of Statistics, Bangladesh Demographic and Health Survey 2007, Government of Bangladesh Bangladesh Bureau of Statistics (2011), Population and Housing census (preliminary results), Government of Bangladesh Canadian International Development Agency (2007), Civil Society and Aid Effectiveness: concept paper. David Lewis (2004), On the difficulty of studying .civil society: Reflections on NGOs, state and democracy in Bangladesh, Contributions to Indian sociology , SAGE Publications Directorate General of Health Services (2010), Maternal Health programs in Bangladesh, Ministry of Health and Family Welfare, Government of Bangladesh. Dr. Muhammod Abdus Sabur (Feb 2011), Sexual and Reproductive Health Rights in Public Sector of Bangladesh: Program and Budget, position paper, Dhaka. Dr. Muhammod Abdus Sabur (Feb 2011), Sexual and Reproductive Health Rights in Public Sector of Bangladesh: Program and Budget, presentation, Dhaka. DSW (2011), AHEAD final project report, Bangladesh, Brussels. DSW (2010), AHEAD Advocacy Action Plan, Bangladesh, Brussels. Education Watch (2002), Literacy in Bangladesh: the need for a new vision. Fardaus Ara (2008), Key Issues to Health Governance in Bangladesh, International Conference on Challenges of Governance in South Asia, Kathmandu, Nepal. Kaler Kantho (2011), translated local newsprint article, Dhaka. Government of Bangladesh (2011), National Womens Welfare Policy, Bangla. http://www.unicef.org/bangladesh http://www.worldbank.org.bd Institute of Development Studies (2010), Review of Impact and Effectiveness of Transparency and Accountability Initiatives: Synthesis Report. Ministry of health and Family Welfare (2009), Bangladesh Population Policy, Bangla, Government of Bangladesh. Ministry of Finance (2011), Finance division, Gender Budgeting Report 2011-2012, Government of Bangladesh.
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34. Ministry of Health and Family Welfare (Sept 2010), Planning Wing, HEALTH POPULATION & NUTRITION: SECTOR STRATEGIC PLAN (HPNSSP) 2011 2016 (Draft), Government of Bangladesh. 35. Ministry of Planning, Planning Commission (2009), General Economics Division, The Millennium Development Goals: Bangladesh Progress Report 2009, Government of Bangladesh. 36. Ministry of Planning, Planning Commission, Sixth Five Year Plan, FY 2011-FY 2015, Government of the Peoples Republic of Bangladesh. 37. Ministry of Planning, Planning Commission (2009), General Economics Division, National Strategy for Accelerated Poverty Reduction II: 2009-11, Government of Bangladesh. 38. Overseas Development Institute (2007), Voice for accountability: Citizens, the state and realistic governance, Initial findings from an innovative evaluation of donor interventions, London. 39. Oxford Policy Management (2008), BANGLADESH COUNTRY CASE STUDY: CITIZENS VOICE AND ACCOUNTABILITY EVALUATION, Swiss Agency for Development and Cooperation. 40. Sabina F Rashid et al (2011), Creating a public space and dialogue on sexuality and rights: a case study from Bangladesh, Health Research Policy and Systems, 2011 41. UNAIDS Global Report, 2010 42. WHO, Bangladesh and family planning: an overview, Regional office for South East Asia, Delhi. 43. World Bank (2005), Poverty Reduction and Economic Management Sector Unit, South Asia Region, The Economics and Governance of Non Governmental Organizations (NGOs) in Bangladesh.

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