World Bank Document...This report Is based on the findings of an approloal mission which visited Bangladosh In November 1990 comprising 47 msmbers of the Bangladesh Population and

Document of

The World Bank

FOR OFFICIAL USE ONLY

Report No. 9400-BD

STAFF APPRAISAL REPORT

BANGLADESH

FOURTH POPULATION AND HEALTH PROJECT

MAY 20, 1991

Population and Human Resources DivisionCou-. ry Department IAsia Region

This document has a restricted distribution and may be used by recipients only in the performance oftheir official duties. Its contents may not otherwise be disclosed without World Bank authorization.

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CURRENCY EQUIVALENTS

Currency Unit = Bangladesh Taka (Tk)US$1.00 = Tk 35.79 (November 24, 1990)

FISCAL YEAR

July 1 - June 30

FOR OFmFCIAL USE ONI

ABBREVIATIONS

ADB - Asian Development BankAFPO - Assistant Family Planning OfficerAIDS - Acquired Immune Deficiency SyndromeARI - Acute Reapiratory InfectionBBS - Bangladesh Bureau of StatisticsBFRP - Bangladesh Fertility Research ProgramBFS - Bangladesh Fertility SurveyBIDS - Bangladesh Institute for Development StudiesBPDU - Building Planning and Design UnitBSCIC - Bangladesh Small and Cottage Industries CorporationCBR - Crude Birth RateCDD - Control of Diarrheal DiseaseCDR - Crude Death RateCIDA - Canadian International Development AgencyCMC - Construction Management CellCME - Center for Medical EducationCPR - Contraceptive Prevalence RateCPS - Contraceptive Prevalence SurveyDD - Divisional DirectorDDS - Drug and Dietary SupplementDG - Director-GeneralDNS - Directorate of Nursing ServicesDPHN - District Public Health NurseDPT - Diphtheria/Pertussis/TetanusEEC - European Economic CommunitiesEPI - Expanded Program of ImmunizationFP - Pamily PlanningFPA - Family Planning AssistantFPCST - Family Planning Clinical Surveillance TeamsFPO - Family Planning OfficerFWA - Family Welfare AssistantNwC - Family Welfare CenterFWV - Family Welfare VisitorFWVTI - Family Welfare Visitor Training InstituteGOB - Government of BangladeshGTZ - Deutsche Gesellschaft fur Technische Zusammenarbeit (Germany)HA - Health AssistantHEB - Health Education BureauICB - International Competitive BiddingICDDR'B - International Center for Diarrheal Disease Research in BangladeshICRH - Institute for Cancer Research HospitalIEDCR - Institute of Epidemiology, Disease Control and ResearchIEM - Information, Education and MotivationIMR - Infant Mortality RateIPGMR - Institute for Post-Graduate Medicine and ResearchIPH - Institute for Public HealthIUD - Intrauterine DeviceKfW - Kreditanstalt fur Wiederaufbau (German:

This document has a restricted distribution and may be used by recipients only in the performanceof their official duties. Its contents may not otherwise be disclosed without World Bank authorization.

LCB - Local Competitive BiddingLGEB - Local Government Engineering BureauMA - Medical AssistantMATS - Medical Assistant Training SchoolsMCH - Mother and Child HealthMCMU - Maintenance and Construction Management UnitMCWC - Mother and Child Welfare CenterMDU - Management Development UnitMI - Medical InspectorMIS - Management Information SystemMMR - Maternal Mortality RateMO - Medical OfficerMOHFW - Ministry of Health and Family WelfareMSR - Medical and Surgical RequisitesNFPFS - National Family Planning and Fertility SurveyNGO - Non-Government OrganizationNIPORT - National Institute of Population Research and TrainingNIPSOM - National Institute of Preventive and Social MedicineNNC - National Nutrition CouncilNORAD - Norwegian Agency for Development CooperationNRR - Net Reproduction RateODA - Overseas Development Administration (United Kingdom)PDEU - Population Development and Evaluation UnitPHC - Primary Health CarePHO - Population and Health OfficePPO - Population Program OfficeRD - Rural DispensaryR&R - Reprogramming and RebudgetingSIDA - Swedish International Development AuthoritySMC - Social Marketing CompanySTD - Sexually Transmitted DiseasesRTC - Regional Training CenterTBA - Traditional Birth AttendantTFR - Total Fertility RateUHC - Upazila Health Center/ComplexUHFPO - Upazila Health and Family Planning OfficerUMR - Under-five Mortality RateUNFPA - United Nations Population FundUNICEF - United Nations Children's FundUSAID - United States Agency for International DevelopmentVDP - Village Defense PartyWHO - World Health Organization

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BANGLADESH


Table of Contents

Page No.

Credit and Project Summary . . . . . . . . . . . . . . . . . . . . . . . . iv

Basic Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. vii

I. THE POPULATION AND HEALTH SECTOR . . . . . . . . . . . . . . . . . . 1A. Introduction . . . . . . . . . . . . . . I . . . . . . . . . . . 1B. Background on the Population and Health Situation . . . . . . . . 2C. Overview of the National Population and Health Program . . . . . 3D. Objectives and Strategy under the Fourth Five-Year Plan . . . . . 10E. External Financing . . . . . . . . . . . . . . . . . . . . . . . 12F. IDA's Role and Sector Lending Strategy . . . . . . . . . . . . . 13

II. THE PROJECT . . . . . . . . . .. . . . .. . . . . . 14A. Objectives and Strategies . ..... . . . . . . ... .. ... 14B. Summary Project Description . ........ ... . . . . . . 16C. Detailed Project Description . . .. . . . . . . . ..... . . 19D. Environental Considerations . . ....... . . .. . . .. . 44

III. PROJECT COST, FINANCING, DISBURSEMENTS, AND PROCUREMENT . . . . . . . 45A. Project Cost ....... ...... . . . . . . . . . . . . 45B. Financing . . . . . . . . . ... . . . . . . . . . . .. .. 47C. Disbursements . . . . ... . . . . . . 49D. Procurement . . . . . . . . * . .. . . . . . . . . . 50

IV. IMPLEMENTATION AND SUPERVISION .... ........ . . . . . . . . 52A. Project Organization and Management . . . . . . . . . . . . . . . 52B. Project Management and Supervision Support . . . . . . . . . . . 53C. Monitoring ard Biannual Reviews . . . . . . . . . 5 . 4. . . 54D. Accounts and Audits ...... . . .. . .. . ....... . . 56

V. BENEFITS AND RISKS ...... .. .. .. .. . .. . . .... 57

VI. AGREEMENTS REACHED AND RECOMMENDATION ............. . . . 58

This report Is based on the findings of an approloal mission which visited Bangladosh In November1990 comprising 47 msmbers of the Bangladesh Population and Health Consortium for the FourthPopulation and HNaIth Project representing IDA, Australia, Blglum, Canada, the European EconomicComunitioe Germany, Japan, the Netherlands, Norway, Sweden, and the United Kingdom, 10r.prosentativose of UNFPA, UNICEF and HO which will act as executiln agencies to the Consortium,4 representatives of FAO and ILO, and 7 representatives of Denmark, Switzerland and the UnitedStates as observors. Th. IDA team Included Messrs./Mos. C. 0. Pann.nborg (Mission Leader/TaskManager), P. Valad (Projocto Officer) S. K. Sudhakar (Population Specialolt), P. Cowers (HealthSpeciallt), A. M. Haque (Program Officer), L. Kiang (Operations Assistant), K. A. Pisharoti(Consultant, Population), A. I. Begum (Consultant, MCH), S. Sundararajan (Consultant, PublicHoelth) and L. Dunaway (Consultant, Cofinancing). This report has ben endorsed by Menrs. S.As numa (Director, ASIDR) and M. Karchor (Chlef, ASIPH). The Poor Reviewers for the project wereMessrs. S. Sinding (Senior Adviser, Population, PHRDR), W. de Coyndt (Senior Public HealthSpecialist, ASTPH), and C. Walker (PHN Specialist, EMUPH).

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AN4NEXES Page No.

Annex 1: Core Investments for Population, Health and Edlucation . . . . 62

Annex 2s Contraceptive Prevalence, South Asia . . . . . . . . . . . . 74

Annex 3: Total Fertility Rates . . . . . . . . . . . . . . . . . . . . 75

Trends in Age-Specific Fertility Rates. . . . . . . 76

Annex 4: Trends in the Infant Mortality Rates . . . . . . . 77

Annex 5: Infant Mortality: Neonatal . . . . . . . . . . . . . . . . .. 78: Postneonatal .. . . . . . . . . . . . . . . 79

s Infancy . . . . . . . . . . . . . . . . . 80Annex 6: Child Mortality t 1-4 years .y.e ................ . 81

s 5-14 years. . . . . . . . . . . . . . . . . 82

Annex 7: Distribution of Defacto Population by Age,Sex and Urban/Rural Residence . . . . . . . . . . . . . . . 83

Annex 8: Distribution of Adult Deaths (other than Maternal)by Cause and Sex . . . . . . . . . . . . . . . . . . . . 84

Annex 9: Adult Mortality . . . . . . . . . . . . . . . . . . . . 8Annex 10: Disease Categories of Patients Presenting to

Clinics for Treatment . . . . . . . . . . . 86

Prevalence of Illness in a r.ohort of Rural

Bangladesh Children. 87

Annex 11: Enumerated Population, By Age and Sex.. . . 88Annex 12: Causes of Maternal Mortality . . . . . . . . . . . . 89

Annex 13: An Overview of the Population and Health Systemin Bangladesh . . . . . . . . . . . . . . . 91

Annex 14: Knowledge of and Visit by Female Workers. . . . . . . . . . . 97

Annex 15: Current Users of Specified Methods of Contraceptives. . . . . 98Annex 16: Distribution of Currently Married Women Who Want

No More Children or Have Been Sterilized. . . . . . . . . . 99

Annex 17: Issues in the Population Sector . . . . . . . . . . . . . . . 100

Annex 18: In-Patients at Health Facilities. . . . . . . . . . . . . . . 101

Out-Patients at FP and Health Facilities. . . . . . . . . . . 102

Annex 19: Comparative Indicators of FP and Health . . . . . . . . . . . 105

Annex 20: List of Low Priority Projects .... . . . . . . . . . .. .106

Annex 21: Contraceptive Method Mix .... . . . . . . . . . . .. . . 107

Annex 22: Summary of Previous IDA-Assisted Population and

Health Projects . . . . . . . ........ . . . . .. . 108Annex 23: Bangladesh: A High Point in Donor Coordination. . . . . . . . 109

Annex 24: Indicators for Monitoring Women in Development Strategy . . . 112

Annex 25: Nursing Services . . . . . . . . . . . . . . . . 115

Annex 26: Institute for Child Health . . . . . . . . . . . . . . . . . 117

Annex 27: Technical Assistance Projects . . . . . . . . . . . . . . . . 120

Annex 28: The Three Women's Programs. . . . . . . . . . . . . . . . . . 123

Annex 29: Population and the Environment. . . . . . . . . . . . . . . . 125

Annex 30: Project Cost Summary. . . . . . . . . . . . . . . . . . . . . 127

Project Components by Year .... . . . . . . . . . . . . . 128

Annex 31s Summary Account by Year . . . . . . . . . . . . . . . . . . 129

Summary Account by Project Component. . . . . . . . . . . . . 130

Annex 32: Costs at Appraisal of the First, Second, Third and

Fourth Bangladesh Population and Health Projects . . . . . 135

Annex 33: Financing Plan By Project Components. . . . . . . . . . . . . 136

Financing Plan by Summary Account . . . . . . . . . . . . . . 138

Annex 34: Forecast of Annual Expenditures and Disbursements . . . . . . 140

Annex 35: Project Implementation Schedule - Summary . . . . . . . . . . 141

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Page No.

CHARTS

Chart ls Organization of the Ministry of Health and FamilyWelfare . . . . . . . . . . . . . . . . . . . . . . . . . . 142

Chart 2s Organization of the Rural Health and Family WelfareProgram . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Chart 3: NIPORT Organization for Training. . . . . . . . . . . . . . . 144Chart 4: MCH Program Organization . . . . . . . . . . . . . . . . . 145

IBRD 22837: Bangladesh Fourth Population and Health Project

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BANGLADESH


Credit and Project Summary

Borrower: People's Republic of Bangladesh

Beneficiary: Ministry of Health and Family Welfare

Amount: SDR 1.33.2 million (US$180.0 million equivalent)

Terms: Standard with 40 years maturity

ProjectDescription: The project, which cover a five-year time slice of GOB's

development program in population and health (1992-96),has four main components: (a) strengthening FP servicedelivery; (b) strengthening health services delivery; and(c) improving supportive activities to the delivery of FPand health services; and (d) women's and nutritionprograms. It will strengthen FP service delivery byimproving access to FP services, strengthening MCHservices, enhancing clinical service delivery and FP/HCHquality assurance, imparting in-service training ofupazila and district staff in FP/MCH, construction andrenovation of FP/MCH facilities, and marketing ofcontraceptives through the private sector. The projectwill strengthen health service delivery through increasingthe range of maternal and neonatal health care,strengthening nursing and medical education, introducingmedical quality assurance, supporting medical research,strengthening disease prevention and control, developingurban primary health care, continuing and expanding schoolhealth programs, improving district and upazila healthfacilities, and improving the utilization of UpazilaHealth Centers. In support of the fir't two components,the project will assist in strengthening informationsystems, improving FP and health management, expaindingcommunications programs, supporting NGO activities, anddeveloping innovative projects. Finally, the project willassist continuation of the three women's programs financedunder the previous three projects and will strengthen anddevelop the National Nutrition Council, in anticipation ofa substantial program of nutrition interventions.

Benefits andRiskss The project will have a positive impact on family welfare,

particularly among women and children, through greaterbirth spacing and better health status. In the long-term,the intense pressure on the limited land and naturalresources due to population growth will be mitigated andthe challenge of providing social services and employmentto the growing population will be eased. Other benefitswill be enhanced effectiveness and efficiency of the FP

and health programs due to the cooperation between the FPand health subsectors, reorientation of medical education

v

towards communit medicine and public health, andincreased utilization of improved services. The main riskof the project is the Government's potential inability .oimplement fully the extensive reform program in the healthsubsector, including the reorientation of medicaleducation toward community medicine and public health.Another risk is the possible weakness of the managementcapacity of the health subsector, although the financialabsorptive capacity is expected to be sufficient. Tominimize these risks, the project has been so designed asto contribute to the Government's ability to handle thereforms successfully and strengthen its managerialabsorptive capacity and intensive collaboration is plannedamong important medical organizations and colleges inBang'ladesh and abroad.

Project Costs:

Project Components Local Foreign Total…US$ (million)-------

FP Service Delivery 208.9 112.8 321.7Health Service Delivery 102.9 41.3 144.2Supportive Activities 55.0 11.2 66.2Women's and Nutrition Programs 11.1 0.5 11.6

Base Costs 377.9 165.8 543.7

Physical Contingencies 4.4 5.7 10.1Price Contingencies 33.8 13.8 47.6

Total Project Cost 416.1 /a 185.3 601.4

a/ Includes about US$22.9 million in taxes and duties.

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Financing Plan:

Financier Local Foreign Total…US$ (million) ----------

Government 165.1 0.0 165.1IDA 124.0 56.0 180.0Australia 7.0 2.6 9.6Belgium 0.7 2.1 2.8Canada 26.1 14.2 40.3EEC 16.6 31.2 47.8GermanyGTZ 11.1 1.7 12.8KFW 8.4 30.4 38.8

Japan 8.9 0.2 9.1Netherlands 9.8 15.0 24.8Norway 14.3 18.9 33.2Sweden 4.3 9.1 13.4United Kingdom 19.8 3.9 23.7

Total 416.1 185.3 601.4

Estimated IDA Disbursements:

IDA Fiscal lear92 93 94 95 96 97

-__---_-----_-- (US$ million) ----------…--

Annual 17.8 38.4 38.7 36.7 33.5 14.9Cumulative 17.8 56.2 94.9 131.6 165.1 180.0

Economic Rate of Return: Not applicable

IBRD 22837: Banglaiesh Fourth Population and Health Project

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3ANGLADISN

FOJRTH POPULATION AND ELSTH PROJECT

Basic Data

Low-IncomeMost Recent Asia Countries

1970 1981 Estimate (Region) (Worldwide)

AREA

(thousand sq. km.)Total 144.0 144.0 144.0 .. toAgricultural 97.0 97.4 97.6 .. ..

GNP per Capita (US$) 100.0 140.0 /a 1?0.0 410.0 310.0

Energy Consumptionper Capita(kg. of oilequivalent) 20.0 35.0 47.3 386.8 323.7

POPULATION ANDVITAL STATISTICS

Population (million) 68.12 89.9 117.0 /b .. ..Urban population

(Z of total) 7.6 12.0 /c 15.0Annual Growth Rate 2.7 2.6 2.4 1.8 2.0Crude Birth Rate 48.0 46.0 38.0 /b 26.8 30.4

(thousand)Total Fertility Rate 7.2 6.4 Ia 4.9 /d 3.3 3.8Crude Death Rate 20.9 18.0 /a 14.0 Ie 8.8 10.0

(thousand)

POPULATION DENSITY

Per sq. km. 473.0 663.2 812.5Per sq. km. (Agri.

Land) 702.5 955.3 1,198.6 /b .. ..

POPULATION AGESTRUCTURE

0-14 Years 46.2 46.7 Id 43.2 /d 33.2 35.415-64 Years 51.1 49.9 Id 53.0 /d 62.1 60.265 and above 2.6 3.4 Id 3.8 /d .. to

FAMILY PLANNG

Acceptors, Annual(thousand) 373.0 1,607.0 4,770.0 to ..

Users (Z ofmarried women) .. 25.0 33.0 57.8 57.4

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Low-IncomeMost Recent Aswa Countries

1970 1981 Estimate (Resion) (Worldwide)POPULATIONPROJECTION

Population in Year2000 (zdlilion) 145.0 /f

Stationary Populatirmn(million) 346.0 /f

FOOD AND NUTRITION

Index of Foodproduction(1979/81 - 100) 105.3 * 87.6 118.7 116.4

Per capita supply ofcalories (daily) 2,061.0 1,960.0 If 1,880.0 2,452.0 2,392.0

Daily Proteinsupply (gm) 45.0 42.0 40.0 58.0 57.0

HEALTH

Life Expectancyat Birth (years) 44.9 48.0 If 51.0 63.7 61.4

Female .. .. 49-51 64.6 62.3Male .. .. 52-54

Infant MortalityRate (thousand) 150.0 132.0 110.0 /g 61.5 72.6

Under FiveMortality Rate 250.0 211.0 /8 188.0 /8(thousand)

Maternal MortalityRate (thousand) .. 6.0 6.0-8.0

Access to HealthServices (2 ofpopulation) .. .. 45.0 /g

Immunized under12 months (Z ofChildren) .. .. 85.0 ..

ACCESS TO SAFE WATER(Z of population)

Total 45.0 38.0 /h 46.0 /8Urban 13.0 26.0 /h 24.0 /8 72.5 73.4Rural 47.0 40.0 /h 49.0 /8

MEDICAL CARE

Population perPhysician 8,430.0 7,810.0 5,936.0 1,422.0 1,462.0Nurse 76,810.0 22,570.0 25,843.0 1,674.0 1,746.0Hospital bed 7,020.0 4,090.0 3,309.0 733.0 756.0

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Low-IncomeMost Recent Asia Countries

1970 1981 Estimate (Region) (Worldwide)

EDUCATION

(Z of school agegroup)

Primary: Total 52.0 60.0 59.0 /f 105.3 99.3Female 34.0 51.0 49.0 /f 94.4 87.8

Secondary: Total 29.0 24.0 18.0 If 37.5 33.4Female 8.0 6.0 11.0 /f 30.5 26.1

Pupil-Teacherratio: Primary 45.0 35.0 48.0 /f 10.0 10.0

Secondary 26.0 21.0 29.0 19.0 19.0

LABOR FORCE

Total (million) .21.9 /i 25.9 30.9Female (Z of total) 4.0 6.0 9.0 36.6 36.0

* Not ApplicableNot Available

Unless otherwise noted, data are from Social Indictors of Development, 1989.

/a World Development Report, 1983.lb Census 1991 Estimate./c 1982./d Data from BFS 1989.ie 1988.jf World Development Report, 1990./g UNICEF 1990, The State of the World's Children./h 1980./i 1974.

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BANGLADESH


I. THE POPULATION AND HEALTH SECTOR

A. Introduction

1.1 Population and Family Planning. Over the past 16 years, theGovernment of Bangladesh (GOB) has invested in the institutionalization ofincreasingly effective family planning (FP) and Maternal and Child Health(MCH) care programs (Annex 1). This investment is beginning to bear fruit interms of key demographic indicators, albeit not to the extent envisioned inthe early stages of the programs. The Contraceptive Prevalence Rate (CPR) hasrisen substantially (from 82 in 1975 to 332 in 1989) comparing favorably withNepal, Pakistan and less developed parts of India (Annex 2). The impact ofsuch increased contraception is reflected in a significant decrease in (a) theTotal Fertility Rate (TFR) from over 7 in the mid-1970s to just under 5 in1989 and (b) the Crude Birth Rate (CBR) from 48 per 1.000 in 1970 to 38 in1989 (Annex 3). Nevertheiess, these results are no cause for complacency.They are still far from the levels required to match the population with thecountry's resources and keep it within limits that the infrastructure couldsupport. With a population density of over 800 people per sq. km., Bangladeshcan hardly afford a growth rate of 2.42 per annum which would lead to adoubling of her population in just over 30 years. In the light of this grimoutlook, the achievements mentioned afore can only be described as modest.But they are significant inasmuch as they show that the approach and theefforts have been in the right direction and need to be further intensified.

1.2 Maternal and Child Health. Along with the endeavors in thepopulation field, GOB has attempted to tackle the problems of morbidity andmortality among women and children. The accomplishments on these fronts areless gratifying. The Infant Mortality Rate (IMR) and the Under-five MortalityRate (UMR) show some decline in the past ten years (the former from 132 to 110(Annex 4) and the latter from 211 to 188, both per 1,000 live births], but theMaternal Mortality Rate (MMR) still hovers at a very high level of 6-8 per1,000 live births. Comparisons of the main causes of infant and childhoodmortality in India, Indonesia and Bangladesh are shown in Annexes 5 and 6. Arecognition that FP and population measures cannot be effective without aconcurrent improvement in the general health status of women and children ledto the formulation of a coordinated strategy towards FP and MCH goals.

1.3 Health. Besides the FP and MCH activities, another significantfactor in the social and economic development of Bangladesh is the extremelypoor health status of the general population. Although a national frameworkfor addressing these issues exists in the form of a Ministry of Health and anetwork of health care facilities, the structural and functional efficacy ofthis infrastructure leaves much to be desired. It would be fair to state thatthe concentration of the country's attention on FP/MCH concerns has resultedin the relative neglect of the broader health questions. Despite adopting the"Health for All" policy, Bangladesh realistically will be nowhere nearattainment of this objective by the end of the century.

1.4 A comprehensive approach. FP/MCH and health services are closelyinterlinked in terms of similarity of objectives; types of personnel,

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equipment, training and technologies used; infrastructure and servicefacilities requ.redt facilitating factors, such as higher levels of literacy,improved socio-economic conditions, women's development and other socio-cultural determinants; and, most importantly, recipients of the services. AnIDA-led Consortium of external donors has been largely supporting GOB effortsin the population sector through the three successive five-year projects from1975, the last of which is scheduled for closing in December 1991.Acknowledging the close linkages between health and FP and in line with theoutcome of discussions between GOB officials and IDA, an integrated andbalanced approach is being favored for these two sectors [now subsectors whoseprograms are managed by the Ministry of Health and Family Welfare (MOHFW)].Consequently, the !Fourth Project is envisaged as a Population and HealthProject with considerable inputs into health as well as FP. This explains thesubstantially larger size of the pr -sed project compared to its predecessor.

B. Background on t e .iation and Health Situation

1.5 The population and heait; s`tuation in Bangladesh is characterizedby the: (i) enormity of the populatio- pressure, (ii) extraordinary level ofpoverty and illiteracy that hurts the country's productivity as well as itshealth status, (iii) generally gloomy picture of morbidity and mortality and(iv) remarkable differential between the health status of females and that ofmales (clearly in favor of the latter). However, some recent social anddemographic developments have begun to alter, although not yet radically, thisdifficult background in which population and health programs have had tooperate.

1.6 With the exception of some city-states, Bangladesh is the mostdensely populated country in the world (over 800 people per sq. km.). Itspopulation is currently estimated at 117 million, compared to 89.9 million in1981 and 76.4 million in 1974 (Censuses). The increased population pressurein rural areas has resulted in considerable migration to urban areas, wherelarge sections of the population increasingly live under overcrowded andunhygienic conditions due to the inability of the urban settlements to copewith such migration.

1.7 With a per capita income of US$170 (1989) and with more than halfthe population living below the poverty line, Bangladesh is caught in avicious cycle of poverty and ill health. Such severe economic deprivationcombined with low literacy levels is responsible for a large share of themorbidity and mortality, which in turn hampers productivity and growth. Theimpact of a poor health status on economic growth is more apparent when oneconsiders that at any given time, three-quarters of the population (mainlywomen and children) are ill and malnourished and that the health and nutritionstatus of adult males remains very poor as well. Moreover, due to the largeproportion of young people (Annex 7), the dependency ratio is high at 96?(also adversely affecting productivity).

1.8 Life expectancy is currently 52-54 years for men and 49-51 yearsfor women. Although the Crude Death Rate (CDR) per 1,000 has declined from 18in 1981 to 14 in 1990, Bangladesh remains among the countries with the lowestlife expectancies in South Asia, at par with Nepal and behind India, Pakistan,and Sri Lanka. Annex 8 gives the distribution of adult deaths by cause andsex in Bangladesh and Annex 9 compares Bangladesh with Indonesia and Indiawith respect to selected causes of mortality. Some of the principal risks ofmorbidity and mortality stem from high fertility, diarrhea, tuberculosis,

leprosy, tetanus, worms, measles, acute respiratory infections, malaria andother vector-borne diseases. An idea of the morbidity patterns can beobtained from Annex 10. High levels of chronic disability and severemalnutrition are other leading health problems. Malnutrition, which is amajor cause of childhood mortality, affects adults as well, particularlywomen. Almost all rural mothers are considered malnourished in terms ofweight for height. About 502 of the newborn babies have low birth weights,one of the worst situations even among developing countries. Malnutrition ismade more severe by traditional dietary practices as well as infections. Thedeficiency is not me:ely one of calories and proteins, but also of severalspecific nutrients, some leading to serious disabilities, such as blindness.Despite this rather dismal picture, a positive aspect of feeding practice inBangladesh is the almost universal breastfeeding of babies in both rural andurban areas, although exclusive breastfeeding seems to be declining, aworrying trend. Besides its nutritional benefits, breastfeeding acts as anatural contraceptive.

1.9 A particular concern in Bangladesh is the divergence in healthstatus of females and males. Although the gap between life expectancies ofmen and women narrowed recently (Annex 11), Bangladesh deviates from thepattern seen in most countries where women live longer than men. Childhoodmortality among girls is higher than that among boys by almost 15-252 (IMR=105-125 per 1,000 live births for girls and 90-115 for boys; CDR=16 per 1,000for girls and 13 for boys). Women run an additional risk of mortality frommaternal causes with an MMR more than 100 times the rate in industrializedcountries and much higher than even that of most developing countries. Themain causes of maternal mortality are: self-induced miscarriages (abortion),eclampsia, infection, hemorrhage, and mechanical complications (Annex 12).These higher rates of mortality, traditional male gender preferences anddiscriminatory allocation of family resources have resulted in a sex ratio of104 males to 100 females (126:100 in the urban areas) and give an indicationof the unfavorable situation of women in Bangladesh.

1.10 In terms of recent social and demographic changes, thetraditionally young age at marriage of women has risen from 16 years onaverage in the mid-1970s to 18 years in 1989. The proportion of single womenaged 15-19 has increased from 8? in 1961 to 492 in 1989. Similarly, theproportion of single men age 20-24 has risen from half of the cohort in 1961to three-quarters in 1989. In the last decade, the median age of women atfirst birth rose by more than one year and the average number of children bornto women before age 20 fell by about 30Z. The large age difference betweenhusbands and wives has begun to narrow but remains at 7.5 years on average,giving husbands considerable advantage in status, experience, anddecision-making in the family. Thus, despite some welcome changes, thedisproportionate male influence on decisions about family size and health carepersists; the low social and economic status of women remains a key element inthe demographic and health problematique of Bangladesh.

C. Overview of the National Population and Health Program

1.11 In the 1950s, voluntary efforts to promote FP and MCH began inBangladesh (at the time still East Pakistan). They led to a national programin 1965 aimed at reducing population growth from 31 in 1965 to 2.7? in 1970through reducing births from 50 to 40 per 1,000 and deaths from 20 to 15 per1,000. The program was partly based on a network of FP clinics administered byan autonomous FP board, independent of the health service. It depended on

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doctors for sterilization, lady FP visitors for intrauterine device (IUD)insertions, and incentive payments to personnel and acceptors. The programsharpened public awareness of population issues and modern contraceptivemethods and created a latent demand for FP. Revisions in the program plannedfor Pakistan's Fourth Five-Year Plan (1970-75) could not be implemented due tothe civil war.

1.12 Although FP efforts nearly stopped in the early 1970s, considerablediscussion continued about the program. Through the first three five-yearplans, successive population programs contained new strategies, efforts atstreamlining administrative structures and increasingly more realistictargets. The planning, policy-making and coordination of the program wasinitially vested with an autonomous PP board under the Ministry of Health,later to be replaced by an interministerial board. Some of the highlights ofthe steps taken under the population program during the first three planperiods were: a progressive move towards cooperation with the Ministry,multisectoral efforts for communication and women's activities, research andevaluation, community-based FP services through female and male field workers,functional integration of FP and health sectors at the subdistrict level,formation of the Family Welfare Centers (FWCs) and a serious attempt to reducemorbidity and mortality among women and children. The fertility anddemographic targets set for the Third Five-Year Plan (1985-90) were: 32 birthsand 13 deaths per 1,000 population, a CPR of 402 by 1990 and a NetReproduction Rate (NRR) of 1 by the year 2000.

1.13 Despite its commitment to the overall goal of "Health for All bythe Year 2000", Bangladesh has been so preoccupied with the pressing problemof its population explosion that the general health situation has not receivedenough attention. However, health is recognized by GOB as a fundamental rightand the stated policy is to provide essential minimum health care to allthrough Primary Health Care (PHC). The GOB has inherited a health systemstrongly oriented to curative care, with vertical programs being the onlychannels of preventive activities. Steps were taken in the Third Plan towardthe direction of PHC. The construction of Upazila Health Complexes (UHCs) andthe network of FWCs in addition to the secondary and tertiary facilities isthe clearest evidence of these efforts. Annex 13 presents in greater detailan overview of the FP and health sector.

Policy Formulation and Coordination

1.14 At present, population policy is formulated by the NationalPopulation Control Council which replaced the National Council for PopulationControl. Health policy is formulat:ed by the MOHFW. The Council is chaired bythe President and includes about 350 members (all the cabinet ministers,parliament representatives, and eminent public personalities from differentwalks of life) who meet every three to six months. Its main functions includeproviding policy guidelines, approving strategies and innovations, ensuringinterministerial coordination, identifying impediments to implementation andplanning possible corrective actions. An executive committee headed by thePresident and comprising all cabinet ministers helps translate the Council'sdecisions into action programs and monitors implementation. Similar bodies arebeing constituted at district level to focus attention on population, FP andMCH concerns.

1.15 The Population and Health Sections of the Planning Commissionassist in developing policy options for consideration by the National Economic

Council, and formulate the five-year plan proposals for population and forhealth. They are also responsible for an independent evaluation of key MOHFWactivities. At the beginning of the Third Plan, the Population and DevelopmentPlanning Unit and the External Evaluation Unit were merged into a PopulationDevelopment and Evaluation Unit (PDEU) within the Planning Commission.

Program Implementation by the MOHFW

1.16 Institutional Framework and Functions. The MOHFW is headed by aMinister (see Charts 1 and 2). One full-time Secretary and one AdditionalSecretary manage MOHFW's major functions, which are divided between an FP wingand a health wing, each having its own planning unit. Directorates, one eachfor FP and health, headed by Directors-General (DGs) and supported byDirectors of functional units assist the Secretariat and are responsible forprogram planning, implementation, supervision, training, logistics andsupplies, and monitoring activities in their respective areas. Theeducation/communication function in FP is vested with the Information,Education and Motivation (IEM) Unit under the DGFP, while a separate HealthEducation Bureau (HEB) functions under the DG Health. Beyond Dhaka, theorganizational structure is separate according to FP and health activit:Les atthe 64 districts, 397 rural upazilas, 4,403 unions, and 13,500 wards. The 349UHCs and 1,274 Rural Dispensaries (RDs) at upazila level and 2,500 FWCs atunion level comprise the main service delivery infrastructure. Field staffinclude the envisaged 23,500 Family Welfare Assistants (FWAs) and 21,500Health Assistants (HAs) who are to work as teams providing outreach services.The impact of visits by field workers for conveying FP knowledge is shown inAnnex 14. Attempts have been made to integrate the FP and health servicesstructure, but generally without success, largely due to staff concernsregarding their position in the bureaucracy.

1.17 Training. Recognizing that successful fertility control effortslargely depend on a well trained and motivated work force, GOB has investedconsiderably in training institutions. Orientation of basic training ofMedical Officers (MOs) to community health through posting at selected UHCs isyet to materialize. Model FP and MCH clinics intended as sites of basictraining for all undergraduates and interns exist in all the eight Governmentmedical colleges. !elected clinics run by NGOs, particularly the BangladeshAssociation for Voluntary Sterilization, provide in-service training insterilization techniques to MOs. Basic training and retraining of field staffand supervisors is provided at 12 Training Institutes for Family WelfareVisitors (FWVTIs), 8 Medical Assistant Training Schools (MATS), 20 RegionalTraining Centers (RTCs), the National Institute of Population Research andTraining (NIPORT), and the National Institute of Preventive and SocialMedicine (NIPSOM). NIPSOM caters to postgraduate training in public healthand in-service training of MOs working in UHCs. NIPORT has been successfullyupgraded to an apex institute for FP and some MCH training, headed by aDirector General. Several institutes outside FP and health are beginning toprovide management training for FP and health personnel.

1.18 Training of Family Welfare Visitors (FWVs) and Medical Assistants(MAs) was discontinued temporarily during the Third Plan; 8 of the 12 FWVTIsare being used for initial training of new FWAs and the other 4 for refreshertraining of FWVs. Similarly, the MATS are being used for training of new HAs.Out of tune with the needs of the country, the medical colleges overproducespecialist clinicians, resulting in a serious shortage of familypractitioners, gynecologists, obstetricians, pediatricians, public health

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physicians, etc. While the physician/population ratio is far from adequate,the country's health care system cannot yet accommodate the number of ruralPHC physicians required for effective coverage. Training of nurses remainsunsatisfactory and the nurse/population ratio is 1:26,000. Much remains to bedone in the fields of MCH and PHC training which lagged behind over the lastten years while FP training was strengthened.

1.19 Information, Education and Motivation (IEM). This program is toinform, educate and persuade people about the benefits of a small-sized andmanageable family ar4 about healthy lifestyles in general. It aims to reachnot only eligible Juples but also those at home and in the community whoinfluence decision-making. The program depends on three mutually reinforcingapproaches: mass media, small group contacts, and individual contacts.Infrastructure, developed during the first two Plan periods, includes theunits of the Ministry of Information and Broadcasting, the IEM Unit &nd HEB ofthe MOHFW, the FP and health field workers, voluntary agencies, and Swanirvar.Three women's projects supported under the first three projects also serve asmajor communication channels.

1.20 Mass media now reach a large segment of the rural population thanksto the impressive improvement in access to radios including those distributedto union councils, mothers' clubs, radio listening fora, etc. Health and FPmessages are broadcast for 70 minutes a day through the national studio and230 minutes a day through the various regional stations. A governmentlaboratory produces film on population-related subjects. BangladeshTelevision devotes more than four hours a month to FP and health programs.Information campaigns are being held, billboards and neon signs are being putup in important places, and large quantities of pamphlets and leaflets arebeing printed and distributed. Folk songs and Swanirvar's program for FP andMCH-related activities also have had significant impacts. The result is that afairly large population of rural women know about FP methods. Sensitizationof males, however, remains weak.

1.21 Economic Welfare of Women. RecognizLag that an enhanced status ofwomen is critical to economic development of the country and long-termreductions in fertility, GOB started three programs to assist women throughMothers' Centers, Women's Cooperatives and Women's Vocational Training in1976. Under the current project, they cover 238 upazilas and about 730,000women. They provide gainful employment to women through income-generatingactivities and impart nonfonmal education with emphasis on FP, health,nutrition and child care. Program inputs like training and credit facilitieshave helped women earn some income which they otherwise would not have earned.They have also helped women reduce fertility as the CPR is higher in programareas than in non-program areas.

1.22 Logistics. The DGFP and the DGHS each have a separate Directorateresponsible for procurement and delivery of most drugs, kits, medical andsurgical requisites, and other supplies for the FP and health programs.Distribution is through central warehouses in Dhaka, various regionalwarehouses and district stores. Logistics management is done by teams ofmonitoring officers, supported by a Logistics Management Information System(LMIS), and technically assisted by UNFPA, WHO, UNICEF, USAID, CIDA, and IDA.

About 5,000 static distribution points serve the country. Some commodities,such as donated contraceptives and specialized drugs, are procured directly bydonors and distributed to intermediary institutions.

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1.23 Monitoring, Evaluation and Research. Infrastructure for theseactivities consists of the Management Information System (MIS) of the FP Wingof MOHFW with its special service statistics cell, the PDEU in the Planning

Commission, HEB of the Health Wing, the Population and Health Study Centers of

the Bangladesh Institute for Development Studies (BIDS), the Research Wing of

NIPORT, and the Bangladesh Bureau of Statistics (BBS). Besides, agencies likethe Bangladesh Fertility Research Program (BFRP), International Center forDiarrheal Disease Research in Bangladesh (ICDDR'B), NIPSOM, Institute forPost-Graduate Medicine and Research (IPGMR), the medical colleges, DhakaUniversity and some NGOs are involved in research. The NGO sector has alsomade contributions in operational research and evaluation. Apart from many

significant, internationally respected, results in clinical and MCH careregarding diarrheal diseases and MCH/FP service delivery effectiveness,important progress has been made with the publication of the BangladeshFertility Study (BFS) 1989, the sample registration system of the BBS, themonthly reporting system of the MIS, and the evaluation studies of thePlanning Commission. However, evaluation and research remain weak in terms of

quality, relevance, and systematic collection of gender-disaggregated data.

1.24 Clinical Supervision. To assist GOB in monitoring and improvingthe quality of its clinical family planning effort, four clinical SurveillanceTeams were created in 1982. Through regular visits to health facilitiesperforming clinical contraception (sterilizations, IUDs, injectables,implants, etc.), the four teams provide medical surveillance and in-servicetraining. The quality of care has improved considerably since. The teamswere reorganized in 1986 under the DGFP and renamed Family Planning ClinicalSurveillance Teams (FPCST). A recent survey of client satisfaction (1990)

indicates that emphasis on reversible contraceptive methods should becontinued.

1.25 Management Development. The Management Development Unit (MDU) wasestablished in 1987 to improve the effectiveness of the FP/MCH programprimarily through strengthening efficient and effective management practices,resulting in greater managerial absorptive capacity. Field work started onlyin May 1988. The professional staff consists of four internationa' d.i four

national experts, one assigned to each of two districts per division. The MDU

tries to strengthen at district level managerial capacity through operationalplanning, coordination, training, service delivery and supervision. MIS data

are used for local level evaluation and planning. Notable achievements haveoccurred in the districts and upazilas where the MDU operates. A review ofMDU's functioning by GOB, IDA and the Cofinanciers in 1990 suggested that the

MDU should build on and disseminate experience from the current project andfunction as a resource center and strategic management group for MOHFW with a

close liaison between the FP and Health Directorates.

1.26 Acceptance and Use of FP and MCH Services. The utilization ofthese national programs is reflected as follows. A closer scrutiny of the

increased use of contraceptive methods reveals a growing popularity of

injectables in 1988 and 1989, with a continued decline in sterilizations.About 45Z of ever-married women in 1989 have ever used modern contraception(BFS). Preference of methods among users in 1989 in rural and urban areas and

by number of children is shown in Annex 15. Ever more women are willing to

use modern contraception. In the area of MCH, the Expanded Program of

Immunization (EPI) increased the immunization coverage (six childhooddiseases) from 2Z in 1985-86 to over 602 in 1991. While the use of OralRehydration Solution against diarrhea has reduced or postponed infant and

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child mortality and many programs have been initiated to address suchimportant problems as acute resptratory infections (ARI) and maternalmortality and morbidity, the proportion of women receiving at least oneprenatal visit remains at a low of 35Z and the proportion of deliveriesreceiving skilled care is no more than 252 (the number of trained TraditionalBirth Attendants (TBAs) now is a little over 12,000, out of a total of62,000). The BFS 1989 shows that the number of children desired by women hascome down to about three, demonstrating an unmet demand for FP services. Thedistribution of women who want no more children or have been sterilized isshown in Annex 16.

Sector Development Issues

1.27 Issues of concern to GOB and to the IDA-led Consortium of donorsarising during formulation and implementation of the first three Projects butresolved satisfactorily included the determination of demographic targets, thecorrect calculation of the required contraceptive mix, the establishment of aFP and MCH service balance, and questions regarding the appropriate use ofseveral "incentives". They are discussed in more detail in Annex 17.

1.28 Key issues currently requiring substantial attention in respect ofFP and health programs include the quality of care, use of FP and healthfacilities, human resource development, organization and management of FP andhealth services, operations of NGOs, and financing of the sector programs.These issues have been analyzed in detail in the extensive Project CompletionReports of the first two projects (paras 1.43 and 1.46) and the lessonslearned are being applied in the ongoing dialogue between GOB and theConsortium.

1.29 Quality of Care. Over the last 16 years, GOB's focus has been onextending FP services and limited attention has been paid to the quality ofhealth services. The quality of FP/MCH clinical services continues to beaddressed through the FPCST. The currently unacceptable level of quality ofhealth care is related to several factors: inadequately trained personnel, anabsence of professional standards, poor patient-doctor interaction, inadequatemedical supplies, a non-operational referral system, insufficient diagnosticfacilities, substandard physical facilities and scant career prospects.Quality assurance requires: development of standards for health workers basedon outcome measures, orientation of health managers and service providers tothese new standards, development of reporting and recording forms, formationof a quality assurance resource center, introduction of a medical audit andother measures (para 2.38).

1.30 Use of FP and Health Facilities. A continuing problem is that theuse of PP and health facilities, which were built up at significant cost,remains unbalanced with some facilities highly overused and others underused(Annex 18). In 1985-90, the average daily patient load was over 1,250 in eachof the 8 medical college hospitals, 300 per district hospital (14 in all), and175 per UHC (349 in the country). In 1989, the bed occupancy rate of UHCs wasless than half that in the hospitals. Apart from epidemiological patterns ofdisease and from cultural determinants (e.g. female literacy, female socialmobility, etc.), the complex issue of use of FP and health services is relatedto management capacity, skills and knowledge of service providers, relation ofproviders with clients, quality of care, adequate supplies, and communityinvolvement. In view of this, a holistic approach to the problem was agreedupon as followss initially, in several districts (50 upazilas) this issue will

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be addressed in-depth, ensuring the availability of medical and FP supplies,improving diagnostic facilities, enhancing motivation and commitment of thework force, encouraging community participation, strengthening the districtand upazila managerial capacity, promoting more effective client-workersrelationships, and many other steps, such as improving the effectiveness ofthe referral system (managerially and medically a notoriously complicatedissue) (para 2.59).

1.31 Human Resource Development. The general focus so far has been toupgrade the quality and number of staff at upazila level and below throughpreservice and inservice training. While these efforts have largelysucceeded, there is an increasingly stronger case to focus current attentionon medical and nursing personnel. Earlier programs and projects did notaddress these cadres, with the result that they have slipped badly over thelast decade and the quality and quantity of medical and nursing care are in anunacceptable state. The curriculum lacks the essential emphasis on maternaland neonatal health, clinical contraception, management of FP and healthservices and poverty-related diseases, e.g., tuberculosis and leprosy. Fieldtraining in PHC and preventive medicine is vital and the planned reorientationof medical and nursing training away from urban curative care, towards ruralhealth and community medicine, thus is of utmost priority. At the same time,GOB is still to formulate a comprehensive overall human resource developmentplan for the FP and health sector. Such a plan would address central matterslike needs assessment, education, training, employment of women at all levels,career development opportunities, and other areas neglected in the past (para2.70).

1.32 Organization and Management of FP and Health Services.Organization of FP and health services has attracted considerable attention inrecent times. The proposal to integrate the two services, approved in 1980,and even a more modest subsequent proposal, have not worked satisfactorily.Despite this setback, the case for integrating both services is strong due tothe close relationship of the two services, sharing of common physicalfacilities and complementarity between job functions of staff at variouslevels. But a phased approach is necessary. Moreover, integration alone willnot be the solution. The sector is too centralized, much of the managementcadre (22Z) is vacant, and frequent charnges of senior staff, often away fromtheir fields of expertise, indicate weak personnel management. Highlyinsufficient travel and daily allowances impede village-based care. Concernsexist as to GOB's capacity to manage the envisaged substantial expansion ofthe FP and health programs and the increasing sectoral resources under theFourth Plan. The planning units in the MOHFW are to be strengthened andplanning cells to be set up within both FP and Health Directorates. Thesewill be linked to the envisaged Health Economics and Financing Pilot Projectand the MIS of both FP and Health; the data from the EPI Surveillance System,the demographic and health surveys, the CPSs every two years, the 1994 BFS andthe 1991/1992 Census will be fed into these. Departmental work plans will beestablished by the planning units. The MOHFW supports an analytical exerciseto assess the combined capacity of all the various units as part of a SectorReorganization Plan in response to the above-mentioned concerns (para 2.69).Combined efforts would be made by a team of expatriate and Bangladeshimanagement specialists and FP/health personrnel.

1.33 Operations of NGOs. While many NGOs are in place to provide FP andhealth services, GOB's approval procedures for activities have constrainedtheir effectiveness. Recently GOB established an NGO Bureau under the

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President's Secretariat to provide a one-stop approval system for NGOsreceiving foreign funds. The system is intended to avoid the complicated andcostly interministerial process that NGOs had to deal with in the past. Sometime will be needed to assess the effectiveness of the new system (para 2.81).

1.34 Financing of FP and Health Services. In the Fourth Five-Year Plan(1990-95), GOB has provided for a substantial increase in its allocations tothe health and FP subsectors. During the previous three Plans (1975-90).investments in health and FP roughly doubled every five years, a trendreflected in the total cost of the previous projects (US$45.7, 110.0 and 213.8million, successively). This raises concerns regarding the long-termsustainability of these very significant increases (Annex 1 analyzes thisconcern in the social sectors in Bangladesh further). From a perspectl-- ofsubstance, the need for these increases is inherent in the objective ofexpanding coverage of FP and health services. Paradoxically, in thisparticular sector, as services become more effective they necessarily lead togreater expenditures: on the one hand, this is due to the increased demandconsequent upon better care and the resultant greater longevity, in turnleading to higher medical "maintenance" costs; on the other hand, while unitcosts in Bangladesh still remain extremely low (e.g., US$0.11 per person perannum for medicines, see Annex 19), the increased costs are due to populationgrowth, the planned doubling of service coverage (up to 10? of population) andthe wider range of services.

1.35 In its Third Five-Year Plan (1985-90), GOB had allocated 5.68? ofits overall investment budget to the sector (2.2? for health and 3.48Z forFP). In its Fourth Plan, GOB intends to invest 7.3Z (US$793.4 million) of itstotal Plan outlay, in health (2.82), and FP (4.52). During the review of theoverall public expenditure plan of GOB and the subsequent three year "rollingplan", the FP and health sector has been protected from the cuts made acrossthe board. Thus US$501.5 million was allocated to the FP and health sectorfor 1991-94. This amounts to more than 60% of the original five-year planallocation, indicating that the sectoral allocation for the three year periodhas not been cut back and in fact been marginally increased (Annex 1, p. 9).

1.36 GOB has allocated sufficient overall investment budgets to thesector in line with the requirements of the proposed Fourth Project. Theoperational capacity of the sectors to absorb the increased funding has beenestablished (for managerial absorptive capacity, see paras 1.32 and 2.67-2.72). At issue remains intrasectoral priority setting leading to appropriateallocations (Annex 20 lists low priority components within the sector). Atpresent, GOB's limited capacity to apply cost-effectiveness and efficiencycriteria to the sector remains a serious obstacle for such intrasectoralprioritization. Therefore, a new Health Economics and Financing Pilot Projectin the MOHFW is to be set up for assisting GOB to build up its analyticalcapabilities in both macro- and micro-economics and financing of health and FPservices (on recurrent costs, see para 2.73). The pilot project will alsoaddress the technically complex issue of cost recovery in health care and laythe ground work for the introduction of a rational system of user charges.

D. Objectives and Strategy under the Fourth Five-Year Plan

1.37 Introduction. More favorable circumstances than in the pastprevailed at the time of formulating the Fourth Plan. Fertility decline hasset in. EPI covers the whole country with a remarkable increase in the levelsof immunization. A basic FP and health infrastructure now caters to most of

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the country. GOB recognizes that the original target of NRR of 1 by 2000 is

unattainable and acknowledges that the MCH component of the FP/MCH program isstill weak. GOB is determined to make much moze progress in the Fourth Five-

Year Plan.

1.38 Oblectives. The demographic objectives of the Fourth Plan are to

increase the CPR from around 332 to 50X and consequently bring about a

fertility decline of 27Z, i.e., TFR falling from just under 5 to 3.3 and CBRfrom 38.2 to 30.1 per 1000 in the period 1990-95. However, based on pastexperience and the maximum achieved by some of the best performing FP programs

in the world, more realistic targets would be a CPR of 45-50., a CBR of 30-35

per 1,000 and a TFR of around 4. The proposed contraceptive mix (Annex 21)

relies heavily on sterilization of both sexes, expected to be 33? of allmethods by 1995, and even more heavily on other female methods (52X).

1.39 Objectives for crucial MCH and health indicators include reducing

the IMR from 110 to 80-85 per 1,000, the MMR from 6-7 to 4-5 per 1,000, theUMR from 188 to 140-145 per 1,000, neonatal mortality from 72 to 55-65 per1,000 and the CDR from 14 to 12 per 1,000, all from 1990 to 1995. Lifeexpectancy at birth is targeted at 55 years by 1995. Prenatal care would cover

50-602 of pregnant women (currently 35Z) and 40-501 of all deliveries would be

attended by trained personnel (currently 20Z). PHC services are to be

extended to 80? of the population and a beginning made to address PHC for the

urban poor with an emphasis on poverty-related diseases.

1.40 Strategy. The broad strategy for achieving the FP and health goals

has been defined by GOB as an intensified and concerted effort at improving PP

and health services at grassroots levels through better management and a

comprehensive approach. This strategy could be briken down into the following

elements: (a) conversion of the population progrp-i progressively into a socialmovement; (b) decentralized and functionally integrated services for FP andhealth; (c) improved effectiveness and efficiency of management practices,better supervision, higher quality of care, and a wider range of services; (d)

improved satellite clinics; (e) an intensified and expanded MCH program; (f) a

functional two-way referral system; (g) adequate and appropriate humanresources in FP/MCH, health care and nursing; (h) improved supply systems and

local production of esst-tial drugs, vaccines and contraceptives; (i)

sharpened communication programs to cover FP and health (j) active involvementof and cooperation with NGOs; (k) community participation; (1) increasedfinancial allocations to cost-effective FP and health care; and (m) improvedsocial, health and nutritional status of women and their greater participation

in PP and health activities.

1.41 The strategy would be implemented through four major areas ofconcentrationt family planning service delivery, including most MCH services,

FP and MCH training, facilities and supplies; health service delivers,including medical and nursing education and research, disease control, PHC and

improved health facilities; supportive activities, including managerial and

financial capacity, quality assurance, information systems, and community-oriented programs; and women's programs and nutrition.

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E. External Financing

1.42 Assistance to FP and health activities in Bangladesh has beenprovided through bilateral donors, specialized agencies, and the IDA-ledConsortium of donors. While most of the major public and private donorsactive in FP/health have assisted Bangladesh at one time or another, thepublic agencies supporting MOHFW on a continuous basis are UNICEF, UNFPA, WHO,ADB, USAID and IDA. UNICEF contributes about US$40 million annually,supporting child health, e.g., immunization, essential drugs and nutrition.UNFPA's country program amounts to roughly US$5.5 million a year and focuseslargely on FP service delivery and population education, while WHO is MOHFW'smain internatiotnal source of technical assistance in the health field,supporting a wide array of projects ranging from PHC and MCH to infectiousdiseases and technical skills for drug testing (approximate annual budget ofUS$5.0 million). ADB recently agreed to support a project costing US$58million, mainly on curative medical care (secondary and tertiary hospitals,health technology institutes, medical equipment), but also including supportfor health planning capacities, nursing education and indigenous medicine.USAID currently supports the largest FP program of all donor agencies, with anannual outlay of nearly US$ 25-27 million, more than 75? of which is directfunding to NGOs and the rest to MOHFW. USAID's main support is for the supplyof contraceptives, social marketing, logistics, FP service delivery, NGOs,management information and evaluation, EPI and technical support.

1.43 S'nce 1975, IDA has supported three projects for a total creditamount of US$124.9 million. Under the First Project (Cr. 533-BD), the creditof US$15 million was fully disbursed (total project cost of US$45.7 million).A Project Performance Audit Report (No. 6303) was completed in June 1986.Under the Second Project (Cr. 921-BD), about 96? of the credit of US$32million (total project cost of US$110 maillion) was disbursed. A ProjectCompletion Report (No. 7792) was prepared in May 1989. The Third Populationand Family Welfare Project (Cr. 1649-BD) provided IDA financing of US$77.9million (total project cost of US$213.8 million), of which US$50.4 million hadbeen disbursed as of December 31, 1990. Australia, Canada, Germany (GTZ andKfW), Norway and the United Kingdom have cofinanced all three projects; theNetherlands, the second and third projects; and Sweden, the first and secondprojects. For details about the projects and their compoxients see Annex 22.

1.44 The Fourth Five-Year Plan extends from 1990 to 1995 while theFourth Population and Health Project covers the period 1992-96. Almost all ofthe project components and subcomponents coincide with those of the GOB'sFive-Year Plan. This reflects IDA's and Consortium's very considerable inputinto the formulation of the Plan itself, through extensive and detailedconsultations between MOHFW and the Planning Commission on the one hand andIDA and the Consortium members on the other. These consultations took placebetween 1988-1990, on a continuous basis by PPO in Dhaka, as well as throughfive major GOB-donor workshops and conferences in Bangladesh and Geneva,preceding the formulation of the GOB's Plan Document and the IDA Consortium'sProject Brief Document. This close cooperation is expected to enhance theeffective and appropriate absorption of the project funds. Since most of the(sub)components are intended to strengthen the GOB's infrastructure and its FPand health service delivery system, they are expected to continue beyond thePlan period. However, the IDA, cofinancier and GOB funds proposed for thisoperation are tied to specific items and activities within the framework ofthq project.

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P. IDA's Role and Sector Lending Strategy

1.45 IDA has long been a major supporter of Bangladesh's PP and MCHprograms. In recent years, IDA has become the leader of a donor Consortiumcomprising seven external donors and three multilateral executing agencies.In that capacity, IDA has helped GOB mobilize substantial financial andtechnical support for FP and health programs and to coordinate the donors'assistance to this sector critical to the country's socio-economicdevelopment. It has been instrumental in keeping the Consortium from breakingup over potenttally damaging issues such as compensation payments tosterilization acceptors. IDA has contributed significantly to the currentconsensus as to the priority of the population programs. For the FourthPopulation and Health Project, IDA has been able to enlist the support of fouradditional donor agencies. Furthermore, USAID has observer status in theConsortium, while ADB will informally participate in the Consortium fromSeptember 1991 onwards. The Bangladesh Population and Health Consortium forthe Fourth Project thus would comprise as its members Australia, Belgium,Canada, the EEC,. Germany (both KfW and GTZ), Japan, the Netherlands, Norway,Sweden and the United Kingdom, with USAID as observer and ADB as an informalparticipant and potential member; UNFPA, UNICEF and WHO would act as executingagencies to the Consortium for specific project components. Annex 23 gives adetailed description of the Consortium and its workings.

1.46 As documented in the Project Completion Reports, the first twoprojects have been implemented satisfactorily and have helped GOB establish aviable population program. After a 10-month delay in project effectiveness,the current Third Project is moving ahead and expected to be completed by theend of 1991. Following Board approval in 1989, sizable savings have beenallocated to the purchase of contraceptive supplies and rehabilitation ofhealth facilities. The main lessons learned, pertaining to the importance offormative evaluations, a participatory GOB-donor approach to strategy andprogram formulation, a strong IDA presence in the field, and the need forbetter management practices and for a long-term commitment to the sector, havebeen incorporated into the project design and, indeed, into the very processof project formulation.

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II. THE PROJECT

A. Objectives and Strategies

2.1 In line with the twin national goals of Health for All andfertility reduction leading to an NRR of 1 by the turn of the century or assoon as possible thereafter, the major objectives of the proposed project areto: (a) reduce fertility by increasing the CPR to 45-50Z; (b) lower morbidityand mortality in children under five; (c) improve maternal care and ensuresafer deliveries thereby reducing maternal mortality from the current 6-8 to4-5 per 1,000 live births; (d) reduce disability, morbidity and mortality fromcommon poverty-related diseases; (e) enhance the nutritional status of womenand children; and (f) improve effectiveness and efficiency in the planning anddelivery of FP and health services to accelerate the achievement of the aboveobjectives. The project seeks to achieve these objectives in the followingmanner.

(a) Reduced fertility would be achieved by increasing the CPR throughimproved access to FP/MCH services by outreach visits, satelliteclinics, and the enlarged network of FWCs and through ensuringtimely supply and providing a wider range of contraceptives.

(b) Lower morbidity and mortality of children under five would beachieved by expanding EPI coverage and strengthening programs ofdiarrheal disease control (CDD), ARI control and nutritionalsupplementation by Vitamin A.

(c) Improved maternal care and reducer! maternal mortality would beachieved by: training TBAs; screeining and referring high riskpregnancies: strengthening anteratal, natal and postnatal services;supporting a special maternal aad neonatal health care project; andstrengthening obstetric and gynecological services at UHCs anddistrict hospitals.

(d) Reduced disability and morbidity -,account of poverty-relateddiseases would be achieved by stre.vthening programs relating totuberculosis and leprosy control, vector-borne diseases, entericdiseases, and worm infestation.

(e) Improved nutritional status of mothers and children would beachieved by distributing Vitamin A mainly for infection andblindness control, producing iodized salt for goiter control,dispensing ferrous iron to pregnant mothers, and strengthening theNational Nutrition Council to enhance its leadership capacity forplanning, implementing and monitoring niutritional promotionuctivities for mothers and children.

(f) Improved effectivenees and efficiency of FP and health serviceswould be achieved by: strengthening the planning capability ofMOHFW; improving quality of services; supporting a project onrational use of drugs; improving utilization of UHCs and FWCs;strengthening management and supervision of the FP and healthprogram; encouraging a well-coordinated approach to communicationthrough interpersonal, group and mass media; continuing the threewomen's programs; strengthening management information systems;improving epidemiological surveillance; reorienting PDEU;

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reorganizing the FP and health program; promoting NGOs; supportinginnovative projects; setting up of a Health Economics and FinancingPilot Project; constructing a Population and Health Building, andother related measures.

2.2 Women in Development (WID) Strategy. In accordance with GOB'srecent initiatives to mainstream women into development, the followingguidelines were identified by the Consortium in order to improve women'saccess to health and FP services and to increase their participation in thedelivery of these services through the Fourth Population and Health Projectt

(a) the project focus should be broadened from female reproductivehealth to all aspects of female health and the health facilitiessupported by the project should be expanded to deliver the range ofservices required by females sta;ting from birth;

(b) women should be represented at all levels of the PP and healthsystem, in all committees, and in project implementation units andshould be given increased access to training and to scholarship andfellowship programs;

(c) gender equity should be considered in promotion decisions withinthe Directorates of Health and of FP;

(d) field-level female workers should be provided with adequatetransportation arrangements and safe accommodations;

(e) personnel statistics, baseline surveys and operational research tobe undertaken through the project should systematically includegender-disaggregated data;

(f) field-level workers should not be compelled to meet FP acceptortargets;

(g) the IEM program focus should be broadened to address both men andwomen on such topics as age of marriage, birth spacing, maternaland female nutrition, and contraceptive methods;

(h) gender awareness topics should be included in basic and in-servicetraining curricula of field workers of the Directorates of Healthand of FP;

(i) a gender strategy should be included in all NGO activitiessupported by the project; and

(j) gender equity should be included as a topic in the terms ofreference for all local and international consultants financedunder the project.

Broad performance indicators for monitoring the WID strategy are set out inannex 24. They will be developed in more detail during projectimplementation. Progress will be monitored during review missions for theproject (paras 4.12 and 4.13).

2.3 Intersectoral Population Activities Strategy. Improving healt' andreducing fertility depend not only on interventions in the FP and health

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sectors; rather, factors such as improving female and general education,reducing poverty and assuring equity in socio-economic development allinterrelate with and contribute to the success of efforts in the FP and healthsector. In view of their importance and size, intersectoral populationmeasures in sectors including '.ndustry, agric_lture, education and women'sdevelopment are proposed to b4 pursued as a separate project. However, thecurrent project will provide bridge financing for at least two years or longerto the three women's programs that have been an integral part of the previouspopulation projects for two years, by which time the programs are expected tobecome part of the comprehensive Intersectoral Population Activities Project.

2.4 Overall Strategy. The Fourth Population and Health Project hasbeen designed to incorporate the assistance of most of the donors to the GOB'sFP and health program for the Fourth Five-Year Plan. This strategy reflectsthe lesson learned from the three previous projects regarding the importanceof a participatory GOB-donor approach to strategy and program formulation. Itis intended to ensure that the support provided through the project is in linewith agreed GOB and donor priorities, minimize GOB's aid management burden,and prevent donor competition in the FP and health sector. Apart fromcontinuing relevant activities under the Third Project, the Fourth Projectwill finance additional PP and health activities from GOB's Fourth Plan andextend into the Fifth Plan. The project will particularly respond to thecontinuing need to improve the quality and use of the GOB's PP and healthservice delivery systems and will strongly support new initiatives to improvematernal health.

B. Summary Project Description

2.5 The project, which covers a five-year time slice of GOB'sdevelopment program in population and health (1992-96), has four maincomponents: (a) strengthening FP/MCH service delivery; (b) strengtheninghealth services delivery; (c) improving supportive activities to the deliveryof FP and health services; and td) women's and nutrition programs. It willstrengthen FPIMCH service delivery by improving access to PP services,strengthening MCH services, enhancing clinical service delivery and FP/MCHquality assurance, imparting in-service training of upazila and district stafin FP/MCH, construction and renovation of FP/MCH facilities, and marketing ofcontraceptives through the private sector. The project will strengthen healthservice delivery through increasing the range of maternal and neonatal healthcare, strengthening nursing and medical education, introducing medical qualityassurance, supporting medical research, strengthening disease prevention andcontrol, developing urban primary health care, continuing and expanding schoolhealth programs, improving district and upazila health facilities, andimproving the utilization of URCs. In support of the first two components,the project will assist in strengthening information systems, improving FP andhealth management, expanding communications programs, supporting NGOactivities, and developing innovative projects. Finally, the project willassist continuation of the three women's programs financed under the previousthree projects and will strengthen and develop the National Nutrition Council,in anticipation of a substantial program of nutrition interventions. Each ofthe components listed below is described fully in project-related ProjectProformas, for which GOB approval is a condition of credit effectiveness. Thecosts indicated reflect base costs exclusive of contingencies.

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Component A. Strengthening FP/MCH Services Delivery (US$321.7 million)

(1) Improving Access to FP Services (US$180.1 million)

(2) Strengthening MCH Services (US$38.6 million)

(3) Enhancing Clinical Service Delivery and FP/MCH Quality Assurance(US$31.5 million)

(4) Imparting Inservice Training in FPIMCH to Upazila and DistrictStaff (US$17.3 million)

(i) Training FP/MCH Staff through NIPORT (US$12.4 million)

(ii) Training TBAs (US$4.9 million)

(5) Construction and Renovation of FP/MCH Facilities (US$41.6 million)

(i) Construction and Upgrading of FWCs and RDs (US$31.2million)

(ii) Upgrading the Maternal and Child Health Training Institute(US$8.3 million)

(iii) Strengthening the FP/MCH Logistics and Supply SystemUS$2.1 million)

(6) Private Sector Contraceptive Marketing (US$12.6 million)

Component B. Strengthening Health Service Delivery (US$144.2 million)

(1) Comprehensive Maternal and Neonatal Health Care Pilot Project(US$2.1 million)

(2) Strengthening Nursing and Medical Education (US$41.8 million)

(i) Nursing Education (US$11.4 million)

(ii) Medical Education (US$13.7 million)

(iii) Medical Quality Assurance (US$1.1 million)

(iv) Community-based Medical Education (US$1.8 million) 1

(v) Institute for Mother and Child Health (US$8.7 million)

(vi) NIPSOM (US$6.9 million)

(3) Supporting Medical Research (US$1.5 million)

Although this subcomponent is included here for purposes of logic, itis actually considered to be an innovative project under C(5) and hasbeen costed accordingly.

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(4) Strengthening Disease Prevention and Control (US$52.5 million)

(i) Reorganizing Programs for Tuberculosis and Leprosy (US$28.0million)

(ii) Continuing the EPI and CDD Programs (US$6.6 million)

(iii) Supporting the Vitamin A and Iodine Deficiencies and ARIPrograms (US$14.7 million)

(iv) Developing Control of Vector-Borne Diseases (US$1.2million)

(v) Assisting the Intestinal Parasite Control Project (US$0.5million)

(vi) Expanding the Institute of Public Health (US$1.0 million)

(vii) Modernizing the Drug Testing Laboratory (US$0.5 million)

(5) Developing Urban PHC (US$2.2 million)

(6) Continuing and Expanding School Health Programs (US$1.1 million)

(7) Improving Health Facilities (US$21.8 million)

(i) Renovating District Hospitals and UHCs (US$10.7 million)

(ii) Constructing UHCs (US$11.1 million)

(8) Improving Utilization of UHCs and FWCs (US$21.2 million)

Component C. Improving Supportive Activities to the Delivery of FP and HealthServices (US$66.2 million)

(1) Strengthening Information Systems (US$5.4 million)

(i) MIS for FP/MCH (US$2.3 million)

(ii) MIS for Health (US$2.4 million)

(iii) Health and Demographic Survey (US$0.5 mii- i)

(iv) Epidemiological Surveillance System (US$0.5 million)

(2) Improving FP and Health Organization, Management and Financing(US$22.8 million)

(i) MDU Support to FP and Health Services (US$3.2 million)

(ii) Reorganization of Health and FP programs (US$1.5 million)

(iii) Strengthening the PDEU (US$1.2 million)

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(iv) Establishment of the MCH Coordination Cell (US$1.0 million)

(v) Establishment of the Health Economics and Financing Project(US$0.4 million)

(vi) Restructuring of the Project Finatace Cell (US$0.3 million)

(vii) Project Management Support (US$4.9 million) 2

(viii) Construction of a FP and Health Building (US$8.8 million)

(ix) Establishment of the Maintenance and Construction ManagementUnit (MCMU) (US$1.5 million)

(3) Expanding Communications Programs (US$15.3 million)

(i) Functional integration of the IEM and HEB Units (US$7.0million)

(ii) Support for Mass Media Activities (US$3.4 million)

(iii) Promotion of Community Participation (US$4.9 million)

(4) Supporting NGOs (US$7.8 million)

(5) Developing Innovative Projects (US$4.9 million) J

(6) Supporting Technical Assistance Projects (US$10.0 million)

Component D. Women's and Nutrition Programs (US$11.6 million)

(1) Continuing the Three Women's Projects (US$9.2 million)

(2) Coordinated Nutrition Program of the National Nutrition Council(US$2.4 million)

C. Detailed Project Description

Component A. Strengthening of FP/MCH Service Delivery (US$321.7 Million)

2.6 Component A will support GOB efforts to expand and strengthen theentire range of services of its FP and MCH program. This includes moreemphasis on providing outreach services and supervision, ensuringcontraceptive supplies, enlarging the satellite clinic program, and enhancingthe quality of clinical services. It also covers all training activities,

2 This subcomponent is discussed in detail in Chapter IV,Implementation and Supervision, para 4.10.

a Cost estimate is inclusive of B(2) (iv).

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including TBAs, and renovation and construction of new FP and MCH facilities.Finally, it supports provision of contraceptives through the private sector.

A.(l) Improving Access to FP Services

2.7 Outreach Services. Currently, about 16,500 male HAs and about20,000 female FWAs provide outreach services. Vacancies exist for 5,000 HApositions. GOB has agreed to fill these by female workers and graduallyreplace the majority of male HAs by females. GOB also plans to recruit anadditional 3,500 FWAs. It has been agreed that a common job description willbe drawn up for all female field workers (FWAs and HAs) and that the presentgeographical area/population covered by these workers will be divided intotwo; each worker will be placed in independent charge of one area, thusreducing by half the number of households she/he covers. The supervisor-worker ratio under the arrangement will work out at 1:5, which is manageable.Agreement was reached with GOB during negotiations that, by January 1, 1995,it will employ qualified women to fill at least 4,500 of the 5,000 vacant HApositions in its outreach services and, by March 31, 1992, prepare and furnishto IDA for comments a plan on the recruitment of HAs including the appropriateproportions of male and female staff, and subsequently carry out such plantaking into account IDA's comments.

2.8 In view of the recurrent cost implications in expanding the HA andFWA cadres, GOB plans to use female members of the Village Defense Party(VDP), Swanirvar (NGO) and the Mothers' Clubs and Women's Cooperatives tofunction as an interface between FWAs and clients. These volunteers will needadditional training, a clear job description, supervisory support, andcommunity support. The project will assist GOB plans to use the volunteerforce; components on community participation (para 2.80), NGOs (paras 2.81-2.82) and innovative projects (para 2.83) will be used to supplement thestrength of field workers.

2.9 In view of the strategic importance of female health and FPworkers, GOB will absorb increasingly the cost of their salaries. GOB willfinance 11,500 HAs and 13,500 FWAs and the Consortium, upto 5000 female HAsand 10,000 FWAs (partly from the proceeds of fertilizer sales in Bangladeshunder a separate agreement between the Government of Canada and GOB).Currently Consortium financing accounts for 14,500 out of 20,000 FWAs. Theproject will also finance field worker supplies as these supplies willdirectly contribute to field worker efficiency and proper storage ofcontraceptives. The recruitment of female health and FP workers will be donein line with the human resource development plan (para 2.70).

2.10 FWC-based Services. The present sanctioned strength of each FWC isone each MA, FWV, pharmacist, aya and peon-cum-night watchman. The post ofpharmacist is often vacant and found to be superfluous. Due to increaseddemand, a single FWV can no longer cater to the full needs of her area inproviding prenatal, natal, and postnatal care, inserting IUDs, providinginjectables, etc. The project will therefore support a second FWV to each FWCin lieu of the pharmacist. The few pharmacists posted at FWCs will bedeployed at UHCs and district hospitals. During the project, 2,000 FWVs willbe trained and posted to districts and upazilas where performance has beencomparatively poor. The project provides for all operational costs for thenewly recruited FWVs.

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2.11 Supervision. The supervisory tiers developed under the ThirdProject, i.e. of Senior FWVs, Assistant Family Planning Officers (APPOs), anddivisional directors, will be continued and strengthened. A major weakness at

district level will be removed by renewing the post of Assistant Director(MCH/FP) and by the PWVs supervising the FWAs. Recruiting for the 460sanctioned positions of AFPOs will be completed under the project (168 hadbeen recruited by February 1991). The mobility of supervisory staff will alsobe improved through a suitable mechanism, such as the payment of expensestowards the hire-purchase of suitable transport, e.g., motorcycles, rickshaw-vans, etc. and/or adequate travel/daily allowances (para 2.13). Procurementof 22,500 bicycles will be continued for field workers. The type of transportfor three female categories, i.e. FWVs, Senior FWVs and female M0s, remainsproblematic. GOB will prepare a working paper on transport provisions and onpayment of travel-related expenses or suitable alternatives for review by IDA

and the Cofinanciers and subsequent implementation of the agreedrecommendations (para 2.13). During negotiations, agreement was reached thatGOB will establish transportation arrangements, satisfactory to IDA, for FPand health field workers to attend satellite clinics.

2.12 Provision of Contraceptives and Other FP Supplies. The projectwill finance the purchase of contraceptives and other FP supplies to ensuretheir uninterrupted availability. The MOHFW has improved its logisticsmanagement to an extent by addressing key issues such as forecast of demand,timely procurement, in-country distribution, and logistics monitoring andsupervision. Based on the targeted CPR of 45-50Z to be achieved by 1995 (para1.38) and the mix of contraceptive methods envisaged (Annex 21), GOB hasprojected requirements for contraceptives and nedical and surgical requisites(MSR) for the Fourth Plan period as follows:

Contraceptive Method Number of Acceptors 4 Contraceptives or MSRs(millions) Required (millions)

oral pills (low dose) 12.50 188.0 cyclesCondoms 7.20 1,088.0 piecesInjectables 6.50 32.5 dosesIUDs 2.89 2.89 piecesSterilization 2.08 MSR for 1.24 Tubectomies

0.84 Vasectomies

These requirements would be reviewed quarterly to reflect the emerging programneeds through an established GOB mechanism. The condoms required are planned

to be procured and supplied directly to the Social Marketing Company (SMC)(para 2.28). While high-dose oral contraceptive pills are currently stillused in the program, eventually only low-dose pills will be procured under the

project, following a phased transition period. Apart from those described inpara 2.18, new contraceptive methods to be introduced up to 1997 may be funded

as well (para 2.83 and Annex 21). Agreement was reached with GOB duringnegotiations that a fertility survey will be carried out by December 31, 1994,

and a contraceptive prevalence survey will be carried out every two years,commencing by March 31, 1993, both in accordance with terms of referenceacceptable to IDA, and the results furnished to IDA for comments.

4 Acceptors in terms of person-years for all methods, except IUD and

sterilization.

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A.(2) Strengthening MCH Services

2.13 Satellite Clinics. The project will significantly expand thesatellite clinic system which possesses great potential to delivercomprehensive MCH and FP services nearer to the community. To maximize theclinics' effectiveness, some of the requirements that the project will supportare training and supervision of FWC and upazila staff, supply of essentialequipment, Drug and Dietary Supplement (DDS) kits and transport. NIPORT willinclude a module on satellite clinics as part of training of all upazilastaff. The disease patterns and drug requirements at satellite clinics willbe closely monitored ar,d analyzed after a year to assess any modificetion inthe drug supply that may be needed. To increase the mobility of ke, staff,the project will provide for special payment of travel-related expenses and/orhire-purchase of appropriate transport, such as bicycles, motorcycles,rickshaws, rickshaw-vans and boats. A condition of credit effectiveness isthat GOB will establish transportation arrangements, satisfactory to IDA, forFP and health field workers to attend satellite clinics.

2.14 Essential MCH Drugs and Equipment. The requirement of DDS kits forthe project duration is estimated to be around 130,000 for stationary clinicsand another 100,000 to 200,000 for satellite clinics, i.e. 5 kits a year perfunctional FWC, 10 kits a year per MCH unit, and 4 kits a year per satelliteclinic. The project will firance the supply of DDS kits, to the requiredextent, starting with around .10,000 and reviewing in 1993-94, the rate ofabsorption of this initial allocation. GOB will keep accurate records ofattendance and types of cases at the clinics and analyze the records on asample basis at the end of each year to facilitate review of the types,quantities and appropriateness of drugs needed starting in 1992. The contentsof kits for satellite clinics will then be suitably recalculated and modified.The project will also finance MCH and midwifery kits at the rate of at leastone kit per service facility. Apart from the requirements of new centers,replacement equipment will be provided to 2,725 MCH service facilities and to2,925 midwifery rooms.

A.(3) Enhancing Clinical Service Delivery and FP/MCH Quality Assura--3

2.15 FPCST. Periodic reviews of the performance of the FPCST havehighlighted not only its usefulness in improving the quality of clinical PPservices but also the need to widen the scope of the teams. Under theproject, the teams will therefore also review clinical MCH services. Theywill assist with internalizing quality of care supervision of clinical FP andMCH service delivery at district level and below by linking up with thedepartments of obstetrics/gynecology of the medical colleges (para 2.35). Thesubcomponents on Medical Quality Assurance (para 2.38), technical assistancefor Health Care Quality Assurance (para 2.86) and maternal and neonatal healthcare (para 2.30) would be implemented in close cooperation with the FPCST.Staffing of the FPCST is to be reorganized. The Director (Clinical Services)will be the Project Director of the FPCST, which will comprise eight teams,each composed of one national medical and one national nurse consultant. Theexpatriate consultants, a physician and a nurse, will serve as counterparts tothe Project Director. A national level committee will be constituted tomonitor and advise on the teams' activities and MOHFW action, as necessary.Technical support to the FPCST will be provided by UNFPA, with the support ofan international resource group providing external backstopping.

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2.16 Support to FP Clinical Services Delivery. The project will supportthe provision of FP clinical services. Whereas increasing priority will begiven to non-clinical FP methods such as oral contraceptives and condoms,clinical FP services will remain a very important factor in reducing fertilityand enhancing maternal and child health for a long time to come. The clinicalFP services will include vasectomies and tubectomies, menstrual regulation,IUD insertions, provision of injectables and implants, clinic-basedsupervision and examination of women using oral contraceptives and all otherFP services for which an institutional facility is necessary. The projectwill finance operational expenditures, staff salaries, equipment andtransportation connected with clinical FP services.

2.17 Mohamedpur Fertility Services and Training Center. This clinicalcenter has been developed to promote a variety of FP services, includingmenstrual regulation, clinical contraceptive training and adaptivecontraceptive research. The center will give comprehensive FP services to15,000 clients annually, MCH services to all women and children visiting thecenter, and clinical training to 1,145 female physicians and FP/MCH cadres.Laboratory facilities are planned for evaluating side-effects of clinicalcontraception. The project will finance the continuation and strengthening ofthe center in terms of salaries and allowances, equipment and transport.

2.18 Introduction of Contraceptive Technologies. GOB proposes tointroduce laparoscopic techniques for tubectomies, expand the implant program,and introduce nonscalpel vasectomies. It has been agreed with GOB that newand existing contraceptive technologies will be introduced after properevaluation and in a phased manner, given the priority need to improve qualityand coverage of services. Introduction of laparoscopic techniques will bebased on phase IV clinical trials to assess the types of personnel best ableto learn the techniques, associated training requirements and potential oflaparoscopy for increasing the acceptance of tubectomy. Expansion of implantsis proposed to be taken up for 1993, while addressing such issues as trainingof relevant staff. Nonscalpel vasectomy is already being supported by USAID,and GOB proposes to extend it to at least four government clinics. The GOBhas agreed to consult IDA and the Consortium before each new phase ofexpansion and to carry out a midterm review. The Bangladesh FertilityResearch Program (BFRP) will, among others, be responsible for evaluations andclinical trials. The project provides for purchase of laparoscopes, implants,training costs, IEC activities and evaluation, as well as for research anddevelopment expenditures by BFRP and other research institutes. Additionalfunding from the Innovative Activities component may be used if necessary(para 2.83).

2.19 IUD Kits. To ensure the effectiveness and smooth delivery of IUDinsertion services, the project will finance the purchase of 5,581 IUD kits,i.e. one per clinical IUD service facility in the country.

A.(4) Imparting Inservice Training in FP/MCH to Upazila and District Staff

2.20 Training of FP/MCH Staff through NIPORT. During the Third Planperiod, NIPORT advanced a long way toward building infrastructure, improvingcapacity utilization and, to some extent, the quality of training, andconducting research. Some of the steps taken were: introduction of MobileTraining Teams' for trainer training at FWVTIs and RTCs, links with BangladeshRural Advancement Committee for treining methodology and management, and a

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more skill-oriented curriculum. Despite the good progress, staff shortagespersist.

2.21 Integration is proposed of the 12 FWVTIs, 20 RTCs, and NIPORT intoa single "Institution" to impart collaborative training to program managersand staff at all levels (Chart 3). The focus of NIPORT research will largelybe on training. A total of 28 program/training-related studies have beenplanned for 1991-95. NIPORT will undertake logistics management training aswell as training of physicians on sterilization. About 67,000 personnel willbe trained during 1991-95, including about 9,100 program managers. NIPORTwill also organize mobile training teams to train 8,000 FPAs/AHIs at UHCs.About 2,000 FWVs will undergo 18 months of basic training during the period(para 2.10). Gender awareness topics will be included in basic and in-servicecurricula of field workers.

2.22 The project will continue to finance NIPORT and its strengthening.It will cover the addition of about 90 positions to NIPORT staff, replace 34worn out vehicles and purchase 8 new jeeps. The existing three expatriateconsultants will be complemented by the addition ol a specialist in training-related research and evaluation. An outdoor service unit for PP/MCH consistingof one FWV, one midwife/nurse and two Grade IV staff will be established ineach of the 12 FWVTIs. Provision will be made for additional accommodationsfor NIPORT.

2.23 Training of TBAs. The training of TEAs initiated under the ThirdPlan (10,000 so far) will be continued and expanded. In close cooperationwith UNICEF and complementing its funding, the project will support trainingof a total of 48,000 TBAs (out of 52,000 yet to be trained). In addition, theSenior FWVs will receive refresher training. The training management unitestablished under the Third Plan will be continued. The number of projectofficers will be increased from the present four to eight and trainingallowances for all categories of personnel will be doubled from currentlevels. The project officers will be supplied with vehicles on hire-purchasebasis. The training program will be closely monitored and evaluated withspecial reference to: (i) appropriate referral of high-risk pregnancies; (ii)safe delivery techniques; (iii) number of clients serviced annually by eachTBA; (iv) community acceptance and utilization of TBAs; and (v) impact of theTBA project on MCH.

A.(5) Construction and Renovation of FP/MCH Facilities

2.24 Construction and Upgrading of FWCs and RDs. Phased expansion ofthe network of FWCs will continue. As of January 1991, of the 4,403 unions inBangladesh, 460 were served by UHCs, 1,275 by RDs (of which 310 have beenupgraded) and 2,500 by FWCs. A further 100 FWCs will be established in unionscurgently not having any FP or health facility and 500 RDs will be upgraded tounion FWC level. At the end of the Fourth Project, this will leave 68 unionswithout any NWC or other facility and 465 RDs still needing to be upgraded. Inview of the importance of new or upgraded facilities being fully utilized forFP and MCH services, agreement was reached with GOB during negotiations that asurvey of the physical condition and the utilization of existing FP and healthfacilities will be carried out by September 30, 1992 and the results furnishedto IDA for comments.

2.25 The standard design for FWCs adopted in the previous projects andmodified slightly from time to time will be adopted for the Fourth Project.

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All buildings will have reinforced roofing. The plinth level of the buildingswill be located above the highest flood level observed so far (1988). GOB hasagreed that utmost care will be observed in the selection of sites to ensuremaximum utilization, with final site selection subject to approval by IDA andthe Consortium. The standard equipment for each FWC includes one each of MCHkit, Midwifery kit, IU) kit, TBA kit and FWC kit (items specially required bythe MA). The project will finance the procurement of these items in case theyare not provided by other agencies. Costs for design and supervision of theworks, either through the Local Government Engineering Bureau (LGEB) orproposed Maintenance anid Construction Management Unit (MCMU)-lecconsultancies, will also be funded by the project. Based on annualmaintenance requirements, 8,892 maintenance works for keeping FWCs operationalwill be provided for during the Fourth Project period. The project will meet502 and GOB the other 50Z of the maintenance costs. Rehabilitation of flood-affected FWCs has been assigned to LGEB, which will continue during theproject. The proposed MCMU will be responsible for maintenance work (para2.76). During negotiations, agreement was reached that GOB will furnish toIDA the list of sites for construction of FWCs, selected based on criteriaacceptable to the Association and subsequently construct the centers inaccordance with standard design agreed with IDA.

2.26 Upgrading the Maternal and Child Health Training Institute. TheMaternal and Child Health Training Institute at Azimpur and Lalkuti will heupgraded to provide high quality, essential and comprehensive MCH/FP servicesfor the urban area of Dhaka city. It will train medical and paramedicaltrainers and personnel, TBAs, field workers and FWVs in essential MCH andobstetric functions (including the importance of breastfeeding). The existingMCH hospital at Azimpur will be expanded and a new building constructed atLalkuti. The targeted training capacity is 60 staff per month, for whichexpatriate assistance will be covered throughout the project. The projectprovides for renovation of existing buildings; construction of additionalbuildings; purchase of equipment, vehicles, and furni.ure; appointment ofadditional staff; and maintenance of buildings. At Azimpur, the componentincludes renovation and extension of the main building to provide anadditional 50 training beds as well as construction of a building forextension of the present training and outpatient facility. The conatructioncomponent of Lalkuti envisages a 250-bed MCH training hospital, staff quartersand a training hostel for 40 trainees.

2.27 Strengthening the FP/MCH Logistics and Supply System. The projectwill improve the efficiency of the logistics and supply system through anumber of interrelated activities. One is improving the capacity forcommodity forecasting and strengthening the existing procurement cell withinthe FP Directorate with additional staff and training. The cell will workwith the LMIS at the central warehouse to prepare projections forcontraceptives, drugs and MSR. Seven additional posts will be supported.Another is strengthening of the logistics system itself through training oflocal staff. The third is provision of training for each of the fourdivisional logistics monitoring teams. The last is addition of staff to thecentral warehouse and regional warehouses (73) in view of the larger quantityof supplies to be handled. The project will replace worn out transport ofvarious types. The service of a forecasting and procurement adviser underConsortium (e.g. EEC) or USAID-financed schemes will be funded by the project,with special reference to direct funding for condom supplies to SMC ofBangladesh. Technical assistance and counterpart training for the procurementof pharmaceuticals, including quality assurance, will be performed by a

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pharmacist to be posted by UNICEF, while condom testing will be contracted outto a technically competent agency. The project will support a maintenancecell that will look after the upkeep of the warehouses, including those atUHCs for storing FP and health supplies. Following a feasibility study toidentify the exact storage requirements for FP and health supplies at UHCe,the project will finance the cost of such storage requirements. Agreement wasreached with GOB during negotiations that, by December 31, 1992, a feasibilitystudy to identify the storage requirements for FP and health supplies will becarried out and the results furnished to IDA.

A.(6) Private Sector Contraceptives Marketing

2.28 Condom Supply through SMC and Other Suitable Organizations. Theprovision of condoms t'.rough the SMC currently accounts for about 382 ofcontraceptive prevalence for condom use. SMC is a fully private agency, whichessentially acts as a private sector foundation and recovers its operatingcosts by selling condoms at a minimal price. Condoms so far have beensupplied by USAID directly to SMC. USAID, however, is obliged to purchasecondoms domestically at a rate four times higher than could be obtained atinternational competitive bidding level. Agreement has been reached with GOBand USAID that the IDA Consortium will take over condom supply to the SMC(totalling around 411 million pieces over the project period), thereby freeingUSAID resources for more productive activities in the sector and ensuring moreefficient use of resources for condom procurement. The principle of directsupply will be maintained and the existing logistics system will continue tobe used as far as possible. Condom distribution through other suitableorganizations may be financed as well.

Component B. Strengthening Health Services Delivery (US$144.2 million)

2.29 Component B will expand the Consortium's support from the PPsubsector to the Health subsector. It will assist the establishment ofmaternal and neonatal health care as a GOB priority area, reorient nursing andmedical education towards community and public health, and strengthen criticaldisease prevention programs. It will also make a start with developing urbanand school health programs. Renovation and construction of health facilitiesfor MCH will be supported. A special effort will be made to improve theutilization of health care facilities.

B.(l) Comprehensive Maternal and Neonatal Health Care Pilot Project

2.30 This component will develop comprehensive maternal and neonatalhealth care services in selected districts. The major approaches proposed aresound planning a-ad implementation of a combination of outreach and clinicaAmaternal health interventions, training of health personnel in epidemiologicaland essential obstetric functions, use of IEM (e.g., regarding breastfeeding),improved operational management and provision of essential supplies (e.g.blood). All the 295 unions in the districts of Kushtia, Tangail, Feni andSirajganj/Pabna will be covered.

2.31 Beginning with a comprehensive baseline survey, the project will,among others, include: continuation of refresher training of TBAs, specialtraining of physicians in abnormal maternity cases, development of IEMmaterials, implementation of maternal referrals, outreach pregnancy-riskassessments, logistics of blood supplies, intravenous fluids and otheressentials at UHC or union-level, etc. The Project Director will be assisted

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by an expatriate MCH Advisor and MCH Coordinator. The project offers a uniqueopportunity to integrate some of the strategies developed in other componentsinto one coherent program through coordination between the other relatedprcjects like IEM, TBA training, medical and nursing education, and qualityassurance (paras 2.15 and 2.38). The entire cost of the component, includingadministrative costs, training, research and evaluation, production of IEMmaterials, transport and contingencies, will be met by the project. Duringnegotiations, agreement was reached with GOB that, by March 31, 1992, acomprehensive baseline survey of maternal and neonatal health care in thedistricts of Kushtia, Tangail, Feni and Sirajganj/Pabna will be initiated andthe results furnished to IDA for comments.

B.(2) Strengthening Nursing and Medical Education

2.32 The Fourth Five-Year Plan addresses the issue of reorienting theBangladesh medical and nursing education system to support more appropriatehealth care priorities, including FP/MCH and PHC. This is planned to beachieved through: (i) enhancing staff strength, trainer training, providingstipends for students, and improving infrastructure; (ii) reinforcing thetraining in obstetrics and gynecology, pediatrics and community medicine inmedical and nursing colleges including rural field placements of students andfaculty; (iii) attempting community-oriented medical education throughinnovative approaches; (iv) supporting specific national institutions alreadyactive in this area, such as the Center for Medical Education (CME), NIPSOM,Institute for Epidemiology, Disease Control and Research (IEDCR), andInstitute for Public Health (IPH), and creating a new Institute for Mother andChild Health.

2.33 Nursing Education. To address the underdevelopment of nursingeducation and services, the project will: (i) strengthen the College ofNursing's post-basic program for sister-tutors, nurse administrators and nursesupervisors; (ii) strengthen teaching and field work methods for implementingthe revised basic nursing curriculum in the 38 basic Nursing Institutes; (iii)create additional essential nursing posts; (iv) expand continuing educationfor nurses; (v) develop fourth-year options for the basic nursing curriculum;(vi) develop rural education curriculum for field training of students inurban Nursing Institutes; and (vii) develop an MIS for the Directorate ofNursing (Annex 25). The project will finance additional staff, curriculumdevelopment and library teaching materials and language training; constructionand rehabilitation of the nursing colle3e, Nursing Institutes, continuingeducation centers, and rural health care training centers; equipment andsupplies; and technical assistance, including support by WHO. Agreement wasreached with GOB during negotiations that additional nurse positions inNursing Institutes and UHCs will be created by September 30, 1992, inaccordance with a schedule agreed with IDA.

2.34 Medical Education. The eight Government medical college hospitalsand four post-graduate institute hospitals of the country endeavour to providetertiary health care services, including referral services for patients sentby primary and secondary health care points. In fact, they have become sooverwhelmed by primary care patients and so derelict due to budgetary,managerial and professional neglect that even primary care is no longer ofacceptable quality, let alone MCH or referral services. This component aimsto improve and consolidate the program for training doctors in MCH andcommunity medicine through improvement of physical facilities, modern butappropriate technology, and better clinical training for relevant categories

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of staff. At four medical college hospitals (Mymensingh, Rajshahi, Sylhet andSalimullah), the project will support creation of mother and child welfareoutpatient rooms and 20-bed children's wards; repair of water supply, sewagedisposal and drainage systems; repair of electrical systems and equipment;procurement of essential MCH eqt'ipment; and recruitment of personnel. It willalso finance renovation of the eight medical colleges and construction ofhostel facilities for female students with 50-60 units each, at the Barisal,Sylhet, Mymensingh, Chittagong and Salimullah medical colleges.

2.35 The eight medical colleges will develop preventive MCH services andtraining through their Model Clinics. The project will support theDepartments of Obstetrics and Pediatrics and the Model Clinics, which willbecome the medical college hospitals' out-patient departments for MCH. Thefunctioning of the Model Clinics will be improved by placing them under theDepartments of Obstetrics and Gynecology and Pediatrics, appointing ten fieldworkers to each clinic, enlarging the scope of the services to encompass allMCH services, and revising the MCH curriculum for interns (including emphasison such issues as breastfeeding). A new post of coordinator will be createdunder the project. Other aspects to be supported are obstetric equipment andsupplies, journals and books, new posts (ranging from community obstetricianto librarian), language training and study tours. Technical assistance willbe provided through WHO and institutional linkages overseas.

2.36 All vacancies in the Departments of Community Medicine in the eightmedical colleges will be filled. The project provides for training ofteachers in modern teaching methods, special allowances for field placements,purchase of two 15-seat microbuses for each medical college, renovation ofseven field training sites, and construction of one new field training sitefor Sher-e-Bangla Medical College. A full-time expatriate consultancy,institutional linkages overseas, short-term visits by foreign experts andstudy tours/fellowships by senior staff are expected to lend strength to thiscomponent.

2.37 In each medical college, special units for medical education existunder the authority of the CME in Dhaka. Under the project, the CME willfurther develop those units, formulate a pilot scheme outside Dhaka for staffdevelopment, and develop a capability to produce teaching materials andprepare a manual for training teachers and evaluating medical education. TheCenter will also implement the Human Resources Development Program (para 2.70)and the Resource Center for 'Development of Health Care Quality Assurance'(para 2.38), which will be funded by the project.

2.38 Medical Quality Assurance. A major effort will be made towardimproving the quality of health care to motivate use of FP and medicalservices. Apart from strengthening FP clinical surveillance through linkageswith FPCST (para 2.15) and the rational use of drugs (para 2.42), thedevelopment of quality assurance in medical practice will be undertaken. Theproject will finance a quality assurance system at two levels for enablinghealth professionals to tackle quality problems in health care delivery. Atthe central level, the project will support a Resource Center at the CME (para2.37). At the field level, it will finance 14 health institutions, selectedfor the first phase of the project, where baseline assessments of patient carewill be conducted and task groups, with technical assistance, will identifyproblems, set priorities, establish criteria and standards of good care, anddevelop manuals, training and continuous evaluation. Linkages will beestablished with local professional groups like the Bangladesh Medical

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Association and with overseas groups such as the International Society for

Quality Assurance in Health, the IHCAR of the Karolinska Institute and WHO.

2.39 Community-based Medical Education. To develop medical personnelsuited to community needs, a pilot project will be supported. Thisreorientation in training will follow the McMaster module of medicaleducation. It will focus on community diagnosis of health problems and theirprioritization using epidemiological tools; planning, implementation andevaluation of community health programs; appropriate treatment of commondiseases; training of community health teams; supervision and coordination ofthese health teams; facilitation of behavioral change and communityparticipation; and multisectoral efforts. The project will be located at amedical college other than Dhaka and Chittagong, with technical support from

the International Network of Community-Oriented Medical Institutes. It willmainly be funded from the Innovative activities sub-component (para 2.83).

2.40 Institute for Mother and Child Health. The MCH programs of the GOBdirected at preventing and treating the illnesses of children under 15 andwomen of reproductive age (50? and 20X respectively, i.e. 702 of totalpopulation) still remain weak. A structural cause is the severe shortage ofMCH staff adequately trained in combined clinical and preventive pediatric and

obstetric skills; absence of institutional MCH leadership in the countrycontributes to the low priority accorded to such training. The project willfund the establishment of an Institute for Mother and Child Health withlimited clinical facilities in a semi-rural area. It will be modelled on theChild Health Institute in London and will follow the Morley approach to MCHtraining. The Institute is meant to establish a leading position in MCH andpediatrics to promote appropriate MCH strategies and policies. A strong linkwill be established with the community-based medical education subcomponent(para 2.39). Subject to final design approval by IDA, the project will fundphysical facilities, pediatric equipment, MCH supplies, training and trainingsupplies and transport. Strict adherence to the Morley approach in design andexecution of the Institute will be closely monitored by the annual IDAConsortium Review Missions (Annex :6). Agreement was reached with GOB during

negotiations that the final design of the Institute for Mother and ChildHealth will be furnished to IDA for clearance.

2.41 NIPSOM. The focal point for the production of public healthprofessionals and for health service research in Bangladesh is NIPSOM. Theproject will address some of the current constraints of NIPSOM and upgrade thequality of training and research capability. The objectives include: humanresource development as per Health for All by the year 2000 strategies; healthsystems research; establishment of a dialogue between planners, managers,providers and consumers of health care; better occupational health services;and promotion of the rational use of drugs. The project provides for:administretive, institutional and departmental reviews; construction/renovation and furnishing of offices, including a special project office forthe rational use of drugs; a student hostel; and a field practice area. Allaspects of the library will be upgraded. The project will also fundequipment for occupational and environmental health, promotion of field workthrough improved transportation arrangements, support for health serviceresearch through grants, increase in staff strength, and an institutionallinkage of NIPSOM with a center in Australia. In addition NIPSOM will developlinkages with the IEM, HEB, CME, NIPORT, Maternal and Child Health Institute,ICDDR'B and others.

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2.42 Within NIPSOM, a special project will be funded on the Rational Useof Drugs, seeking to influence prescribing and utilization practices inaccordance with WHO guidelines. Emphasizing IEM, it will develop medicalpractice guidelines through workshops, reference materials, a reporting systemfor prescription profiles, a system to monitor prescription patterns, studies,etc. Support includes special staff, consultancies, furniture and equipment,and drug management material, among others.

B.(3) Supporting Medical Research

2.43 The activities of the Bangladesh Medical Research Council, the mainorganization for the promotion of medical research in the country, have beenhampered, largely due to inadequate funds. The component aims to develop astrategy for essential national medical research with short and long termobjectives, better coordinate medical research, disseminate research findings,and ultimately improve quality of medical education. Proposed actions includea national consultative meeting for research strategy, research cells in eightmedical colleges to coordinate research and a focus of research on communitymedicine and MCH. The project will fund research grants to prioritydepartments of obstetrics, pediatrics and community medicine, awards forresearchers to visit overseas institutions for specific training relevant totheir research project, visiting overseas experts, enhanced literature searchcapacity of medical colleges, research dissemination and logistic support,such as office equipment and vehicles. Agreement was reached with GOB duringnegotiations that recipients of research grants and of project-financedtraining will remain in their institutions/areas of specialized expertise forat least two years after completion of training or research to enable creationof institutional capacity.

B.(4) Strengthening Disease Prevention and Control

2.44 Reorganizing Programs for Tuberculosis and Leprosy. These poverty-related diseases have grave socio-economic consequences. Estimates put theprevalence rate at 1.6 million for tuberculosis and 1.3 million for leprosy.Tuberculosis is more fatal but leprosy has a devastating social impact due tothe high rate of disability. Both diseases are completely curable and controlis possible through concerted case-detection, case-holding and completetreatment. The project will finance reorganized and intensified controlprograms with the following main objectives: (i) reduction of morbidity andmortality due to tuberculosis and leprosy; (ii) an effective informationsystem, adequate manpower development facilities, and supply of drugs; and(iii) rehabilitation and health education.

2.45 Salient features of the project include: (i) baseline surveys onthe extent and distribution of the two diseases; (ii) training and deploymentof staff (8,000 for tuberculosis and 4,000 for leprosy, including about 450new leprosy control assistants); (iii) enhanced local diagnostic andmanagement facilities; (iv) expanded coverage of case-detection and bettercase-holding through outreach follow-up by providing transport to fieldworkers; (v) strong surveillance and information systems; (vi) bettercoordination between GOB and NGOs; and (vii) increased rehabilitationfacilities, particularly for leprosy. District tuberculosis coordinators anddistrict medical officers (leprosy) will be appointed and foreign consultantswill be employed to assist the project. Agreement was reached with GOB duringnegotiations that baseline surveys in accordance with terms of reference

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acceptable to IDA will be carried out by September 30, 1992 and the resultsfurnished to IDA for comments.

2.46 Continuing the EPI Program. The EPI program seeks to reduce the

morbidity, mortality and disability arising out of six important childhooddiseases (diphtheria, tetanus, pertussis, measles, polio and tuberculosis).The program aims at 85? coverage of the main target groups. The strategyincludes social mobilization, an intersectoral approach, strengtheninginstitutional services, and sustaining and improving a vast network ofoutreach services. While GOB will provide for the majority of EPI staff, the

project will support: all existing development staff and recruitment of new

staff, namely, 3 assistant directors, 16 MOs, 3 cold-chain engineers, 10 cold-chain technicians, 19 drivers and 64 assistant storekeepers; refreshertraining of all staff: purchase of vaccines; maintenance and replacement ofcold-chain equipment; and renovation and modest expansion of the EPIDirectorate facilities. In addition, 400 motorcycles and 500 bicycles are to

be provided to staff on a hire-purchase basis for monitoring of coverage andEPI target disease surveillance. Three expatriates from UNICEF and two fromUSAID will be available for technical assistance to this component.

2.47 Continuing the CDD Program. Under this component, the majorobjective is to reduce childhood mortality from diarrheal diseases. Theproject will support education and training of both the health serviceproviders and community. Fifty new district diarrheal disease centers, 50more Oral Rehydration Treatment corners to cover at least one upazila perdistrict, and an upazila surveillance system to cover 20 sentinel upazilas areplanned. The project will provide technical and management training to 20

national CDD facilitators. In coordination with the IEDCR, it will alsostrengthen epidemiological surveillance, provide for study tours, use 3? ofthe budget for IEC activities (e.g. regarding breastfeeding), and fund theproduction and/or procurement of oral rehydration salts. The usefulness of aseparate reporting system for diarrheal diseases will be examined under theproject.

2.48 Supporting the Vitamin A and Iodine Deficiencies and ARI Programs.

These components will provide support to prevent and treat (night) blindness(Vitamin A deficiency), goiter (iodine deficiency), and ARI. Vitamin Adeficiency is very prevalent in the country and is implicated in nutritionaldisorders leading to higher rates of common infections; more directly visibleare the millions of disabilities due to Vitamin A blindness. Assistance will

be given for the expansion of an anti-blindness program under which Vitamin Ais given to children 6 weeks-6 years old. Children with xerophthalmia up to15 years and lactating mothers also will be treated. FWAs, HAs, and NGOs willbe involved actively for both implementation and monitoring.

2.49 Over 10 million people in Bangladesh suffer from iodine deficiencydisorders (goiter). Universal iodization of salt is the treatment. In view

of the delay in the salt iodization process, the project will finance iodineinjections, which were started as a stop-gap measure. UNICEF evaluation shows

that the program is well monitored and of high social value. The medicaliodine application will be phased out over the project period as salt-iodization proceeds. The project will fund iodization in each of the existing

210 salt crushing units over two years, beginning with severely affecteddistricts. The Bangladesh Small and Cottage Industries Corporation (BSCIC)

and UNICEF will provide technical assistance and equipment. Eight salt

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testing centers will coordinate and monitor the iodization process country-wide.

2.50 The second major cause of mortality among children is ARI. Theproject component aims to reduce the incidence, severity and complications ofand mortality from ARI, especially pneumonia. Beginning with 8 upazilas and 2slums, the project will be extended to 248 upazilas and 62 slums by 1996.Support will be provided for the training of health workers to diagnose andtreat ARI, purchase of equipment and medicines, IEM, monitoring andevaluation, and rational use of antimicrobial drugs for treatment, includingsurveillance for antibiotic multiresistencies. Liaison will be maintainedwith WHO and the project on Rational Use of Drugs (para 2.42).

2.51 Developing Control of Vector-Borne Diseases. An integratedapproach to the control of vector-borne diseases, such as malaria, kala-azar,filariasis, dengue fever and japanese encephalitis, is proposed in theinterest of efficiency. Existing units are to be harnessed to form a programfor Integrated Control of Vector-Borne Diseases, with an emphasis onsurveillance. The aims are to: improve parasite control through betterepidemiological surveillance and vector control through entomologicalsurveillance; train manpower on diagnostic procedures, effective control andpreventive measures; and conduct field-based research. The project will fundnew posts (a chief scientific officer, two medical officers, entomologists,and support staff); provision of essential drugs; transport, including amobile laboratory; training of staff, including fellowships; cost ofaccommodation; investigation of epidemic outbreaks and revision ofsurveillance maps; basic and applied research on changing vector and pathogenbehavior; and, where necessary, ezpatriate consultants. Expenditure relatedto the procurement of insecticides, particularly DDT, will be fi:..nced by GOBoutside the purview of the project. The reorganized project unit will beheaded by a director, supported by a deputy director and administrative staff,and coordinated by the DG Health and NIPSOM with a linkage to national (IEDCR)and international (WHO) centers experienced in this approach.

2.52 Assisting the Intestinal Parasite Control Project. Some 50X-70Z ofBangladeshi children (35-40 million) are infested with worms. This componentwill support relative cost-effectiveness analysis of alternative interventions(e.g. health education, antihelminthic treatment, and promotion of waterseallatrines). The study will cover eight unions and include measuring theprevalence of worms and the effect of reduced worm infestation on thenutritional status of children (through the IEDCR and NIPSOM). The projectprovides for temporary staff, purchase of drugs, transport, subsidy forwaterseal latrines and health education (to be coordinated with the IEM/HEBUnit, para 2.76).

2.5., Expanding Institute of Public Health (IPH). Blood and intravenousfluids are extremely important elements in addressing the problem of maternalmortality. IPH production of sterile blood and intravenous fluid bags will beexpanded, while capacity to produce nutritional fluids and diagnosticreagents, equally necessary for acute emergency patients, will be established.The project will fund an additional 120,000 blood bags, 10,000 nutritionalfluid bags and limited quantities of diagnostic reagents. Staff andfacilities at the IPH will be strengthened, with WHO and other technicalassistance if and when necessary. The IPH will produce reports for theConsortium, covering capacity in terms of human resources, facilities andequipment. At least 70Z of IPH output will go to maternal and MCH care at

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district hospitals and UHCs, with priority distribution to the various project

areas (paras 2.31 and 2.59).

2.54 Modernizing the Drug Testing Laboratory. The Laboratory has had asubstantially increased workload since the introduction of the National DrugPolicy of 1982. It will be modernized to:(i) improve drug testing capacity of

imported and local drugs from 5,000 to 10,000 samples per year; (ii) improvequality centrol; and (iii) extend training to pharmaceutical laboratories on acost recovery basis. To achieve this, the project also will support buildingsand equipment, in close association with WHO and ADB funding, chemicals,furniture and stationery.

B.(5) Developing Urban PHC

2.55 Despite an expanding urban population and a clear need for PHCservices in urban areas, these have yet to be systematically planned andorganized (para 2.69). The project will support the development of acomprehensive strategy and action plan for urban PHC for a phasedimplementation, following a survey of exisUing health facilities and a mappingexercise. A beginning is to be made in five unserved wards of Dhaka.Existing urban dispensaries are to be renovated. Eleven PHC centers withfemale outreach workers will be constructed. Consultants and fellowships areprovided to develop the plan. Essential drugs, training and equipment willalso be funded. In view of the need for strong management and extensiveevaluation, a new post of Assistant Director (Urban PHC) within theDirectorate of PHC is envisaged. Agreement was reached with GOB duringnegotiations that, by July 31, 1992, responsibility for urban PHC will beassigned either to the national or to the local government and that IDA willbe informed of the decision.

B.(6) Continuing and Expanding School Health Programs

2.56 Children in primary and secondary schools constitute 152 of thetotal population. Especially in a country like Bangladesh, an investment inschool health is central to the quality of life of the population. Currentlythere are 27 school health clinics, with three in Dhaka and the rest indistricts, serving 1,116 primary and secondary schools. Each clinic has twoMOs, one pharmacist and three support staff. Forty-four more school healthclinics will be funded in the uncovered districts, resulting in one clinic perdistrict. Apart from the current program of medical examination andtreatment, which is largely clinic based, a new emphasis will be placed onhealthy living, nutrition and personal hygiene through health education,control of communicable diseases, and health promotion in schools and homes.Linkages between the school health clinics, the general health system and theeducational system will be systematized. Funding of the programs will beconditional on the development of a master plan for school health during thefirst year of the project, to be finalized through revised Project Proformasafter discussions and agreement between GOB and IDA/Cofinanciers. Duringnegotiations, agreement was reached that GOB will prepare, by March 31, 1993,a masterplan for school health programs in accordance with terms of referencesatisfactory to IDA and thereafer, carry out such programs taking into account

IDA's comments.

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B.(7) Improving Health Facilities

2.57 Renovating District Hospitals and UHCs. The number of beds in the59 district hospitals ranges from around S0 to 200. These hospitals serve anaverage population of 1.5 million each. They all have medical and surgicalspecialists and an operating theater, but smaller ones (50-100 beds) have onlytwo wards - one male and one female. Many need renovation and those with onlyone female ward lack labor wards and delivery units. Depending on theavailability of funds, the project will renovate/reconstruct upto sixteendistrict hospitals and three UHCs, which may be upgraded to small districthospitals. Selection of the district hospitals and UHCs will be reviewed byGOB and IDA/Cofinanciers and remain subject to final Consortium approval. Theproject provides for construction, equipment, furniture, land development,salaries and allowances of additional posts and additional supplies of medicaland surgical requisites. During negotiations, agreement was reached that GOBwill carry out plans, by April 30, 1992, for the allocation of 70? or more ofthe beds in district hospitals and UHCs for women and children.

2.58 Constructing UHCs. UHCs are the country's lowest level health carefacility providing in-patient care. With a maximum of 31 beds and 9professional staff, they serve on average a population of 330,000 and areessentially out-patient oriented, larger rural health centers with some in-patient capacity (1 bed:l0,000 population). Of the 397 rural upazilasrequiring a UHC, only 351 have one. As part of GOB's long-term plan to buildUHCs in the remaining upazilas, the project will establish 10 new upazilahealth complexes. The design adopted for the UHC is the same as that approvedby IDA for the previous projects, with the following modifications: officesfor four physicians, FP/MCH stores, and allocation of at least 70? of beds forwomen and children. Besides construction costs, the project provides forequipment and furniture as per the standard list, previously approved by IDA.Agreement was reached with GOB during negotiations that the architecturalplans for the new UHCs will be made available to IDA by April 30, 1992 forcomments and that the plans will include indication of the selected sites,allocation of at least 70Z of the beds for women and children, and acomprehensive maintenance plan.

B.(8) Improving Utilization of UHCs and FWCs

2.59 The underutilization of UHCs, FWCs and RDs seems to be largely dueto poor quality of services, which in turn is due to poor management coupledwith a lack of community participation and socio-cultural factors,particularly those that prevent women from making use of the facilities.Following successful examples in other countries, the project supports aholistic UHC-centered approach to improving service delivery and utilization,both vis-a-vis outreach and institutional care and family planning services.The underlying strategy of the project will be to motivate the staff at theUHC level and below, both as individuals and as a team, to improve graduallytheir management and job performance in high priority service areas, and toprovide them with the necessary inputs and support to accomplish this. UHCparticipation in the project will be performance-oriented and phased in orderto guarantee optimal use of limited resources. Support actions will combinevarious inputs (e.g. essential equipment, drugs and supplies, laboratoryfacilities, separate MCH units, accommodation, transport facilities, repairand maintenance of buildings, sound management practices, clinical qualityassurance, an effective referral system, promotion of community participationand advisory and training services), all of which will be provided within the

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context of a functional improvement training effort and action plan worked outand agreed with each UHC individually.

2.60 Implementation will be through a special implementation unit in theHealth Directorate and is initially planned for 50 upazilas, selected from atleast one district in each Division, according to agreed criteria. TheDirector PHC will ensure coordination between the Directorates of FP andHealth. A "National Steering Committee" under the chairmanship of theSecretary of MOHFW and with adequate representation of both the Health and PPDirectorates, as well as from other relevant Ministries and Institutes, willmeet at least twice a year to approve overall work plans, and allocations.Steering committees at district and upazila levels, with adequaterepresentation of all parties involved, will approve the selection of UHCs andthe proposed functional improvement training and action plans includingdetailed allocations. Multidisciplinary teams are envisaged, for eachdistrict and at the center, for technical and daily operational work. In viewof its crucial significance to the overall objectives of the sector, thiscomponent will be very closely monitored by the Consortium in its annualreviews. Agreement was reached during negotiations that GOB will carry out,by June 30, 1994, an in-depth review of the outcome of the special program toaddress capacity utilization at the UHCs and FWCs, prepare an action plan forthe expansion of the program to the remaining upazilas, furnish the review andaction plan to IDA for comments, and carry out the action plan taking intoaccount IDA's comments.

Component C. Improving Supportive Activities to the Delivery of FP and HealthServices (US$66.2 million)

2.61 Component C provides for support to the project activities underComponents A and B. It will emphasize strengthening the MIS for the FP andhealth subsectors, with a particular emphasis on gender-specific datacollection sufficiently disaggregated to permit meaningful analysis of policyissues in terms of the WID strategy for the project (annex 24). It also willfocus on improving managerial and financial capabilities in both sectors, andexpanding community support for FP and health services. The component willhighlight the importance of NGOs and innovative approaches and providetechnical assistance to specific subcomponents of the project.

C.(l) Strengthening Information Systems

2.62 MIS for FP/MCH. To make effective use of the MIS as the main sourceof monthly FP and MCH performance data, the system will be reorganized to makeit more of a management tool and ensure better quality of data. A needsassessment will be made from upazila to central level in 1992; the systemdesign, field testing, the preparation and implementation of workingguidelines for management information flows, training on the production anduse of MIS reports, and recommendations on hardware, software and personnelrequirements will be funded by the project. The future basis for MIS datawill be the Field Worker Record Keeping System, replacing the coupleregistration system. Supervision and guidance of registration work will bedone at upazila level through (refresher) training of FWVs and FPAs.Agreement was reached with GOB during negotiations, that the needs assessmentand system design will be carried out by July 31, 1994 and furnished to IDAfor comments.

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2.63 The LMIS is another management tool for decentralized decision-making. The project's support to it aims at more efficient use ofcontraceptive supplies by assurance of quality of data, rapid processing andtransmitting of reports, and comparison with performance statistics on thesame form to enable managers to see linkages and inconsistencies. Potentialduplication of data collection will also be addressed, e.g. with the healthinformation systems under development or other information schemes in thesector.

2.64 MIS for Health. The project seeks to coordinate the separatefunctions of the Health Information Unit into a coherent MIS for decision-making. To ensure meaningful information, the Unit wills (i) prioritizeinformation for health management based on a needs assessment; (ii) design,field-test and establish a computer-based MIS; (iii) train health personnel;and (iv) ensure quality of information on a gender-disaggregated basis. Adatabase on health personnel, health service utilization and logistics, andmorbidity and mortality statistics by sex will be set up under the project.Staff will be augmented, (inter)nationally trained, and equipped. The MISwill be decentralized from the perspective of reliable data collection and useof information for decision-making. The Unit will closely cooperate with andreceive assistance from WHO, IPGMR, and NIPSOM. Agreement was reached withGOB during negotiations, that the needs assessment and system design will becarried out by July 31, 1994 and furnished to IDA for comments.

2.65 Health and Demographic Survey. This survey by BBS aims atcollecting data disaggregated by gender, on morbidity, mortality, immunizationcoverage, health services utilization, health behavior and socio-economic anddemographic characteristics. A number of pretested questionnaires/scheduleswill be used to collect the data on carefully selected priority areas to besurveyed. BBS will coordinate its efforts with other agencies planningsimilar surveys, e.g. NIPORT and USAID, avoiding duplication (e.g., with theplanned CPSs and the BFS). Qualified women will be recruited to fill 50Z oflocal enumerator positions. UNDP will provide technical assistance. Thedetailed objectives and design of the study will be finalized in consultationbetween GOB and IDA/Cofinanciers. During negotiations, agreement was reachedthat GOB will carry out, by December 31, 1994, a health and demographic surveyin accordance with terms of reference acceptable to IDA and furnish theresults to IDA for comments.

2.66 Epidemiological Surveillance System. Epidemiological surveillanceis key to sound preventive disease strategies. Under the project, thecurrently too-weak IEDCR will be strengthened as a center of epidemiologicalsurveillance by improving its field-based surveillance, assisting dataanalysis at central and peripheral levels, and conducting periodicepidemiological surveys and investigation of disease outbreaks. This includesproviding a new biostatistics unit, data processing, increasing and trainingstaff, technical assistance, renovating and adding space, and supportingtransport and equipment.

C.(2) Improving FP and Health Organization, Management and Financing

2.67 MDU Support to FP and Health Services. The project will continueto support the successful MDU, whose focus will be enlarged to includemanagerial capability at the directorate, district and upazila levels. Theaim will be for managers to apply planning concepts, problem-solving methods,team work and supportive supervision in their work. The MDU will continue to

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emphasize the improvement of key management skills of program personnel and to

provide regular feedback on operational constraints, solutions and improved

management practice from the field to the central level. Its work during the

Fourth Plan period will extend to management issues at central level and to

work in both the FP and Health sectors.

2.68 The MDU will continue functioning in each of the four divisions of

the country, with a stronger presence at district level. The composition will

include four divisional teams and at the central level one team leader plus an

advisor. UNFPA will provide administrative backstopping under an MOHFW

Steering Committee. For professional support, the MDU will continue to have

linkages with selected international management institutions.

2.69 Reorganization of Health & Family Planning Programs. In view of the

lessons from the previous projects that point to the importance of soundmanagement, MOHFW's structure and functions will be reviewed to propose: (i)

improvements in management and planning performance; (ii) allocation of

resources to priority areas considering potential outcomes and recurrentcosts; (iii) enhancement of the coordination of donor inputs; (iv) fostering

of decentralization of reoponsibilities; and (v) integration of FP and healthfunctions. A strong, integrated information system and a central planningstructure that avoids the present duplication of efforts will also be

developed at a later stage (para 2.63). The project will support the

analytical work needed, the conduct of various operations, and the testing of

assumptions and proposed solutions and their implementation. Duringnegotiations, agreement was reached that GOB will carry out, by August 31,

1993, a Dolicy study on the reorganization of the health and family planningprograms in accordance with terms of reference satisfactory to IDA, furnish

the recommendations of the study to IDA for comments, and thereafter, prepare

and carry out an action plan taking into account IDA's comments.

2.70 A very important factor determining the success of any project,particularly in the FP and health sector, is the adequacy and appropriateness

of human resource development. A comprehensive review of the human resourcesituation will be carried out considering, among other aspects, the (i) matchbetween the assessed need and available staff; (ii) optimal staff mix in termsof the various cadres (right from the physician through the FWA) and in termsof gender; (iii) geographic distribution of staff as per population spread and

epidemiological considerations; (iv) policy and operational implications in

terms of employing staff either in the development or the revenue budget; (v)

career development plans for all staff; (vi) issues surrounding single-purpose

workers such as leprosy control assistants in the context of an integrated PHC

approach; and (vii) possible sharing of human resources between the FP andhealth subsectors. Gender equity should be encouraged insofar as possible in

all of the preceding factors. WHO will assist this subcomponent which is

being supported as a technical assistance project (para 2.85). Agreement was

reached during negotiations that GOB will prepare, by March 31, 1994, a human

resource development plan for strengthening the capacity for human resource

development planning which takes specific account of female representation at

all levels of the FP and health system, furnish the plan to IDA for comments,and carry out the plan taking into account IDA's comments.

2.71 Strengthening the PDEU. Considering the lessons of past projects

regarding the need for adequate evaluation, the project will continue to

finance PDEU in carrying out operational research to support policy-making

within the Planning Commission. It will be strengthened through refocussing

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its function on evaluating the population control program as to its nationallyimportant intersectoral links and effects. PDEU will analyze existingresearch and data sets from other institutions for policy implications. Thestudies to be contracted out every year will be part of a research work plan,based on identified information needs for policy decisions to be preparedperiodically and reviewed by NASCOPOR and the IDA/Cofinanciers annual reviewmissions. The review will also consider the qualification and efficiency ofdifferent institutions for contract research projects. This approach willenable the GOB to reduce the size of PDEU staff substantially by the end ofthe Fourth Plan period. All future research/evaluation supported by theproject will provide for gender disaggregated data collection and analysis.

2.72 Establishment of the MCH Coordination Cell. More than any otheractivity, MCH services cut across both the health directorate and the FPdirectorate. To enhance coordination, the project will finance theestablishment of an MCH Coordination Cell in the MOHFW (Chart 4). The MCHCell will serve as a secretariat to the National MCH Coordination Committee,support MCH Coordination Committees at district and upazila level, and monitorthe Maternal and Neonatal Health Care Pilot Project (para 2.30-2.31). TheCell will be attached to the Joint Secretary concerned, and will be staffed byat least four professionals (including one senior international adviser), withtechnical backstopping by WHO. During negotiations, agreement was reachedwith GOB that the MCH Coordination Cell will be established and maintained inaccordance with terms of reference satisfactory to IDA and with competentstaff in adequate numbers. A condition of credit effectiveness is theestablishment of the MCH Coordination Cell within the MOHFW in line with theterms of reference already agreed upon between GOB and IDA.

2.73 Establishment of the Health Economics and Financing Project.Sustainability of the program is a serious concern of GOB and the Consortium.It has various dimensions: (i) long-term donor and GOB commitments to thedevelopment needs of the sector and increasing GOB commitment to meetrecurring costs; (ii) efficiency and cost effectiveness considerations; (iii)cost-sharing aspects, subject to equity principles; (iv) privatization scope;and (v) public/private mix of FP and health services. The Banglad-< ;iealthFinancing Study 1988/89 underlined the lack of relevant expertise, which sofar has prevented in-depth analyses by GOB of the complex issues involved.The project will thus support strengthening capacities within GOB,particularly in MOHFW and the Planning Commission, for appreciating andanalyzing health economic and financing issues. It will fund all developmentcosts for a separate Health Economics and Financing Pilot Project under aDirector in the MOHFW for FP and health, which will interact continuously withor become part of the existing planning cells. A high powered committee,headed by the Secretary, MOHFW with membership from senior officers of MOHFW,the Ministry of Finance, ERD, the Planning Commission and a few experts, willprovide overall guidance regarding project prioritization. Agreement wasreached with GOB during negotiations that (a) it will establish, by August 31,1992, a Health Economics and Financing Pilot Project in the MOHFW withcompetent staff in adequate numbers and with terms of reference and a workprogram acceptable to IDA, (b) take all actions required to strengthen theMOHFW in accordance with policy-related financial and economic analyses by theproject and (c) by September 30, 1993, furnish to IDA for comments a plan toaddress the issue of long-term sustainability, including among others:proposals for achieving an acceptable balance between the MOHFW's revenue anddevelopment budgets, proposals for transfer of specific expenditure items fromthe development to the revenue or the local government budget as well as

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specific proposals on cost-sharing mechanisms and improved cost-effectivenessand carry out the plan taking IDA's comments into account.

2.74 Restructuring of the Project Finance Cell (PFC). The current roleof the PFC in handling only population-related projects will be restructuredto include monitoring of health-related projects funded through theConsortium. The Director of the PFC will be made responsible to the Jo'ntSecretary (Planning and Development) who combines the functions of plarningfor the FP and health wings of the MOHFW. The project will also financecomputerization of the PFC. During negotiations, agreement was reached thatGOB will maintain the PFC with competent staff in adequate numbers untilcompletion of the project.

2.75 Construction of a FP and Health Building. The Directorates of PPand Health are currently located in a number of different rented buildings,scattjred over the city and of dismal quality. Due to rental contracts andfinancial considerations, many offices are regularly relocated to other rentedpremises. Apart from ever higher recurrent costs of renting theaccommodations, this has led to serious administrative dislocation, loweffectiveness of supervision and virtual managerial isolation of soneprograms. More serious is the fact that the physical separation of the FPDirectorate and the Health Directorate has hampered earlier integrationattempts by MOHFW (paras 1.32 and 2.69). To redress these constraints, GOBplans a common facility for both directorates, which would also facilitatemany of the integration and merger components under the project (paras 2.68,2.76 and 2.77). The project will support the construction of a commonbuilding to house the FP and Health Directorates at Mohakhali. It willaccommodate 328 officers and 1,229 staff, with common facilities and replantedgrounds, in a ten-floor, 15,800 sqm building. Maintenance will come under theMCMU (para 2.76). Funding will be shared between GOB, the IDA/CofinancierConsortium and USAID.

2.76 Establishment of the MCMU. Several agencies are involved in theimplementation of construction, renovation, maintenance and rehabilitationworks pertaining to MOHFW. No clear delineation of responsibility existsamong the four main agencies, i.e. CMC, the Building Planning and Design Unit(BPDU), Public Works Directorate and LGEB. This often results in inefficiencyand a serious lack of coordination and accountability. Under the project, thetwo current engineering units of MOHFW, i.e. the Construction Management Cell(CMC) and BPDU, will be merged and renamed as "Maintenallce and ConstructionManagement Unit (MCMU)". The newly created MCMU will coordinate and implementall the facility-related works of MOHFW under the project, with full financialand technical authority. Subjec; to satisfactory completion of rehabilitationof the flood-affected FWCs by LGEB under the Third Project and subject todocumented future capacity at LGEB, construction and maintenance of facilitiesbelow upazila level will be delegated to LGEB with an appropriately definedsupervisory role for the MCMU. Agreement was reached with GOB duringnegotiations that BPDU and CMC will be unified by June 30, 1992 and given therequired administrative and financial authority to carry out its constructionand maintenance responsibilities.

C.(3) Expanding Communications Programs

2.77 Functional integration of the IEM and HEB Units. The project willfinance continuation and strengthening of the communications program followingan integrated IEM strategys (i) classifying target audiences; (ii) identifying

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audience needs; (iii) developing audience-specific messages; (iv) promotinglocalized message planning; (v) ensuring complementarity of interpersonul,group and mass media approaches; (vi) improving coordination of all agenciesconcerned; (vii) training all personnel involved in communication; and (viii)providing research, evaluation and monitoring support. To plan and implementthe strategy successfully, GOB proposes to integrate functionally the IEM Unitof the FP Directorate and the HEB of the Health Directorate. This would meana close working relationship between the two units, a common work program anda practical action-plan towards the integrated IEM strategy. Production ofmaterials and research and evaluation will be contracted-out. The staff canthus be reduced in phases. A cell will be created to address women's IEMissues and have its five posts staffed by women. The project will supportaudience research, message development costs, evaluation studies, training offield staff, community leaders and folk singers, publication of newslettersand production of FP and health educational materials and films. Agreementwas reached with GOB during negotiations that a strategy and work plan,acceptable to IDA, for functionally integrating PP and health communicationsactivities will be furnished by August 31, 1992, such strategy to includeindicators related to gender awareness and that the functional integrationshall be put into effect by December 31, 1992.

2.78 Support for Mass Media Activities. The project will supportstrengthening of the Radio Bangladesh programs for FP/MCH/PHC communication.The broadcast time will be increased from 305 to 330 minutes a day, providingfor 30 minutes of broadcast from each of the three subcells. The contents ofbroadcasts will be diversified by inclusion of more health subjects. Theproject will provide for improving production facilities, transport for thesubcells, spares and equipment, artists' services, fellowship training andoperational expenses.

2.79 About 300 minutes of television programs are broadcast every monthunder six titles linking population with health, religion, child care, etc.In addition, NGOs buy time for their programs on FP and health. Thepopulation cell finds it difficult to retain technical personnel recruited toproduce programs as the cell is treated as temporary. Because BangladeshTelevision has not been able to fill sanctioned positions for so long, alumpsum provision will be made available for programs to be produced in theprivate sector. Bangladesh Television's Population and Health Cell willdecide on the nature of telecasts, messages to be conveyed, and reviews oftelecasts produced by the private sector. The project will also financeregular evaluations of program effectiveness.

2.80 Promotion of Community Participation. Progressive involvement ofthe community in promoting FP and health activities will continue throughcommunity volunteer programs, such as the VDP and Swanirvar. Besides theirmoti.tstional works, the VDP women members will act as village depot-holdersunder the FWA. Each will maintain contact with 40 households. VDP coveragewill expand from 64 to 96 upazilas. The project will finance training,subject to a formal evaluation of the current program by an independentagency. Swanirvar's population activities have expanded to 138 upazilas in 39districts (1,486 unions and 2,500 villages). Population planning andeducation are integrated into the overall village development program and the

credit program for disadvantaged women, with an evaluated positive impact onfertility. The project will support training for coverage of all villages inthe upazilas, following the agreed method for funding through NGOs. Duringnegotiations, agreement was reached with GOB that the community volunteer

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programs will be evaluated by June 30, 1993 and the resu:.ts furnished to IDAfor comments and that by December 31, 1992 all actions required will be takento ensure that contraceptives are provided on a priority basis to the Mothers'Centers, Women's Cooperatives and Women's Vocational Training Programs beingsupported under the project.

C.(4) Supporting NGOs

2.81 The project will continue to provide significant funding for NGOparticipation in national population and health efforts. Currently about 156such projects are operated by NGOs besides those financed through the nowdefunct MOHFW Subvention Committee. These projects cover over 364 sites ofwhich more than 200 are located in rural areas. MIS data of 1989 estimatethat NGOs may contribute up to 36.52 of the total couple years of protection.NGOs train their own staff and contribute to government field staff trainingin FP and health.

2.82 The project will finance NGOs that complement governmental effortstowards a CPR of 48Z-50Z and infant and child mortality rates of 80 and 140per 1,000, respectively, by 1995. Following the new one-stop clearance system(para 1.33), it has been agreed with NGO leaders and GOB that under theproject: (i) vertical NGO FP programs will develop integrated PHC programs;(ii) NGOs will participate in the production of IEC materials and managementdevelopment; (iii) NGO health activities will be working towards a system ofmore effective MCH referrals; (iv) DGFP will ensure regular contraceptivesupplies to NGOs; (v) FPCST will also cover NGO clinics; (vi) NGOs will extendtheir field activities to areas of greater need; and (vii) the NGO Secretariatwill process new NGO proposals within 90 days of submission. The project will

continue to finance the existing Consortium NGO technical support unit. Inaddition the GOB will allow approximately 38Z of the project's contraceptivecondom supplies to be channelled through the SMC (para 2.28).

C.(5) Developing Innovative Projects

2.83 Substantial financing will be set aside to develop and testinnovative projects that will help achieve sectoral goals with an emphasis ondeveloping ideas, concepts, and program measures for sustainability and cost-effectiveness in FP and health. These activities are aimed at improving theeffectiveness and efficiency of current programs as well as developingadditional program measures to accelerate development in FP and health. Theywill be forerunners to the development of the Fifth Fivu-Year Plan in FP andhealth. Projects will be developed from time-to-time in line with emergingneeds. The major areas envisaged are improved access to services, in-servicetraining, new contraceptive and medical technology, community involvement,'beyond-FP" measures, community-based medical education, environmental healthprograms and health economics, including cost-effectiveness analysis, costrecovery issues and health financirg programs. GOB will continue the existingSteering Committee, which will function as under the current Third Project.The approved studies will be contracted-out and progress will be assessedperiodically during the annual IDA/Cofinanciers review missions. Theinnovative projects component also will include funds to prepare a fifth phaseof donor assistance to the national FP/MCH program. Prior approval of IDAwill be obtained for innovative projects estimated to cost over US$50,000.

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C.(6) Supporting Technical Assistance Projects

2.84 Training Health Personnel in Operational Management. This sub-project will support improved quality of supportive supervision. It will fundtraining of: (i) health workers in operational management, including MCH andFP; (ii) physicians in surgery, internal medicine, gynecology, and simpleanesthesia to improve the quality of care in UHCs; (iii) female volunteers incommunity health (selective); (iv) trainers to form training teams; and (v)local village leaders (selective) on PHC. It will also finance preparationand collection of training materials and development of monitoring andcoordinaticn mechanisms for training activities (Annex 27).

2.85 Human Resources Development Masterplan. A comprehensive plan forthe development of human resources in the health and PP sector will beundertaken with the assistance of WHO and international expertise in the fieldof national health manpower systems. A significant input by nationalexpertise from Bangladesh will be required as well. The project will providetechnical assistance for the preparation of the plan, which is described indetail in para 2.70 (see also para 6.1, xx).

2.86 Health Care Quality Assurance. Currently Bangladesh has noestablished mechanism for systematically monitoring, let alone improving, thequality of health care within or outside the public sector. No professionalstandards have been set. no outcome measures have been agreed upon and noroutine information on quality is available. This subcomponent will providetechnical support to assess and assure the quality of both clinical andcommunity health care objectively and to introduce a system of qualityimprovement to ensure professional accountability of different categories of

health personnel. The development of standards and criteria, training andinformation systems are some of the essential elements envisaged. The projectsubcomponent on medical quality assurance (para 2.37) within the area ofmedical education will provide the institutional base for this technicalassistance subcomponent.

2.87 Control and Prevention of Sexually Transmitted Diseases (STDs). Anurgent need exists to combine the ongoing efforts in AIDS control (with WHOassistance) and an intensified drive to control other sexually transmitteddiseases. This component will provide technical assistance for STDsurveillance, diagnosis, training, and increasing public awareness (Annex 27).

2.88 Control and Prevention of Cancer. Notwithstanding more pressinghealth priorities in Bangladesh, cancer demands its share of attention. Theannual incidence is estimated at over 200,000 and this project component aimsto meet the issue through technical assistance to formulate a control strategy(Annex 27).

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2.89 Establishment of a Pharmaceutical Production Unit at Khulna. Astudy will be conducted on the feasibility of a pharmaceutical plant inKhulna, with a view to meeting the needs of essential drugs in the publichealth system. The existing drug plants at Dhaka and Bogra produce 32 of the45 essential drugs and meet 75Z of the public sector requirements. Twelve newproducts are proposed for the new plant at Khulna. Financing of the new plantwill depend on the outcome of the feasibility study and subsequent GOB-Consortium agreement. Technical assistance will be provided in consultationwith the Essential Drugs Unit and the component on the Rational Use of Drugs(para 2.42 and Annex 27).

2.90 Establishment of Condom Manufacturing Plant. Feasibility studiescarried out in the past on the need for developing local capacity for theproduction of condoms are not only outdated but also lacking incomprehensiveness. A fresh feasibility study will be conducted withcomprehensive terms of reference, addressing: (i) economic and non-economicconsiderations of private or public sector production; (ii) various donorpolicies on the procurement of locally produced condoms; (iii) development ofseveral price scenarios; and (iv) environmental impact. The results of thestudy will be reviewed with the Consortium. Subject to economic viability,availability of funds and other relevant considerations, the project mayprovide funding towards setting-up of local condom production capabilityduring the project period (Annex 27).

Component D. Women's and Nutrition Programs (US$11.6 Million)

2.91 Component D will fund three women's programs in the field of familyplanning and MCH. It will also support the strengthening of the NationalNutrition Council as a potentially important catalysc for country-widecoordinated nutrition programs.

D.(l) Continuing the Three Women's Projects

2.92 Continued financing of the three ongoing women's programs will beprovided during the first two or three years of project implezientation as abridge to the proposed Intersectoral Population Activities Project (para 2.3).The objective of the three women's programs (Mother's Centers, Women'sCooperatives, and Women's Vocational Training) is the economic, social, andleadership development of women, especially the young, in the lowest economicand social segments of society. In line with the lessons learned from thethree previous projects, the strategies for achieving the programs include:(i) improving credit facilities for women; (ii) emphasizing nontraditionaltrades, where possible; (iii) encouraging women's entrepreneurship; (iv)exposing more women to primary health care; and (v) establishing effectivelinks with the FP Directorate. The present programs (para 1.21) will bestrengthened as a result of a thorough review of implementation so far by ateam of expatriate and local consultants, which will analyze in detail the twomajor components crucial to achieving the objectives of the programs: (i)income generation impact, considering the present emphasis on traditionalproducts and the need to identify new areas of non-traditional and innovativeproducts for the local market; and (ii) awareness-raising training (generaland legal literacy, non-formal education, credit usage, savings, knowledge innutrition/health/family welfare, immunization benefits, etc.). Anentrepreneurship program will be developed to facilitate 'graduation' of

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participants who are older in age and length of involvement. Coverage of the

programs will be expanded to additional upazilas. Activities in some existing

upazilas, where projects have been in operation for about 10 years, will betransferred to the revenue budget, with GOB thereby assuming responsibilityfor funding out of its own budget. Adequacy of transport allowances and means

will be analyzed. Standard indicators for monitoring and evaluation of

progress will be agreed to avoid the present confusion caused by differentdata and analyses in reports prepared by project monitors, PDEU, and external

evaluators. In addition to this study, GOB will establish mechanisms for

regular coordination of the management and implementation of activities of the

.hree projects from the directorate level down to the upazilas, develop depot-

holder systems to ensure easy access to contraceptives, use women's projectcenters in the field as service delivery points for FP/health/nutritionprograms, and develop and implement pilot studies for promoting self-financingof the inputs for income generating activities. Annex 28 gives furtherdetails. During negotiations, agreement was reached that G-OB will carry out,

by September 30, 1992, an in-depth review of the three women's programs,prepare an action plan for strengthening of the programs, furnish the results

of the review and action plan to IDA for comments, and carry out the actionplan taking IDA's comments into account.

D.(2) Coordinated Nutrition Program of the National Nutrition Council

2.93 The reconstituted Council has great potential for leadership in a

wide range of nutrition activities in the country. The project componentseeks to strengthen the Council's role. Major objectives will be reflectionof an updated national nutrition policy in GOB and NGO programs and research,and development of a master plan for nutrition activities. Priority will be

given to problems affecting children and adolescent girls. Improvedbreastfeeding practices will be encouraged and infectious disease control will

be addressed (paras 2.26, 2.30, 2.35 and 2.40). Attention will be given to

nutrition improvement through diarrhea control; provision of Vitamin A,

iodized salt, ferrous iron, intravenous fluids, and parasite control (paras

2.47-2.49 and 2.52-2.53). The project will provide for staff, equipment,training, publications, seminars, and grants for nutrition interventionprograms. It will also fund studies on nutrition, determinants of

malnutrition, and reorientation of the public food distribution program.Evaluation is included. The Council will preferentially recruit female staff

for its Secretariat.

D. Environmental Considerations

2.94 The proposed project was determined to be in screening Category D,

which includes projects that are expected to have a positive environmentalimpact. No environmental analysis has been prepared for this project. A

brief overview about population and the environment is provided in Annex 29.

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III. PROJECT COST, FINANCING, DISBURSEMENTS, AND PROCUREMENT

A. Project Cost

3.1 Summary. The total cost of the project, including contingencies,duties and taxes, is estimated at Tk 24,019.0 million (US$601.4 million). Thebase cost is Tk 19,848.8 million (US$543.7 million) and contingencies are Tk4,170.2 million (US$57.7 million). The project cost includes recurrentexpenditures. Detailed cost estimates by component are presented in Annex 30and summarized below:

Table 3.1: Costs by Component

Take (million) ------ USS (million) - X ForeignComponent Local Foreign Total Local Forolgn Total Exchange

FP/MCH Service Delivery 7,628.1 4,116.8 11,744.9 208.9 112.8 821.7 86

Health Service Delivery 8,755.6 1,606.2 6,261.8 102.9 41.3 144.2 29

Supportive Activities 2,009.2 410.7 2,419.9 55.0 11.2 66.2 17

Women's and NutritionPrograms 405.5 16.7 422.2 11.1 0.5 11.6 4

Total Base Cost 18,798.4 6,050.4 19,848.8 377.9 165.8 548.7 80

Contingencies 2,821.7 1.B48.5 4.170.2 88.2 19.6 57.7 84

Total Project Cost 16,620.1 7,898.9 24,019.0 416.1 185.8 601.4 81

Cost estimates by category of expenditures are shown in detail in Annex 31 andsummarized as follows:

Table 3.2: Costs by Category of Expenditure

Category of Take (million) US8 (million) --- X Foreign X of BeExpenditure Local Foreign Total Local Foreign Total Exchange Costa

Investment Costs:Civil Works 2,874.8 68.8 2,941.6 78.6 1.9 80.5 2 15Equipment and Furniture 1,138.1 689.7 1,722.8 81.0 16.2 47.2 84 9Vehicles 193.8 238.4 432.2 6.8 6.5 11.8 56 2Medical and BiologicalSupplies 422.6 4,167.8 4,689.8 11.6 114.1 126.7 91 23

Technical Assistancoand Consultants Services 623.0 787.1 1,890.1 17.1 21.0 88.1 55 7

Training and Followships 1,598.0 142.1 1,740.1 48.8 8.9 47.7 8 9Innovative and NGOActivities 429.6 86.6 466.0 11.8 1.0 12.8 8 2

Subtotal 7,274.7 6,007.9 18,282.6 199.2 164.6 808.8 46 87

Recurrent Costs:Salaries and Allowances 6,516.6 0.0 5,516.6 161.1 0.0 161.1 0 28Administrative Expenses 788.8 4.1 787.7 21.6 0.1 21.6 0 4Project Operating Costs 228.6 88.4 281.9 6.1 1.1 7.2 15 1

Subtotal 6.528.7 42.5 8.566.2 178.7 1.2 179.9 1 88

Total Base Cost 18,798.4 6,050.4 19,848.8 877.9 166.8 548.7 sO 100

Contingencies 2,821.7 1.848.6 4.170.2 88.2 19.6 67.7 84 11

Total Project Cost 16,620.1 7,898.9 24,019.0 416.1 186.8 601.4 81

NOTE: Costa Include taxes and duties.

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3.2 Basis of Cost Estimates. Cost estimates are based on GOB estimatesand reflect recent quotations and appraisal estimates. The costs of civilworks are based on reviews of recently awarded contracts in Bangladesh forsimilar construction. Estimates are based on final designs for standardizedworks and on preliminary designs for other types of construction. GovernmentSchedules of Rates have been used and updated with allowable premiums whereappropriate to reflect recent tender experience. Costs of equipment,furniture, transport and supplies are based on analyses of requirements forthe project and derive from local market p.ices or CIF unit price. Costs ofproduction of FP and Health education materials, training, local andexpatriate consultants, applied research and other services reflect local orinternational prices, as applicable. Overseas fellowships are based onaverage United Nations rates for training in Europe, North America, Australia,Egypt, Indonesia, Japan, Nepal and the Philippines. Costs of salaries andallowances, including training allowances, are based on current Governmentrates. Base costs reflect an exchange rate of US$1 = Tk 35.79 (the exchangerate at the time of appraisal).

3.3 Contingency Allowances. Total contingencies represent 1lZ of thebase cost, or US$57.7 million. Physical contingencies (amounting to US$10.1million, or 22 of the total base cost) estimated at 72 of the boase cost havebeen applied to civil works and at 52 of the base cost have been applied toequipment, vehicles and medical and biological supplies. Price contingencies(amounting to US$47.6 million, or 92 of the total base cost) have beenestimated using projections reflecting Bank guidelines on local andinternational price increases: 82 in 1992, 72 in 1993, 62 from 1994 onwardfor local costs, and 3.42 from 1992 onward for foreign costs. A purchasingpower parity assumption for the exchange rate has been applied to offset thedifference between local and foreign inflation in the project years.

3.4 Customs Duties and Taxes. All imported goods are subject tocustoms duties and taxes. The cost of the project (US$601.4 million) includesimport duties and taxes estimated at about Tk 905.4 million (US$22.9 million),or 4Z of the total cost, to be financed by GOB.

3.5 Foreign Exchange Component. The estimated foreign exchangecomponent of US$185.3 million, or 31Z of the total project cost, is calculatedon the basis of estimated foreign exchange proportions as follow: (a) civilworks 22; (b) equipment and furniture 342; (c) vehicles 552; (d) medical andbiological supplies 912; (e) technical assistance and consultants services55Z; (f) training and fellowships 82; (g) innovative and NGO activities 82;and (i) project operating costs of civil works, equipment and vehicles 42.

3.6 Recurrent Cost Implications. GOB's contribution to the project isestimated at US$165.1 million (Tk 6,593.7 million), representing 272 of thetotal project cost of US$601.4 million. Apart from taxes and duties (US$22.9million, or 42 of the total cost), GOB will finance the bulk of regularrecurrent costs of the project, especially salaries and allowances. Whileunder the First Project (1975-82) GOB contributed 0.4Z to salary recurrentcosts, under the Second Project (1980-86) 22.72, and under the Third Project(1986-91) 43.12, under the Fourth Project GOB will finance 82.1? of allsalaries and allowances (Annex 32). This ncrease in GOB funding for

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recurrent cost is also reflected in the share it will finance of the FWA andHA cadres. Under the Third Project, 14,500 FWAs are being financed by theConsortium and around 6,000 by GOB. Under the Fourth Project, GOBwill increase its financing from 6,000 to 13,500 FWAs, in phases, whereas theConsortium will concurrently decrease its share from 14,500 to a maximum of10,000 FWAs (see Annex 1, page 10). Regarding HAs, GOB will continue tofinance the recurrent costs of 11,500 HAs, while the Consortium will fund5,000 HAs who all will be women. While salaries and allowances generallyconstitute the largest part of recurrent costs in as labor-intensive a sectoras the health and FP sector, it could be argued that supplies such asessential drugs and vaccines also belong to such costs. The long-termunderstanding between GOB and the Consortium regarding recurrent costsenvisages a phased approach, with GOB increasingly absorbing recurrent salarycosts during its Fourth Five-Year Plan (1990-95), whereas recurrent medicalsupply costs would be considered for absorption by GOB under the next Five-Year Plan (1995-2000). Inclusion into the 1990-95 project period of recurrentcost financing by GOB of the majority of both salaries and medical and FPsupplies would not have been sustainable by GOB's budget yet (all supplies anddrugs under the revenue budget are, of course, financed by GOB already). IfGOB would keep to its objective, formally stated during appraisal, to allocate10? of total government outlays - both revenue and development budgets - tohealth and population by FY99, then such a phased approach may indeed prove tobe possible. Although 10? may be too ambitious in view of the averagecorresponding figures in other Asian countries, by FY96 GOB intends toallocate close to 8Z of the revenue budget to health and FP; the revenuebudget, which for health and FP is roughly equal to the Fourth Plan outlay,i.e. US$700-750 million over a five-year period, contains mainly recurrentcosts financed by GOB (see Annex 1, page 9). Taken together with the 81.3?GOB financing of recurrent costs under the project's (development) budget,this reflects an important trend towards assuming a higher level of"ownership" of the population and health programs by GOB.

B. Financing

3.7 Financing Plan. The proposed IDA credit of US$180.0 million wouldfinance 30Z of the total project cost, including 30Z of the foreign exchangecost (US$56.0 million) and 32? of the local cost (US$124.0 million) of theproject. GOB would finance 27? of the project costs, including 36Z of thelocal cost (US$142.2 million) plus taxes and duties (US$22.9 million). Theeleven cofinanciers -- Australia, Belgium, Canada, EEC, Germany (GTZ and KfW),Japan, Netherlands, Norway, Sweden, and United Kingdom -- would finance 43Z ofthe project cost (US$256.3 million), including 70? of the foreign exchangecost (US$129.3 million) and 32? of the local cost (US$127.0 million).Altogether, external financing of the project would amount to US$436.3million, or 73Z of the project cost, and GOB financing would amount toUS$165.1 million, or 27Z. The proposed financing plan is summarized asfollows:

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Table 3.3: Proposed Project Financing

Sourc - US$ (million) -- of Totalot Taxes A Project

Finance Local Foreign Duties Total Costs

G0s 142.2 0.0 22.9 186.1 27

IDA 124.0 6B.0 - 180.0 so

Australia 7.0 2.6 - 9.6 2Belgium 0.7 2.1 - 2.S 0Canada 26.1 14.2 - 40.8 7EEC 10.6 81.2 - 47.8 8Germany

GTZ 11.1 1.7 - 12.8 2KFW 8.4 80.4 - 86.8 6

Japan 8.9 0.2 - 9.1 2Notherlsnds 9.8 16.0 - 24.8 4Norway 14.8 18.9 - 83.2 6Sweden 4.8 9.1 - 18.4 2United Kingdom 19.8 8.9 - 28.7 4

Sub-total 127.0 129.8 - 268.R 43

Total Project Cost 898.2 185.8 22.9 801.4 100

3.8 Project financing by component in summary is the following:

Table 3.4: ProJect Financing by Component

FP/ICH Service Health Service Supporting Women's and Total byDelivery Dolivery Activities Nutrition Financier

Progream---------------------------------USS (million)--------------------------------

Financier Amount X Amount X Amount X Amount X

COB 130.6 80 22.0 14 8.6 12 4.1 a8 166.1

IDA 68.6 19 74.8 48 28.8 89 8.8 87 180.0

Australia 1.8 1 7.6 6 0.2 0 0.0 0 9.6Belgium 0.0 0 2.7 2 0.1 0 0.0 0 2.8Canada 29.7 8 0.0 0 10.6 15 0.0 0 40.8EEC 26.2 7 21.8 14 0.8 1 0.0 0 47.8GermanyCTZ 12.8 4 0.0 0 0.0 0 0.0 0 12.8KFW 88.0 11 0.0 0 0.8 1 0.0 0 88.8

Japan 9.1 8 0.0 0 0.0 0 0.0 0 9.1Notherlands 18.7 4 8.0 6 8.1 4 0.0 0 24.8Norway 20.7 6 4.8 8 8.2 11 0.0 0 83.2Sweden 9.8 3 1.7 1 2.4 8 0.0 0 18.4United Kingdom O.S 0 14.8 9 8.9 12 0.0 0 28.7

Total 359.9 100 167.2 100 71.9 100 12.4 100 601.4

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The financing plan in terms of detailed investment and recurrent costs is

shown in Annex 33.

3.9 Cofinancing Arrangements. Four new donors, Belgium, EEC, Japan andSweden, joined the Consortium and participated in the preappraisal andappraisal missions. All cofinanciers participated in the appraisal mission.

The funds of all external donors will be contributed on grant terms. Germany

and Japan are likely to establish separate financing arrangements with GOB but

all other cofinanciers will make deposits into trust funds to be administeredby IDA. Formal cofinancing arrangements still remain to be completed. A

condition of credit effectiveness will be the fulfilling of conditionsprecedent to the effectiveness of the Canadian, EEC, KfW, and Norwegian GrantAgreements.

C. Disbursements

3.10 The proposed IDA credit covering 302 of the total project costswould be disbursed against the following categories: (a) 902 of expendituresfor civil works; (b) 1002 of foreign and local (ex-factory) expenditures and

652 of expenditure on locally procured items for equipment, furniture,vehicles, and medical and biological supplies; (c) 1002 of expenditures fortechnical assistance, consultants services, training, fellowships; (d) 82 ofexpenditures for salaries and allowances of new female health and FP workers,which represents a declining scale of IDA financing (252 for FY92, 20Z forFY93, 152 for FY94, 102 for FY95, and 52 for FY96); and (e) 302 of totalexpenditures for project operating costs.

3.11 The IDA credit is expected to be disbursed over five years (January

1992 - December 1996), with the Closing Date being December 31, 1996.Although the current regional sectoral disbursement profile is seven years,the five-year period is based on the phasing and programming of projectactivities in line with GOB's sector development plan. The schedule ofestimated disbursements appears itl Annex 34. Funds from the IDA credit and

any other funds which IDA may be authorized to disburse on behalf of otherdonors will be disbursed on the basis of satisfactory documentation submitted

by GOB's Project Finance Office. Disbursements against contracts for goods

and services exceeding US$200,000 equivalent will be fully documented.Disbursements below that level will be made on the basis of Statements of

Expenditures, to be kept available in the PFC for examination by IDA missions.

3.12 To facilitate implementation of the project and ensure thatadequate funds are available for project expenditures, GOB will establish and

open a project special account in a commercial bank on terms and conditionssatisfactory to IDA. The authorized allocation of the Special Account will be

the convertible taka equivalent of US$12 million, representing about four

month's expenditures. Replenishment will be requested in line with IDA

guidelines.

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D. Procurement

3.13 The procurement methods are summarized as followss

Table 3.5: Procurement Methods

TotaliCe LCB Other A N.A Costs

Project Element -------------------------US (illion)------

Civil Works - 91.0 - - 91.0- (62.9) - - (62.9)

Equipment and 89.6 11.0 0.2 - 60.6Furniture (21.7) (5 .) (0. 1) - (27.1)

Vehicles 11.2 1.8 - - 12.5(S 1) (O 6) - - (6.7)

Medical and Biological 186.8 b/ 6.9 0.8 - 148.0Supplies (28.2) (1.4) (0. 1) - (29.7)

Technical Assistance and - - 41.8 - 41.8Consultants Services - - (21.9) - (21.9)

Training and - - - 52.0 52.0Fellowship - - - (16.9) (15.9)

Innovative and NCO - - - 18.8 1S8.Activitis - - - (1.1) (1.1)

Project Operating - - - 197.0 197.0Costs _ - (16.7) (1.7)

Total Cost 18B8 110.2 41.8 262.0 601.4(66.0) (70.2) (22.1) (82.7) (180.0)

Note: Figures In parentheses are the respective amounts financed by IDA.*/ Includes International and local shopping and Bank consultant selection procedure.b/ Includes UNICEF and UNFPA procurement.

3.14 The elements of the civil works program under the project (US$91.0mllion) to be financed by IDA (US$62.9 million) consist principally of: (a) alarge number of small low unit cost FP and health facilities; and (b)upgrading and maintenance work associated with existing FP and healthbuildings. These facilities would be widely dispersed throughout the countryand work would be carried out over five years. Local contractors inBangladesh have the capacity to carry out these works and, on the basis ofexperience with similar projects in the country including the Third Populationand Health Project, foreign firms are considered most unlikely to beinterested in competing. Local Competitive Bidding (LCB) procedures, whichare acceptable to IDA, would be followed for such works (US$50.0 million

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including contingencies). In addition, the building for the MOHFW's FP andHealth Division (US$9.3 million) to be financed by IDA is unlikely to attractforeign bidders not already located in Bangladesh and would be contractedfollowing LCB procedures acceptable to IDA. Nonetheless, any foreign bidderinterested in bidding would be allowed to participate. Other constructionunder the project, financed separately by donors in the Consortium, wouldfollow procedures of the respective agencies.

3.15 Equipment (US$39.6 million), vehicles (US$11.2 million), andmedical and biological supplies (US$135.8 million) will be grouped to theextent possible into bid packages of US$200,000 or more and will be procuredthrough International Competitive Bidding (ICB) in accordance with IDAGuidelines. As far as practical, DDS kits will be procured through UNICEF andcontraceptive supplies through UNFPA following IDA guidelines. For bidcomparison, goods manufactured domestically will be allowed a preferentialmargin of 15Z of the c.i.f. costs of competing imports or the actual customsduties, whichever is lower. Contracts valued at less than US$200,000totalling up to US$12.8 million and furniture totalling up to US$6.4 millionmay be purchased through LCB following procedures acceptable to IDA, in whichforeign suppliers are eligible to participate. Exceptions to the above willbe made where parallel financing agreements directly between cofinanciers andGOB require different arrangements to be made.

3.16 International or local shopping, based on comparison of at leastthree quotations, will be permitted for urgently needed items, includingessential drugs and medical supplies, valued at US$50,000 or less, and will besubject to an aggregate of US$500,000 equivalent during the project.

3.17 Technical assistance and consultants services (US$41.3 million) aswell as training and fellowships (US$52.0 million) will be provided inaccordance with the guidelines of the various cofinancing agencies. All IDA-financed consultants will be selected in accordance with IDA Guidelines forthe Use of Consultants. Standardized documents will be developed for LCB forconstruction, equipment, furniture, and medical supplies under the project.During negotiations, agreement was reached that GOB will submit to IDA draftstandard documents before any bidding is undertaken on the respectivecomponents. Civil works, furniture, goods and supplies contracts overUS$200,000 equivalent, under IDA's purview, will be reviewed by IDA prior toaward. This will cover about 45Z by value of such contracts.

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IV. IMPLEMENTATION AND SUPERVISION

A. Project Organization and Management

4.1 The Fourth Project will be implemented over a five-year (1992-96)period that coincides with a three and one-half year time slice (1992-95) ofGOB's Fourth Five-Year Plan and a one and one-half year time slice (1995-96)of GOB's Fifth Five-Year Plan. Implementation arrangements will be similar tothose under the Third Project. However, recognizing that the new project hasa larger magnitude than the ongoing one, and considering lessons of pastprojects, care has been taken to provide in the design for expansion of GOB'simplementation capacity, including staffing, accommodations, an4 equipment.The schedule of key implementation activities is in Annex 35. The overallresponsibility for management of project-funded service delivery, includingtraining, will be vested in the MOHFW which is generally adequately staffedfor this purpose. DGFP will be responsible for the components of the projectrelating to family welfare, including relevant areas of MCH, while DGHS willbe in charge of the components concerning health services. Assignment andsupervision of staff will be dealt with by DGFP in the case of FWAs, FWVs,FPMOs, the Supervision Directorate, the FPCST and the MDU, and by DGHS in thecase of health personnel. Except for condoms which will be centrally procuredwith the assistance of an independent procurement agent, the respective DG'slogistics staff and procurement units will be responsible for procurement,distribution and control of all project-financed vehicles, drugs, equipmentand supplies. Logistics support will be provided by donors havinginstitutional arrangements with GOB, e.g. UNFPA, USAID and UNICEF, togetherwith the Consortium members and IDA.

4.2 Project-financed training will be organized and managed by NIPORTand the various institutes under the DGFP in the case of FP/MCH services, andby NIPSOM, the medical colleges, the college of nursing, the Institute forMother and Child Health and the various programs under the DGHS in the case ofhealth services. NIPSOM will have a new unit for the purpose of traininghealth personnel, which, together with the colleges, will be accov-.1',e tothe Director of Medical Education. Full- and part-time expatriate advisors(para 2.32) will assist the DGs with implementation.

4.3 The MOHFW (PP and Health wings) has a coordinating committee incharge of all MCH programs, chaired by the Secretary, MOHFW, and assisted byan MCH Coordination Cell. Committee membership includes the MOHFW; the DGs ofboth FP and Health; the Directors of each of the major MCH Programs, of PublicHealth Nutrition, of PHC and MCH services and representatives of NGOs activein MCH.

4.4 The MCMU, comprising the merged CMC and BPDU of MOHFW, willcoordinate and implement all construction and maintenance under the projectthrough local consultants. MCMU will also supervise quality and monitorprogress of the LGEB when it maintains and constructs facilities below upazilalevel. The Chief Engineer, MCMU will have full financial powers to implementthe project works. In the case of the project components 'renovating andconstructing UHCs", a Project Management Unit accountable to the Director, PHCwill coordinate the project activities, although all civil works will becarried out through the MCMU.

53 -

4.5 IEM activities will be functionally integrated between the IEH Unitof DGFP and the HEB of DGHS. Private professionals will be used to developmessages and educational material.

4.6 The MIS for FP/MCH will be organized and managed by a Director andstaff under the DGFP and restructured to promote the use of MIS in decisLon-making. The MIS for Health Services will be managed by the Chief of theHealth Information Unit. The health and demographic surveys will be manageddirectly by the MOHFW, with assistance from both MIS systems, in cooperationwith BBS. The PFC will continue under the Fourth Project to preparewithdrawal applications, keep project accounts and carry out routine audits.The PFC is adequately staffed for this purpose.

4.7 The three women's programs under the present project will beorganized and managed as under the Third Project. Coordination amor!g thewomen's programs and with MOHFW will take place through the continuedoperation of an interministerial committee headed by the Secretary, MOHFW, butlonger-term linkages will be institutionalized through the separately plannedIntersectoral Project (para 2.3).

4.8 The Directors of specific program areas, such as: mycobacterialdisease control, nursing, NIPSOM, medical education, IPH, immunization, TBAtraining, and diarrheal management programs will have direct responsibilityfor management of project components relating to their respective programs.Similarly, existing agencies with specific areas of responsibility within GOBwill oversee and coordinate project components related to those areas, e.g.,the coordinated nutrition program by the National Nutrition Council under theSecretary, MOHFW; development of medical research by the Bangladesh MedicalResearch Council; the epidemiological surveillance project by the Director ofIEDCR; control of vector-borne diseases by the Director, Program for Controlof Vector-Borne Diseases under the MOHFW: urban PHC and school health by theDGHS Directors for PHC, and control of iodine deficiency disease through saltiodization by the Director of the Bangladesh Institute of Salt Iodization andCrushing.

4.9 Special project management units or cells will be set up forspecialized project components, e.g., Omaternal and neonatal health care'(under the DGHS but coordinated with the DGFP through the MCH CoordinationCell); 'quality assurancen, by a combined cell under the Director of Hospitalswithin the Health Directorate of MOHFW and the Director of the Center forMedical Education; and "health economics and financing' by a pilot projectunder the Joint Secretary concerned of the MOHFW, with close coordination withthe Planning Cells of the DGFP and DG Health.

B. Project Management and Supervision Support

4.10 The Population Program Office (PPO) has operated since 1976 in theBank Group's Resident Mission in Dhaka to monitor, report on and assist GOB infinding prompt solutions to issues of population and PP. Because of theincreased prominence of health care with the Consortium, the PPO will beexpanded as a Population and Health Office (PHO), supported by a technicalcommittee consisting of resident professional advisors from the Consortiummembers. The supervisory office at the Bank in Washington, D.C. whichcoordinates and oversees PHO's activities, will continue its function as underthe Third Project. One of the lessons of the three earlier projects was thatthis strong IDA presence provides a Consortium mechanism to promote a cohesive

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and consistent donor dialogue with the GOB on both policy and operationalissues of the national population and health programs. Moreover, IDA'spresence helps to bring about project monitoring and provides technicalassistance to the GOB. The funding arrangements for the offices in Dhaka andWashington will be consolidated and continue as they exist for PPO under thecurrent Third Project, with contributions from the Consortium members,including IDA. The expansion of PPO with additional MCH and health staff willbe fully funded by the cofinanciers. Funding will include vehicles, salaries,equipment, supplies and operating and supervision costs.

C. Monitoring and Biannual Reviews

4.11 Because of the project's slze, scope and central role in GOB'sdevelopment plan for FP and health anu in accordance with lessons from theprevious projects, MOHFIF will carry out in-built monitoring and evaluationduring its regular operations. Reporting tools, structured for each majorproject intervention and supervision reports, covering output and processindicators as well as evidence of compliance with legal covenants, will beprepared at regular intervals by the relevant implementing offices. Managerswill be aided in their reporting tasks by the MIS systems under development.Additionally, data will be obtained through the Bangladesh Fertility Survey,the Contraceptive Prevalence Surveys, and the epidemiological, demographic andhealth surveys under the project.

4.12 Project supervisio4. will be based on Technical and Annual Reviewmissions as shown in the following table:

Table 4.1: Proiect Supervision

Approximate Expected Skill ID Headquarters InputDates Activ;v Requ i roments (Staff-weks) */

2-8/92 Supervision Mission Population/Health Carr 16.0(Project Launch Workshop) Procurement, Disbursement

Leg I

9/92 Annual Review of: Varlous Population and(a) FP and Health Specialists 25.0(b) MCH/PHC Programs

2-8/98 Technical Review of: Various Population and(a) FP and Health Specialiats 1.0(b) MCH/PHC Progras

9/9B Annual Review Same as above 25.0(same as previous year)

2-8/94 Technical Reviow Some as above 16.0(same as previous year)

9j94 Annual Reviow Same as above 25.0(sam as provious year)

2-8/95 Technical Review Same as above 16.0(same as previous year)

9/96 Annual Review Same as above 25.0(some as previous year)

2-8/96 Technical Roview Same as above 16.0(same as previous year)

9/50 Annual Rovlew Same as above 25.0(same ts previous year)

a/ Excluding staff from the consolidated PHO.

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Review missions on behalf of and in conjunction with the Consortium will occurtwice yearly. The first mission, early in the calendar year, will be known asthe Technical Review and the second mission, in September or October of eachyear, will be the Annual Review. Due to the potential number of missionmembers and the scope of the project, intensive dialogue with GOB colleagueswill be fostered on those broad technical and policy issues of greatestconcern at the time. In addition to these large review missions, each projectcomponent may be subject to scrutiny by a small team of experts and specialsupervision missions will be carried as needed, in response to informationfrom progress reports and PHO. While specific documentation and reportingformats will be designed by the Consortium and MOHFW prior to the first reviewmission, pertinent areas of focus are described below.

4.13 Indicators measuring achievement of quantitative project objectiveswill include: CPR, TFR, IMR, and EPI coverage figures. Data on MMR and UMRwould provide relevant supporting information. Indicators measuringqualitative project objectives would include service delivery indices such asutilization rates and costs of human resources deployed, and levels of clientsatisfaction. Particular attention will be given to monitoring of indicatorsmeasuring performance related to the WID strategy for the project (para 2.2and annex 24). In addition, GOB's annual budget allocations for the FP andhealth sectors--both in absolute terms and relative to the total nationalbudget--and the intrasectoral priority allocations will be reviewed annually.

4.14 Further, the goal of increased coordination between the two wingsof MOHFW, as well as administrative effectiveness, will be monitored. Thiswill entail annual expenditure reviews for MOHFW and the degree to which thenew Health Economics and Financing Pilot Project is involved in short and longterm planning for the sector. Finally, intersectoral goals, such as improvingthe status of women, will be evaluated through a combination of indicators(see Annex 35).

4.15 Annual reports as of the end of the fiscal year will be prepared ina mutually agreeable format by the Supervision Directorate, FPCST, MDU,NIPORT, NIPSOM, IEDCR, NNC, IPN, ICRH, IEM/HEB, MCMU, communicationscomponent, evaluation subcomponent, MIS (Health and Family Welfare), women'sprograms and each of the Project Directors within the MOHFW, and furnished bythe Secretary, MOHFW, to IDA and the cofinanciers at least four weeks beforeeach annual review. Specific terms of reference for each annual review willbe worked out among the cofinanciers, IDA and the GOB not later than sixmonths before the review data. GOB will continue the annual review system forthe present project, as established for the Third Project.

4.16 GOB will also provide IDA and the cofinanciers with an interimprogress report every February 15 on physicAl and financial implementation ofeach project component for the six month period ending December 31 in a formatreflecting the approved budget and work plan for that fiscal year. Agreementwas reached with GOB during negotiations that, by September 30, 1992, anannual project review system acceptable to IDA, including a review of annualbudgets for the health and FP subsectors, will be established and the firstannual review of the project will take place in consultation with IDA notlater than October 31, 1992, after which required actions will be taken.

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D. Accounts and Audits

4.17 Each participating ministry or implementing agency will prepare andmaintain in accordance with sound and generally accepted accounting principlesand practices acceptable to IDA: (a) records permitting identification of allreceipts and payments under the project; (b) financial statements, includingsources and uses of funds at the close of each fiscal year; and (c) acertified copy of the accounts together with the auditors' report, to besubmitted to IDA as soon as possible, but not later than nine months afterthe end of each fiscal year, including a separate opinion on the SpecialAccount and on the records and accounts used to support disbursement againstStatements of Expenditure.

4.18 The PFC will continue to audit local currency expendituresquarterly and furnish these reports to IDA within six months of the completionof the audited quarter. Reimbursement in each succeeding quarter will bedependent on the availability of the PFC audit for the quarter ending sixmonths earlier. Agreement was reached with GOB during negotiations thataudits of project accounts by independent auditors acceptable to IDA will bemade available to IDA, within nine months of the close of each fiscal year.

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V. BENEFITS AND RISKS

A. Benefits

5.1 The main benefits from the project will be improved family welfare,particularly among women and children, through greater spacing of births andimproved health status. In terms of the socio-economic and environmentaloutlook of the country, the project will mitigate the intense pressure on thelimited land and other natural resources due to population growth and ease thechallenge of providing social services and employment opportunities to thegrowing numbers of people. The project is a powerful catalyst for increasedinvestment into the social sectors of population and health under GOB's FourthFive-Year Plan, an increase which is strongly supported by the Bank's publicexpenditure review of the country. Additional benefits will be enhancedefficiency and effectiveness of FP and health services due to the: (i) plannedcooperation and possible integration of the currently stiil separatesubsectors of family planning and health services; (ii) reorientation ofmedical education towards community medicine and public health away from theconventional focus on medical and surgical curative care; and (iii)significant improvement of the quality of FP and health care services.Acceptable quality of care would also augment the utilization of services, animportant concern at present.

B. Risks

5.2 The main -isk of the project is the GOB's potential inability toimplement fully the extensive reform program in the health subsector,including the reorientation of medical education toward community medicine andpublic health. Another risk is the possible weakness of the managementcapacity of the health subsector. Whereas the FP subsector has demonstratedits capacity to handle increasingly large investments with reasonably goodresults, the health subsector capacity remains to be tested. While there islittle doubt about the adequacy of financial absorptive capacity, it is themanagerial absorptive capacity that is likely to require strengthening. Tominimize these risks, the design of the project addresses the reorientation ofthe medical profession, while also providing ample support to the GOB'smanagerial, planning and evaluative faculties to facilitate the successfulhandling of the proposed reforms. This would include intensive collaborationwith the Bangladesh Medical Association, the Medical and Dental Council, theMedical Colleges, the World Health Organization (WHO) and various otheragencies to ensure adequate professional inputs into the process of reform andthe establishment of a robust management system.

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VI. AGREEMENTS REACHED AND RECOMMENDATION

6.1 During negotiations, the following agreements were reached that theGOB wills

(i) hire, by January 1, 1995, qualified women to fill at least 4,500 ofthe 5,000 vacant HA positions in its outreach services and prepareand furnish to IDA for comments, by March 31, 1992, a plan on therecruitment of HAs, including the appropriate proportions of maleand female staff, and subsequently carry out the plan taking intoaccount IDA's comments (para 2.7);

(ii) establish transportation arrangements satisfactory to IDA, for PPand health workers to attend satellite clinics (para 2.11);

(iii) carry out, a fertility survey by December 31, 1994 in accordancewith terms of reference acceptable to IDA and furnish the resultsto IDA for comments (para 2.12);

(iv) carry out, every two years, commencing by March 31, 1993, acontraceptive prevalence survey in accordance with terms ofreference acceptable to IDA and furnish the results to IDA forcomments (para 2.12);

(v) carry out, by September 30, 1992, a survey of the physicalcondition and utilization of existing facilities for FP and healthservices and furnish the results to IDA for comments (para 2.24);

(vi) furnish to IDA a list of the sites for construction of FWCsselected based on criteria satisfactory to IDA and subsequentlyconstruct the centers in accordance with the standard design agreedwith IDA (para 2.25);

(vii) carry out, by December 31, 1992, a feasibility study to identifythe storage requirements for FP and health supplies and furnish theresults to IDA (para 2.27);

(viii) initiate, by March 31, 1992, a comprehensive baseline survey ofmaternal and neonatal health care in the districts of Kushtia,Tangail, Feni and Sirajganj/Pabna and furnish the results to IDAfor comments (para 2.31);

(is) create, by September 30, 1992, additional nurse positions inNursing Institutes and UHCs in accordance with a schedule agreedwith IDA (para 2.33);

(x) furnish to IDA for clearance, the final design of the Institute forMother and Child Health (para 2.40);

(xi) require recipients of research grants and of project-financedtraining to remain in their relevant institution or area ofexpertise for at least two years after completion of training orresearch (para 2.43);

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(xii) carry out, by September 30, 1992, baseline surveys of tuberculosisand leprosy in accordance with terms of reference acceptable to IDAand furnish the results to IDA for comments (para 2.45);

(xiii) assign, by July 31, 1992, responsibility for urban primary healthcare to either the national or the local government and inform IDAof the decision (para 2.55);

(xiv) prepare and furnish, by March 31. 1993, a master plan for schoolhealth programs and carry out the programs taking into accountIDA's comments (para 2.56);

(xv) carry out by April 30, 1992, plans reflecting that 70Z of the bedsin district hospitals and UHCs will be for women and children (para2.57);

(xvi) prepare, by April 30, 1992, and furnish to IDA for comments thearchitectural plans for new UHCs, including indication of theselected sites, allocation of 70Z of the beds for women andchildren and a comprehensive maintenance plan (para 2.58);

(xvii) carry out, by June 30, 1994, an in-depth review of the outcome ofthe special program to address capacity utilization at the UHCs andFWCs, prepare an action plan for the expansion of the program tothe remaining upazilas, furnish the review and action plan to IDAfor comments, and carry out the action plan taking into accountIDA's comments (para 2.60);

(xviii) carry out, by July 31, 1994, the needs assessment and system designin respect of MIS for FP and health and furnish the results to IDAfor comments (paras 2.62, 2.64);

(xix) carry out, by June 30, 1993, a health and demographic survey inaccordance with terms of reference acceptable to IDA and furnishthe results to IDA for comments (para 2.65);

(xx) carry out, by August 31, 1993, a policy study on the reorganizationof health and family planning programs in accordance with terms ofreference satisfactory to IDA, furnish the recommendations of thestudy to IDA for comments, and prepare and carry out an action plantaking into account IDA's comments (para 2.69);

(xxi) prepare, by March 31, 1994, a human resource development plan forstrengthening the capacity for human resource development planning,including provision for representation of women at all levels ofthe FP and health system, furnish the plan to IDA for comments, andcarry out the plan taking into account IDA's comments (para 2.70,2.85);

(xxii) establish and maintain a MCH Coordination Cell in accordance withterms of reference acceptable to IDA and with competent staff inadequate numbers (para 2.72);

(xxiii) (a) establish, by August 31, 1992, a Health Economics and FinancingPilot Project in the MOHFW with competent staff in adequate numbersand with terms of reference and a work program acceptable to IDA,

- 60 -

(b) take all actions required to strengthen the MOHFW in accordancewith policy-related financial and economic analyses by the project,(c) by September 30, 1993, furnish to IDA for comments a plan toaddress the issue of long-term sustainability including amongothers, proposals for achieving an acceptable balance between theMOHFW's revenue and development budgets, for transfer of specificexpenditure items from the development to the revenue or localgovernment budget, and on cost-sharing mechanisms and improvedcost-effectiveness in the health care system and carry out the plantaking IDA's comments into account (para 2.73);

(xxiv) maintain the PFC with competent staff in adequate numbers until thecompletion of the project (para 2.74);

(xxv) unify, by June 30, 1992, the BPDU and CMC and assure that the newUnit has the required administrative and financial authority tocarry out its construction and maintenance responsibilities (para2.76);

(xxvi) furnish, by August 31, 1992, a strategy and work plan, acceptableto IDA, for functionally integrating FP and health communicationsactivities of IEM Unit and HEB, such strategy to include indicatorsof gender awareness, and put such functional integration intoeffect by December 31, 1992 (para 2.77);

(xxvii) carry out, by June 30, 1992, an evaluation of the communityvolunteer programs and furnish the results to IDA for comments, andensure that contraceptives are provided on a priority basis tocommunity volunteer programs, to the Mother's Centers, to theWomen's Cooperatives and to the Women's Vocational TrainingPrograms under the project (para 2.80);

(xxix) carry out, by September 30, 1992, an in-depth review of the threewomen's programs, prepare an action plan for strengthening theprograms, furnish the results of the review and action plan to IDAfor comments, and carry out the action plan taking IDA's commentsinto account (para 2.92);

(xxx) confirm that draft standard documents will be submitted to IDAbefore any bidding is undertaken on the relative components (para3.17);

(xxxi) establish, by September 30, 1992, an annual project review system,including a review of annual budgets for the population and healthsubsectors, acceptable to IDA and from October 31, 1992, carry outthe reviews, in consultation with IDA, and subsequently take allrequired actions as a result of the reviews (para 4.16);and

(xxxii) submit to IDA audits of project accounts by independent auditorsacceptable to IDA within nine months of the close of each fiscalyear (para 4.18);

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6.2 Conditions of credit effectiveness are that GOB will:

(i) approve all project-related Project Proformas (para 2.5);

(ii) establish transportation arrangements, satisfactory to IDA, for PPand health field workers to attend satellite clinics (para 2.13)S

(iii) establish the MCH Coordination Cell within the MOHFW (para 2.72);and

(iv) fulfill conditions precede- to the effectiveness of the Canadian,EEC, KfW and Norwegian Grant Agreements (para 3.9).

6.3 Subject to the above conditions, the project would be suitable foran IDA Credit of SDR 133.2 (US$180.0 million) to the People's Republic ofBangladesh on standard IDA terms with 40 years maturity.

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Annex 1Page 1 of 12

BANGLADESH


vore Investments for Population, Health and Education

1. The Core Fourth Five Year Plan (FFYP, FY1991-FY1996) projects forpopulation, health and education will be discussed together, as they areintegral parts of the government's strategy for human resource development andboth raise similar issues for the public expenditure program. There is noquestion that human resource development warrants the high priority accordedit in the FFYP. Current levels of human capital formation are unacceptablylow by any standard and constitute a serious constraint on the country's long-term development prospects and aspirations for social equity. Life expectancyat birth is 52-54 years for males and 49-51 for females, due in part to aninfant mortality rate that is quite high (110 per 1000 live births). Infamily planning, there has been substantial progress, with the contraceptiveprevalence rate increasing from 7.7Z in 1975 to 33? in 1989, while the totalfertility rate has fallen from over 7 per woman of childbearing age in 1975 toaround 4.9 in 1990, due largely to increasing contraceptive prevalence andchanges in nuptiality patterns (especially an increasing age of marriage).Nevertheless, the current population growth rate of around 2.4 per annumremains very high in relation to low per-capita income and high populationdensity (1199 per km2 of cultivable land). The adult literacy rate isestimated at 33?, with a female literacy rate of only about 20?. Enrollmentratios as of 1987 were 61? for primary education (50? for girls) and 24? forsecondary education (15? for girls). Experience from Bangladesh as well asmany other countries demonstrates that significant improvements can beachieved in these "quality of life" indicators, which would also providesubstantial economic benefits over the long-term by improving laborproductivity and accelerating the adoption of improved technologies.Achieving this objective, however, requires a clear political recognition ofthe importance of human resource development, an ability to innovate and adoptnew procedures, many of which may be opposed by entrenched public sectorbureaucracies, and a long-term commitment to allocate substantial amounts ofadditional funding to expanding and improving human resource developmentprograms, while maintaining the necessary financial discipline on other areasin the budget to make these programs sustainable.

2. The primary reason for low levels of human resource development hasbeen inadequate expenditures, both historically and at the current time.Expenditures for health care and family planning, which accounted for a littleover 5? of the total government budget in FY88 (0.8? of GDP), represents anexpenditure of approximately US$l per capita for health services and 50 centsfor family planning, a level that is very lo( both in absolute and relativeterms as compared to other low income countries. Similarly, expenditures foreducation comprised 1.8? of GDP in FY88 (10? of government expenditures), alevel that is one-half or less of the level found in other South Asiancountries (except Pakistan). While these statistics are revealing, they areonly a part of the story, as the quality of services is inadequate as well.

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Annex 1Page 2 of 12

In primary education, the curriculum is overloaded and highly theoretical,while the amount of student-teacher contract time is inadequate (a maximum of472 hours per annum in the initial grades). The drop-out and student wastagerates are very high, such that only 142 of entering primary school studentsactually complete the full five-year curriculum within the stated time (ascompared to 55Z in other low income countries). In the health sector, the1988 BIDS Survey found that while there has been a substantial reallocation ofthe budget to rural health services, reinforced by donor support for thedevelopment of Upazila Health Centers (UHCs), the utilization of thesefacilities has been poor; while this partly reflects socio-cultural patterns,it is also due to inadequate quality of service, with in-patient facilities atUHCs having a utilization rate of only around 50Z and out-patient facilitiesshowing a somewhat higher but similar pattern. Only in family planning doesthe government appear to have established an effect system for providingservices, relying on female outreach workers and the provision ofcontraceptives through both public and private sector channels. Even thoughthe family planning program is cost-effective on a per-capita basis, its totalcost already amounts to one-third of the budget for health and family planningand a substantial increase in total cost will be required in order to raisethe CPR rate to the necessary level of 60Z-70Z.

3. In this situation, the best strategy for the government and thedonors would be to expand the programs for primary health care, familyplanning and primary education as rapidly as possible, subject only toconstraints imposed by local implementation capacity (including the need forimprovements in service quality). This is essentially the strategy adopted bythe Fourth Population and Health and General Education projects, drawing on aunique model of government-donor coordination that has been established forfamily planning and health in the form of the Population and HealthConsortium. The Consortium, which is an informal body chaired by IDA thatreceives direct financial support from several donors to cover administrativecosts, was originally established as a mechanism for coordinating donorprograms in the family planning field and reducing the burden on thegovernment of having to deal with many separate donor agencies. Itssuccessful experience in terms of coordinating policy formulation, avoidingoverlaps in program design, and mobilizing funds to support a rapid increasein family planning activities has encouraged the Censortium to extend itsactivities into the health sector under the Fourth Population and HealthProject, where donor financing has traditionally been limited and provided onan individual project basis. In addition, a similar consortium has beenformed for the education sector to take over the management and financing ofthe General Education project. Eight donors are involved in cofinancing theGeneral Education prrject (which was approved in FY90 and recently becameeffective, while almost twenty donor agencies (including specialized agencies)were involved in the recent appraisal of the Fourth Population and Healthproject, which is expected to be approved during FY91.

4. The approach adopted by the General Education Project is to focusheavily on improvement in education quality in order to address the rootcauses of high student wastage rates and limited educational relevance to thestudent's a needs. Thus, almost half of total project costs (estimated at

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Annex 1Page 3 of 12

US$310 million for the FFYP period) are devoted to quality enhancementprograms, including training and retraining of primary school teachers,textbook development and distribution, and curriculum development at theprimary and secondary level. The program of physical construction isrelatively modest, providing for only 30? of the projected classroom needsduring the project period, with a heavy emphasis on renovation and improvementof existing facilities. Several innovative components are included to testalternative approaches to educational expansion, including a pilot programfor satellite schools in under-served villages which demonstrate strongcommunity support, a grant program to promote involvement by NGOs andcommunity-based groups in non-formal primary education programs and outreachactivities in order to encourage the very poor and girls to participate inprimary education, and experience with reduced construction standards (at acost of 40? of regular school structures). Finally, a special effect is beingmade to develop the management systems and information base needed by thesector institutions to support a take-off of the primary education program by

the end of the FFYP to achieve universal primary education by the year 2000,defined as 90? enrollment of eligible school age children in primary educationprograms of acceptable quality.

5. The Fourth Population and Health Project adopts a more aggressiveapproach to expansion of the sector, based on the successful experienceachieved in the family planning program up to now. Approximately 54? of totalproject costs (roughly $320 million out of $600 million total) will be devotedto family planning activities, of which the delivery of family planningservices, including salaries of outreach workers and contraceptive supplies,represents the largest single activity (approximately $200 million). Another25? of project costs will go to improving health service delivery, includingtraining of health service practitioners, control of preventable diseases(especially those affecting the poor) and renovation of rural healthfacilities (primarily union level facilities and UHCs). The remaining projectcosts will be devoted to support system activities, including informationsystems, management improvements, and communication programs to generatedemand for family planning and maternal health services, as well as effortsin support of intersectoral women's programs. Several notable features of theproject deserve emphasis. First of all, there is a major effort to shift thefocus of public sector health programs increasingly towards services orientedto women, children and the poor, where the deficiencies in health care are

more severe and where the justification for public sector financing (ascompared to private sector services) is strongest. Secondly, there is astrong emphasis on improvements in the quality of care, rather than theexpansion of physical facilities which has dominated the health program up tonow. Quality enhancement requires a multi-faceted approach to the sector,including training, provision of adequate supplies, improvements in managementand supervision, appropriate incentives, and targeting of health services, allof which will be addressed under the project. A third aspect of the projectis the increased recognition of the complementary nature of health and familyplanning services and the need to achieve a closer integration in servedelivery, as compared to the artificial division of responsibilities that hasexisted in the health ministry up to now. Finally, based on the demonstratedsuccess of community outreach programs in the family planning field, greater

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Annex 1Page 4 of 12

efforts will be made to promote community participation and communicationthroughout the health sector.

6. Given the large size of the projects and their stated objective tobring about a permanent increase in the share of GDP devoted to the socialsectors, questions as to their long-term sustainabilit, are clearly relevant.The projects will have a major impact on the recurrent obligations of thegovernment, which, even though the initial impact will be modest because ofextensive donor financing of recurrent expenditures, will eventually have tobe borne largely by the government form its own revenues. Financialprojections prepared for the General Education project indicate that achievingUPE by the year 2000 will require an average annual increase in the budget forprimary and secondary education in excess of 71 p.a. in real terms, of whichthe largest share will go for recurrent costs such as teachers' salaries,school supplies (e.g., textbooks), maintenance of school buildings, andinservice training of teachers. For the Fourth Population and Health Project,financial projections from the 1989 Health Financing and Expenditure Studyindicate that the increase in costs needed to improve service quality andcontinue the expansion of the existing system will require a growth in thebudget for health and family planning in excess of 8Z p.a. in real terms, ofwhich approximately 90Q of the cost increase will be in the form of recurrentexpenditures. Given the very low share of GDP and the government budgetcurrently allocated to these sectors, it is possible to argue tha_ such anincrease should be affordable and manageable by the government. Nevertheless,given the experience of the past ten years during which revenue growth hasstagnated and non-essential recurrent expenditures have increased rapidly, itis clear that a major increase in recurrent expenditures by the social sectorswould put serious pressure on the budget unless the government simultaneouslyincreases revenues and/or reallocates funds from other sectors, or the donorsare willing to accept long-term responsibility for financing recurrent costs.

7. In the short term, there appear to be adequate grounds forconfidence that the government will provide sufficient resources to supportthe efficient implementation of the Fourth Population and Health Project andthe General Education projects. Unlike the experience in many other sectors(e.g., water resources) where shortages of local funding have been a majorcause of poor project implementation, the Planning Commission has providedsufficient local funding to support efficient project implementation of majorfamily planning and education projects; in addition these allocations havebeen preferentially protected during periods of budgetary cut-backs, as in thepast few years. This is reflected in the generally good disbursementperformance of the projects. The recently completed Second Primary Educationproject tended to disburse ahead of schedule. While there were some delays indisbursements in the initial stages of the Third Population and Healthproject, these can be attributed largely to management problems in theMinistry of Health which have now been adequately resolved, so that theproject is disbursing normally. Both the Fourth Population and Health projectand the General Education project place heavy emphasis on upgrading themanagement capacity of sectoral institutions, as well as maintaining closecoordination between the donors within the respective consortiums. Thus,unless there is an unexpected change in the priority afforded to the social

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Annex 1Page 5 of 12

sectors by the government, both projects can be expected to perform reasonablywell.

8. In the longer-tarm, the ability of the government to absorb thefinancial impact of these projects is likely to be determined primarily by theextent to which it can maintain financial discipline on the growth of otherrecurrent costs in the sectors. The government has routinely used the excuseof tight constraints on the recurrent budget as a way to argue for a largeshare of donor financing of recurrent expenditures in social sector projects,generally covering 902 of total costs, including local salaries and othercosts. Thus, for example, in the General Education project, the donors agreedto finance the cost of all net new female teachers over the project period ona declining basis, both in order to moderate the impact of the recurrent costburden on the budget and to provide a positive incentive to the government tohire additional female teachers as a way of encouraging higher enrollments bygirls. In the Fourth Population and Health project, the government has agreedto absorb the salaries of family welfare assistants (i.e., female familyplanning outreach workers) hired under past projects on a phased basis, butthe project will continue to hire additional female health and family planningworkers with the costs largely absorbed by the donors.

9. While the excuse of budgetary constraints is valid in the shortterm and provides adequate justification for financing recurrent expendituresin order to expand services at a rapid pace, in the medium term the governmenthas shown considerable flexibility in varying sectoral shares of recurrentexpenditures, although not necessarily in a manner that is consistent with itsstated policy objectives. For example, between FY83-88, recurrentexpenditures in the education sector grew at the rate of 23.5Z p.a.,significantly faster than the growth of overall recurrent expenditures (18.12p.a.) or the growth of education expenditures in the ADP (17.02 p.a.). Whilea large share of this increase was due to general inflation of public sectorwage scales, as well as some additional teachers hired as a result of newcapacity created by donor-financed projects, the principle factors behind theextraordinary rate of expansion of education costs had relatively little to dowith the government's stated objectives in the sector. Between FY80 and FY9C,the government progressively increased the rate of subvention for teachers'salaries in private secondary schools from 502 in the FY80-85 period, 602 inFY86, 702 in FY87-89, and finally to 802 in FY90; moreover, the number ofprivate secondary schools accredited by the government (and thus eligible forthe subvention) increased at a rapid rate. In addition, approximately 4,000

primary schools were nationalized by the government during the past fiveyears, despite policy statements that the practice of nationalizing schoolswould be strictly limited. While well-conceived policies to mix public andprivate funds may well form a part of a long-term strategy for the governmentto achieve its education goals, the decisions so far have not been justified

on any clear policy basis and appear to have had little impact on improving

educational quality or addressing other major issues in the sector. Instead,the decisions have been made largely in an ad-hoc manner and in response to

the demands of well-organized and politically powerful teachers unions.Similarly, the former government announced its intention during 1990 tointroduce compulsory primary education from January 1, 1991. While such a

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Annex 1Page 6 of 12

goal is clearly desirable in the long term, no attempt has been made toreconcile this policy with the carefully conceived program for achievinguniversal primary education under the General Education Project. Moreover, interms of the availability of classrooms, teachers, school supplies, and anadequate curriculum, the introduction of compulsory primary education isseveral years premature and could result in a further deterioration of thealready inadequate quality of education that is provided. The governmentprovided a block grant of Tk 100 crore in the FY91 recurrent budget in orderto support the achievement of compulsory primary education, although theprecise allocation of this sum has not been announced and it reportedly isbeing reduced because of overall budgetary pressures. Moreover, the majorpolicy instrument that has been announced to achieve compulsory primaryeducation, which is a subvention of TK 500 per month to four teachers inrecognized non-governmental primary schools, appears to have little relationto expanding the quality or quantity of primary education, despite itssubstantial budgetary cost (in the range of Tk 15-20 crore on an annualbasis).

10. In the health and family planning sector, the experience of thepast ten years has been different. Recurrent expenditures rose at an annualrate of 7.22 p.a., from FY83-88, much less than the growth of the overallrecurrent budget, while expenditures for health and population in the ADP grewat the rate of 21.7Z p.a., well above the rate of increase of 10.7Z for theoverall ADP. As demonstrated by the 1989 Health Financing and ExpenditureStudy, while there was a significant change in the targeting of expendituresform urban to rural health services, the net impact was a more extensive andthus more costly but lower quality care system given that the change wasaccomplished within a fixed budget. This explains much of the problemsexperienced by the UHCs in terms of poor service quality and low utilizationrates which is being addressed under the Fourth Population and Health project,with further substantial inputs of donor financing.

11. While much of the focus of the discussion on long-termsustainability has been on aggregate levels of public expenditures, twoadditional factors need to be considered for a complete picture. The first isthe role of non-governmental institutions, including NGOs, charitable bodies,local organizations, and private individuals. Historically low rates ofpublic expenditures in the social sectors do not necessarily imply thatservice were not available. Indeed, as shown by the 1989 Health Financing andExpenditut.e Study, over half of total expenditures on health services, albeitincluding curative adult care, currently take place through non-governmentalchannels. Similarly, in the education sector, most secondary schools are inthe non-governmental sector (although they receive a large share of theirrevenues from the government) as well as a significant number of primaryschools. Given the long-term constraints on the government budget, non-government institutions and individuals should be encouraged to continueplaying a very major role in the provision of health and education services.There are several ways in which this can be achieved. Government services canbe better targeted to address areas where the private sector response has notbeen adequate; as mentioned earlier, the Fourth Population and Health Projectincludes a major effort to target health services increasingly to the needs of

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Annex 1Page 7 of 12

women, children and the poor, including reserving 70? of the facilities in newUHCs and district hospitals for services aimed at women and children.Training of health personnel and teachers and adequate provision of drugs,contraceptives and learning materials through private sector channels can alsoprovide ways in which non-governmental services can be strengthened. Finally,there may be a role for various types of long-term cost-sharing arrangementsbetween the public sector and non-governmental organizations in health andeducation, but these programs need to be carefully evaluated and clearlylinked to objective standards of quality and service enhancement, rather thanunplanned and poorly targeted budgetary transfers that have been introduced upto now.

12. A second area affecting long-term sustainability, which is closelylinked to the role of the non-governmental sector, is cost-sharing forgovernment services. The government made some modest increases in health andeducation fees in 1987 and 1988, but since then there has been little changes,except for a roll-back in fees at UHFWCs and for girls at the primary level inFY90. There is widespread agreement that the social benefits of primaryhealth care and family planning and primary education, so important that feesshould not be raised to a level that would significantly impeded demand.Moreover, better targeting of public services (for example, to maternal andchild health care) may reduce the capacity of the sector to generate revenu.es.Nevertheless, there is some evidence that well-designed programs of cost-sharing enhance service quality and demand, particularly if the revenues areretained at the local level to cover local costs. The argument for increasinglevels of cost-sharing is particularly strong where public funds are beingused to substitute for private contributions or where the socio-economicstatus of the beneficiaries is primarily from the higher income groups (e.g.specialized hospitals and university education). While more work is needed inboth the health and education sectors to design appropriate forms of rnst-sharing (which ideally should be linked to improvement in service quality togenerate public support), the government should also demonstrate a firmerintention to pursue cost-sharing by adjusting the current structure of feesmore frequently.

13. In summary, the government clearly recognizes the importance ofhuman resource development and follows sound policy initiatives in the form ofthe Fourth Population and Health project and the General Education project toput its plans into practice. The broad and enthusiastic response of the donorcommunity to these projects provides an ample demonstration that this strategycommands widespreau support among Bangladesh's development partners. Whileendorsing this approach, recognition has to be given to broader developmentsin these sectors, as well. In this regard, the government's record in thehealth and education sectors during the past decade has not beenL particularlysatisfactory and demonstrates an undue sensitivity to short-term politicalconsiderations, rather than consistent support for the long-term developmentstrategy agreed with and financed by the donors. This is a very complexproblem to resolve. First of all, many of the decisions were not made inconsultation with sector agencies but rather represented ad-hoc politicaldecisions. Secondly, the sector agencies themselves have not developed acapacity to analyze financing issues affecting the health and education

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Annex 1Page 8 of 12

sectors, a problem that is being addressed under both the Fourth Populationand Health and General Education projects. Finally, while the government hasdeveloped some capacity to analyze projects in the context of the developmentbudget, very little attention has been paid to the development impact of therecurrent budget, where most of the problems affecting the sectors haveoriginated.

14. The new government can claim a legitimate mandate to improve thequality and coverage of health and education services in a sound and cor'-effective manner, and Bangladesh has developed a tremendous base of goodwilland technical support in the form of the Population and Health Consortium andthe Education Consortium to put these polices into practice. Up to now, thegovernment has been reluctant to discuss policies and programs that lieoutside the purview of specific donor projects, claiming that this wouldrepresent an unwarranted interference into its internal affairs. Such astance is inconsistent, given that the government has already asked the donorsto provide extensive financing of recurrent expenditures and to supportprograms that would have a major long-term impact on the share of overallresources devoted to these sectors. The government needs to account for itsactions in the sectors, both within the framework of specific projects andmore generally within the context of the overall budget. Questions such aslong-term donor financing of recurrent expenditures, cost recovery, and thegovernment's stated objective of greater self-reliance can only be answered inthe context of overall development prospects for the sectors, not in terms ofthe sustainability of individual project initiatives.

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Annex 1Page 9 of 12

BANGLADESH


An Overview of Sector Financing

(FP and Health combined)

(US$ million)

Period FY91 FY92 FY93 FY94 FY95 FY96

Est. Revenue Budget Yearly/1 133.9 140.5 147.4 154.6 162.2(All financed by GOB) c____________________ --_ >

Total 738.6

Deelovment Program

(Fourth Five-Year Plan) 793.4/2

3-Year Rolling Plan 501.5/"

Estimated TOTAL AD?P <--------------------------------- >FOR FY92 TO FY96 771.0/4

Fourth Popul&tion <---------------------------------->and Health Project 601.4'6

GOB 165.1/6IDA Consortium 436.3IDA 180.0/?Cofinanciers 256.3

ADP other than Fourth Proiect 171.0(GOB, USAID, UNFPA, WHO, ADB, etc.)

NG* proiecto 325.0(Directly funded)

Total Estimated Sectornl Expenditure 1,834.0/'(DURING THE PROJEvT PERIOD, FY92-FY96)

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Annex 1Page 10 of 12

/1 The figures shown are projected estimates (except for FY91) based onplanned expansion of infrastructure assuming an annual increase of 4.9Z(Griffin, 1989: Mobilizing Resources for Health and Family PlannxiLg.1987 Bangladesh Health Expenditure Study. Table 7). This constitutes7.26Z of the total projected revenue budget for GOB.

/2 This constitutes 7.31 of the total Fourth Five-Year Plan outlay.

/3 This amounts to 63.22 of the original Fourth Five-Year Plan outlay forFP and health thus representing a marginal increase compared to the 602that would be expected for the three-year period on a pro-rata basis.This shows the GOB commitment to the FP and health sector, especially inthe light of cuts made across the board in the three-year rolling plan.

/4 This is derived by combining costs of the Fourth Project with those ofother ADP costs, including GOB contributions to them.

A This represents 33Z of the total estimated injection of funds into thesector (i.e., GOB revenue budget, ADP costs and direct NGO funding).

/6 This amounts to 27.5Z of the total Fourth Project costs.

/7 This equals 30Z of the total Fourth Project costs and 9.82 of the total

estimated expenditure in the sector during the project period (FY92-96).

/9 This estimate is derived by adding GOB's estimated revenue budget forthe period, GOB's estimated ADP budget for the period and direct NGOfunding.

- 72 -


BANGLADESH


Salaries and Allowances of FWAsProject Cost-Sharing Plan

15

14-

13-

12-

11

10

~~I 98

Z_ ~6

5

4

3

2

FY91 FY92 FY93 FY94 FY95 FY96

Fiscal YearPaid byGOB 00 Extemal Assistance

- 73 -


BANGLADESH


Salaries and Allowances of FWAsProject Cost-Sharing Plan

100

90

80

40-

30-

20-

0FY9I FY92 FY93 FY94 FY95 FY96

Fiscal YeuPaid by GOB Eitemal Assistance

- 74 -

Annex 2

3ANGLAD3SE

FOURTH POPULATION AND MEALT PROJECT

Contraceptive Prevalence, South Asia

Percentage of Married Women of Reproductive Age50 _

Bangladesh

40 - ~India 40 Pakistan

30

20

10

i970 1975 1980 1986 1990 1996 2000Year

Source: Mauldin 1990, in Phillips, J. F., The World Bank and theBangladesh PoVulation Program, October 1990. Draft.

BANGLADESS

FOPRTH POPMLATION AND HRALTH PROJECT

Total Fertility Rates (Various Sources)

* BFS

A BBS

* cpS

0BLDS

7 0 NFPFS

6

~~" O NFPFS5 <A ~ ~~4BFS -

BLDS CPS BBS (3 years moving average)CPS

3

2

0 -

1979 1980 1981 1982 1983 1984 1985 1986 1987 1988

Source: NIPORT, Bangladesh Fertility Survey 1989, March 1990.

O W0

BANGLADESH


Trends in Age-Specific Fertility Rates (1954158 - 1984/88)

0.35 -

o.3 - ~~~~~~~~~~~~~~~~~~~~AGE GROUP

-- 15-190.25 -

-0- 20-2'40.2 1 25-29

0.15 -0- 30-34

(. I _ 35-39

0.05

54/58 59/63 (04/68 69/73 74/78 79/83 84/88 YEAR


C


Trends in the Infant Mortality Rate, 1981-88 (BFS and BBS)

140 _

130

120 1-

1001

90-

80-I1981 1982 1983 1984 1985 1986 1987 1

o BBS + BFS


BANGLADESH


Infant Mortality: Neonatal

Percent Cause of Death50

20~~~~~~~~~~~~~~~~~~~~~

4 0 p ~. .. .... f. ........ ..... ... ...

10 1t - |l

Pneumonia Diarrhea Tetanus Immun. LBW.esph.Oong def. Malnutr. Other

_ Inwonesia 0 indi i Bangladesh

Note: Abbreviatons shown above:Immun. - ITmmunizable DiseasesLBW, asph. - Low birth weight, asphyxiaCong. def. = Congenital defectsMalnutr. - Malnutrition °

Source: Stanton, B., Paper on The Maternal Health Component of the Fourth Population andHealth in B, ' d- . *989 Draft

BA ADESH


Infant Mortality: Postneonatal


p-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~-

O3" ." 0| D

10~~~~~~~~1

0 -~~~~~~~1

20 DLl!=

ARi Dlerr Tot Immun Infea LBW.Ssph Def. Trauma Mulnut. Other

Indonesia E India ED Bangladesh

Note: Abbreviations shown above:

ARI = Acute Respiratory Infections Infec = Other infections , ,Diarr = Diarrhea LBW, asph = Low birth weight, asphyxia NNTet = Tetanus Def = Congenital defects o UImmun = Immunizable Diseases Malnut = Malnutrition *

Source: Stanton. B.. 1989.

BANGLADESH


Infant Mortality: InfancyPercent Cause of Death

35

30 _. .

25 -

20 _ wn:,_

ARI EDior TB Tet Immun Inf LBW,As Cong Trauma Merlnt Other

= IIndonesia E India E Bangledesh


ARI = Acute Respiratory Infections Immun - Immunizable Diseases o |Diar = Diarrhea Inf - Other InfectionsTB = Tuberculosis LBW As = Low Birth Weight asphyxsiaTet = Tetanus Cong = Congenital Defects 0

Malnut = Malnutrition wStanton, B., 1989.

a d


Child Mortality: 1-4 years


20 1[ ... ffi lq : 0

1010 l Jg Idia * n .ELL...T[ .

Dierr ARI TB Maler Tet MeseTyphoid Inf Maln Anem Asth Acoa Other

Indonesia E2 In(] i 1 BangladeshNote: Abbreviations shown above:

Diarr = Diarrhea Tet - Tetanus Anem - AnemiaARI = Acute Respiratory Infections Heas - Measles Asth - Asthma 0 TB = Tuberculosis Inf - Other Infections Acc - Accidents 0Malar = Malaria Maln - Malnutrition

Source: Stanton, B., 1989.

BANGLADESH


Child Mortality: 5-14 wears


40 _......................................................................................................................................

4-11~~~~~~~~~~~~~

0 l . . ....L ............. ...... I... _ _ __.......................... ....

Dior ARI Male Tet Meos Typhoid Inf ONS ConcerTrauma Other

Indonesia E2 Indi e - Bangladesh

Note; Atbbreviations shown above:

Diar - Diarrhea Tet . Tetanus CNS - Central Nervous System 0ARI = Acute Respiratory Infections Meas - Measles DisordersMala = Malaria Inf - Other Infections o


- 83 -

Annex 7

BANGLADESS


Distribution of Defacto Population by Age, Sex and Urban/Rural Residence

Urban RuralAge Male Female Both Sexes Male Female Both Sexes

- - - - - - - - - - - - - - - 2 - - - - - - - - - - - - - - - -

0-4 13.0 13.0 13.0 15.6 15.7 15.75-9 13.5 13.8 13.7 14.9 15.2 15.110-14 12.4 14.7 13.6 12.9 12.5 12.715-19 11.3 13.5 12.4 10.4 11.4 10.920-24 9.0 10.8 9.9 7.6 9.4 8.525-29 8.2 7.4 7.9 7.1 7.1 7.130-34 6.9 7.6 7.3 5.8 6.4 6.135-39 7.0 4.6 5.8 5.4 4.7 5.140-44 5.0 3.3 4.2 4.4 4.0 4.245-49 3.6 2.7 3.2 3.6 3.2 3.450-54 2.5 1.8 2.2 2.7 2.0 2.355-59 2.2 2.5 2.3 2.4 3.2 2.860-64 1.8 1.6 1.7 2.2 2.1 2.165+ 3.6 2.6 2.7 5.0 3.1 4.0

Total 100.00 100.0 100.0 100.0 100.0 100.0


- 84 -

Annex 8

BANGLDESR


Distribution of Adult Deaths (other than Maternal) by Cause and Sex

Hale Female BothCause z X X

Diarrhea 24.6 27.6 25.9Tetanus 5.1 7.9 6.4Anemia/Malnutrition 1.4 3.7 2.3Pneumonia 7.9 8.4 8.1Urinary Tract Infections 5.1 4.2 4.7Malaria 1.4 1.1 1.2Peptic Ulcer 4.2 3.7 4.0Tuberculosis 5.1 5.3 5.2Diphtheria 1.4 2.1 1.7Asthma 3.2 3.7 3.4Jaundice 5.6 4.7 5.2Hypertension 6.5 4.7 5.7Whooping Cough 0.9 0.0 0.5Heasles 0.4 1.1 0.7Kala-Azar 0.4 0.5 0.5Poisoning/Accident 5.6 4.2 4.9Maternal Problem .0 3.7 I 7Other 20.9 13.7 17.5


BAGLAESH

POURT! POPMLATION AND HEALTH PROJECT

Adult NortalityPercent Cause of Death

40

3 D . ................... ,1 ................................................ ...... .... ...

25 . .............................. ....... ...I.............................. ................. ............................... .....

16 . ..........

0Dior ARI TB Inf OVA OHD Cane Moln OOPD Aaa Ulcer Met Other

_ Indonesia 2:3 India B Eangladesh


Diar Diarrhea CVA - Cerebrovascular Accident COPD - Chrcnic ObstructiveARI -Acute Respiratory Infections CHD - Congestive Heart Disease Pulmonary Disease TB -Tuberculosis Canc - Cancers Acc - Accidents In£f Other Infection$ Maln - Malnutrition Mat - Maternal HealthH

Disorders Source: Stanton, B., 1989.

- 86 -

Annex 10Page 1 of 2

BANGLADESH


Disease Categories of Patients Presenting to Clinics for Treatment

Disease Infants 1-4 years 5-15 years 16+ years Total

Diarrhea 20 16 14 12 14Malaria <1 <1 1 1 1Intestinal Parasites 7 12 12 8 10Peptic Ulcer 0 <1 5 13 8Tuberculosis 0 <1 1 1 <1ARI 10 a 6 6 7Skin Disease 12 10 8 7 8Hepatitis <1 <1 <1 <1 <1Tetanus <1 <1 <1 <1 <1Diphtheria <1 <1 cl <1 <1Xerophthalmia 1 2 1 1 1Nutritional Disorder 5 6 5 4 5Anemia 2 _ 7 8 7Asthma <1 1 1 2 1Whooping Cough 2 2 1 <1 1Measles 2 1 <1 <1 <1Eye Diseases 4 5 4 4 4Ear Diseases 2 5 4 4 4Injuries 1 2 2 3 2

Chicken pox, diabetes, dental diseases (except among those >5 years where theyaccounted for 22 of visits), hypertension, poisoning, obstetric and gynecologicalvisits (except among those aged 16+), kala-azar, and mental diseases eachaccounted for <1Z of all visits by every age category.


- 87 -

Annex 10Page 2 of 2

BANGLADESH


Prevalence of Illnesses in a Cohort of Rural Bangladeshi Children

Prevalence perIllness Days 100 child-days

Upper Respiratory 37,111 60.3Diarrhea 7,904 12.8Impetigo 5,119 8.3Scabies 4,206 6.8Other Skin Infection 2,969 4.8Chronic Otitis 2,457 4.0Stomatitis 2,449 4.0Conjunctivitis 1,363 2.2Asthma 269 0.4Pneumonia 175 0.3Measles 138 0.2Hepatitis 69 0.1Eczema 55 0.1Varicella 41 0.1Tonsillitis 35 0.1Typhoid Fever 20 0.03Other Recorded Illness 15 0.02Humps 14 0.02Pertussis 7 0.01

Note: The study covered 197 children aged 2-60 months.


BANGLADESH

FOURTH POPUIATION AND HEALTH PROJECT

Rnumerated Population, By Age and Sex. 1989 BPS and 1981 Census (PercentaLes)

AGE GROUP

65 +21 60- 64

55 - 5950 - 5445 - 4940 - 4435 - 3930 - 3425 -29 CD

20 - 2415 - 1910 -14

_ _____________ _ 5 - 9________ 0 -4 _____

20 15 10 5 0 0 5 10 15 20MALES FEMALES

Solid Bar - Represents 1981 Census dataCrosshatch - Represents 1989 BFS data

Source: NIPORT, Bangladesh Fertility Survey 1989, March 1990. I!

- 89 -Annex 12Page 1 of 2

BANGLADISH


Causes of Naternal Mortality

Study Source Cause

Chen, L., 1974: Direct obstetric causes(eclampsia, complications fromlabor and delivery)s 802Infection: 202

Khan, A.R. 1986: Eclampsia: 21?Sepsis: 21?Post-partum sepsis: 1OZObstructed labor: 10?Ante and post-partum hemorrhage: 102

Alauddin, M. 1986: Complications of labor and delivery: 33?Sepsis: 271Post-partum hemorrhage: 172Eclampsia: 152Anemia: 42Gastroenterological problems: 2?Suicide: 2?

Rochat, R. 1979: Eclampsia: 27?Self-induced miscarriages: 26ZObstructed labor: 12?Ante-partum hemorrhage: 92Post-partum hemorrhage: 82Retained placentat 7ZUterine rupture: 4ZPost-partum fevers 32Spontaneous miscarriage: 2?Tetanus: 12Ectopic pregnancy: 12Other: 8?

Fauveau, V. 1987: Post-partum hemorrhage: 20ZSelf-induced miscarriagest 18?Eclampsiat 12ZViolence and injuries: 9?Post-partum sepsis: 7?Obstructed labor: 72

- 90 -

Annex 12Page 2 of 2

BANGLADESH


Causes of Maternal Mortality

Study Source Cause

Alauddin, F. 1988: Tetanus/eclampsia: 382Ante-partum hemorrhage: 7?Post-partum hemorrhages 1OZHemorrhage from miscarriages 13?Prolonged labors 32Retained placenta: 142Self-induced miscarriages: 3?Other: 32

Percent attributions of cause vary by study but clearly complications of self-induced miscarriages, eclampsia, infection, hemorrhage and mechanicalcomplications of delivery emerge as the principle contributors to maternalmortality.


- 91 -

Annex 13Page 1 of 6

BANGLADESH

FOURTH POPULATION AND HEALTR PROJECT

An Overview of the Population and Health System in Bangladesh

1. Bangladesh is administratively divided into 4 Divisions, 64Districts, 460 Upazilas and 4,403 Unions. Several villages constitute aUnion, which with a population of 20,000 - 25,000, is the smallestadministrative unit for FP and Health Service delivery.

History

2. Family Planning in Bangladesh has its historical roots in theestablishment in 1952 of the voluntary East Pakistan Family PlanningAssociation. In 1965, d strong program of family planning was initiated andby 1970 a large autonomous organization with field workers had been set up tocarry out and coordinate population activities. After independence it wasmade part of the Ministry of Health and Family Welfare, as one of its wings.The FP program in Bangladesh has had ambitious and unrealistic goals allalong, but these reflected the seriousness with which the problem was viewedand the commitment of the Government to address it. The impact of the FPefforts is apparent from the enhanced awareness about contraceptive methods,the increased use of contraceptives and the resultant decline in fertility.Although falling short of the challenging targets set earlier, the results sofar are a positive indication that the strategies are working.

3. Historically the health sector in Bangladesh has not been mucL of a

priority sector, partly due to the more pressing issues of population andpartly due to the severe resource constraints under which the country has hadto operate. Although the Ministry of Health is committed to the goal of

"Health for All by the Year 2000", the low priority accorded to the sector is

evident from the fact that on average as little as 3.2 X of the totaldevelopment budget was allocated to health during the 19808.

4. Generally, the "health" care and training facilities have beenoriented towards curative "medical" care. Nonetheless, more recently GOB has

endeavoured to bring Primary Health Care (PHC) closer to the community through

the establishment of Upazila Health Complexes (UHCs) and Union Health andFamily Welfare Centers (FWCs) and the development of field workers in health

as well as family planning. The current situation in this regard is beingdescribed below from paragraph 11 onwards.

5. Some major milestones in the development of health services in

Bangladesh were: the adoption of the National Drug Policy in 1982 to ensurethe availability of essential drugs; the establishment of a pharmaceuticalplant at Bogra; the strengthening of the drug testing laboratories; the

constitution of two Medical Boards, one for indigenous systems (Una.ai andAyurvedic) and one for a Homeopathic System to regulate educational standards

and practice of these systems; the adoption of an admission policy for the

medical colleges, setting out criteria based on merit, quotas for women,

- 92 -

Annex 13Page 2 of 6

tribal students, etc.; the introduction of a Private Clinics and LaboratoriesAct (1982) to regulate and monitor private sector medical care; and, theadoption of a policy to post medical graduates in rural areas at least for twoyears.

VP and Health Services Facilities

6. Three categories of agencies provide FP and health services inBangladeshi the Government, non-government organizations (NGOs) and theprivate sector (for-profit). However, systematically organized servicedelivery is largely implemented by the Government through its Ministry ofHealth and Family Welfare and its nationwide infrastructure of training,research and service facilities.

7. Little information is available on the private sector, but GOBestimates that there are currently about 16,000 qualified allopathicphysicians, of which only 6,160 are employed by the Government (who may alsoengage in private practice after-hours). Given the poor economic conditions,especially in the rural areas, most of the private allopathic medical care iscentered around cities and towns where the purchasing power is concentrated.The private facilities are by -to means limited to physicians; there has beenan increase of nursing and medical assistant graduates and many new privatelaboratories, drug stores and clinics have emerged in Dhaka in the last fewyears. In the rural areas, physicians with a medical degree are outnumberedby indigenous practitioners, the quality of care by whom is difficult tomonitor. Contraceptive services provided by the private sector are few andfar between, with the exception of the successful social marketing program.

8. The role played by NGOs is undoubtedly significant, both in FP andin health care. They generally operate as non-profit organizations, funded bycharitable foundations or interndtional development agencies. The NGOs tendto have greater resources focussing on smaller geographical areas, thus beingable to provide a markedly better quality of care than the Governmentfacilities. However, since they bring different types of bureaucracies withthem and operate within their specific mandates, there is a need forcoordinating their efforts to maximize the benefits from their inputs and keepa national perspecLive.

9. The FP and health system of the Government is best described inaccordance with the different levels at which a tangible structural and/orfunctional framework exists (see charts 1-4). At the national level, thehighest body vested with the responsibility of the nation's health andpopulation issues is the MOHFW. Headed by a Cabinet Minister, this Ministryformulates policies and plans and coordinates all the activities related to FPand health in the country, both public and private. The Ministry has aSecretariat with a Secretary, an Additional Secretary, Joint Secretaries,Deputy Secretaries and Section officers, as well as planning and coordinationcells for FP and health. The FP and health wings of the Ministry each has aDirectorate headed by a Director-General assisted by Directors for individualprogram areas. Special units responsible for information activities fur-tionwithin each wing, called IEH in the FP wing and HEB in the health wing. There

- 93 -

Annex 13Page 3 of 6

are also separate Management Information Systems for FP and health wings, thelatter being under development.

10. On the technical side, apex bodies have been established at thenational level, to advise the Ministry and the Directorates on relevant area3of expertise, to train and develop human resources, to provide specializedclinical and preventive care services and to conduc~t research on importantissues confronting the sector. Importaz.t among such institutions are theInstitute of Post-graduate Medical Education and Research, NIPORT, NIPSOM,IEDCR, IPH, CHE, the National Leprosy Institute, the Infectious Disease andChest Hospital and a number of smaller centers and institutes focussing onvarious non-communicable diseases such as cardio-vascular disorders,ophthalmic problems, diabetes and cancer. Tertiary care and medical andnursing training of broader scope is provided to some extent by the 8 medicalcolleges and their hospitals, one nursing college, eight medical assistanttraining schools and two paramedical institutes. Facilities providing generalhealth care to selected categories of the population are one Governmentemployees' hospital, nine railway hospitals, three labour union hospitals, 20police hospitals and 19 jail hospitals. Other special care centers includefour TB hospitals, eight TB sanatoria, three leprosy hospitals, one mentalhospital, one dental hospital, one casualty hospital and eight clinics underfamily planning.

11. Each Division has two full-time Divisional Directors (DDs) one eachfor FP/MCH and health. The major responsibility of DDs is to supervise andcoordinate district staff. The DDs FP/MCH are not provided with technicalstaff to assist in their functions. Like the Secretariat, the presentdistrict and divisional organization, particularly for FP, is the result ofadministrative changes that occurred in the 19808. No specific Dhvisional FPor health care facilities exist.

12. At the level of the district, the Deputy Director PP is in chargeof FP and MCH services and is assisted by one full-time Assistant Director andone Medical Officer (MO) for MCH and clinical contraception. The HO is alsoin charge of the district's urban facilities, and this responsibilityconstrains the time (s)he spends on supervision of the work in rural upazilas.On the health side, each district is headed by a Civil Surgeon who hastechnical support staff for health education, statistics, epidemiology, etc.District hospitals are not uniform in bed numbers and staff ccemplements. Ofthe 64 district hospitals, 43 have 50 beds each and are planned to be upgradedto 100 beds each. In addition to district hospitals, 93 Maternal and ChildWelfare Centers (MCWC, of which 84 are currently functional) service districtand subdistrict levels. Most MCWCs have 10 beds each and a staff of two FWVsand support staff. MCWCs at the district's urban center also have an MO.

13. At the upazila and union levels FP and health services arefunctionally integrated. The three main functionaries in an upazila are theUpazila Health and FP Officer (UHFPO), the Upazila Family Planning Officer(UFPO), and the Medical Officer (MO) in-charge of the MCH/FP Unit at theUpazila Health Complex (UHC). The position of MO (MCH/FP) is filled bydeputation from the Directorate of Health. According to the latest

- 94 -

Annex 13Page 4 of 6

governmental order, the UHFPO and the UFPO report to the Upazila chairman, whois responsible for coordinating both FP and Health services under functionalintegration. In pursuance of the decision o! the NPCC, an Upazila FamilyPlanning Committee chaired by the Upazila Parishad Chairman has beenconstituted in each Upazila. The Committee, consisting of electetrepresentatives and concerned officials as members, has the UFPO a itsMember-Secretary. The Committee ie responsible for implementing the FPprogram in the upazila within the decentralized set-up. Coordination of HCHactivities, shared by the two directorates, is car.ied out by a NationalCoordination Committee headed by the Secretary MOHFW at national level, bydistrict coordination committees chaired by the Civil Surgeon at districtlevel, and by upazila coordination committees chaired by the UHFPO at upazilalevel (see chart 3). Functional UHCs, each with an MCH/FP unit (withfacilities for institutional MCH care), so far have been established in 349 ofthe country's 397 upazilas.

14. FWCs form the focal point for FP and health services in the unions.Each FWC is headed by a Medical Assistant (MA) and has two other positions,one Family Welfare Visitor (FWV) and one Pharmacist. The Pharmacist positionsare mostly vacant. The FWC's field staff comprises a two-member team of onefemale Family Welfare Assistant (FWA) and cne male Health Assistant (HA), eachteam being responsible for about 4,000 people. The FWAs are supervised by aFamily Planning Assistant (FPA) and the HAs by an Assistant Health Inspector(AHI), both males. While the work of field staff is coordinated at the FWCthrough monthly meetings, the first line supervisors are administrativelycontrolled by the UFPO and the Health Inspector (HI) located at the upazilaheadquarters. The FWA is essentially an FP and MCH worker, while the HA isresponsible for malaria control, epidemic control, environmental sanitationand general health work. To complement domiciliary service delivery by fieldworkers, satellite clinics are conducted by FWVs in selected locations onfixed days. Satellite clinic activities are in their very early stages ofdevelopment and much more has to be done to make them effective.Institutional facilities for MCH care are available at all functional FWCs.

15. A second type of health facility at union level is the RuralDispensary (RD), of which 1,275 are in place and are administered under theHealch Wing of the MOHFW. The RDs are staffed in various ways, but mainly byMAs. In 1983, the GOB decided to unify the functions and staffing patterns ofFWCs and RDs and, over time, to upgrade RDs to FWCs in unions without FWCs.Contrary to this decision, the Health Wing in 1983 assigned about 600physicians to RDs. Meanwhile, the MOHFW has decided however, that wheneverRDs are redesignated as FWCs, all the physicians will be reassigned.

16. With completion of the 1,000 FWCs currently under construction,2,500 unions will have full-fledged FWCs and 1,275 unions will have RDs; morethan 70? of the RDs however, provide only rudimentary services.

17. Institutional facilities for sterilization are available in all 351functional UHCs, 84 MCWCs (of which 48 are located at district or sub-districtlevels), 64 district hospitals and the eight medical college hospitals.Selected FWCs provide sterilization services from time to time. This is in

- 95 -

Annex 13Page 5 of 6

addition to facilities in the )rivate sector and hospitals of othergovernmental agencies like the military, railways, etc. Facilities for IUDinsertions are available in all t-ne above facilities, in 2,035 FWCs, in 607hired clinics and in those unions where a trained FWV has been posted,irrespective of the availability of a constructed physical facility or hiredclinic. At union level, some 3,700 FWVs are posted. Injectables aredelivered at 11 UHCs and at MCWCs and unions where FWVs are posted.

- 96 -

Annex 13Page 6 of 6

BANGLADESSH

F'OURTH POPULATION AND HEALTH PROJECT

Breakdown of Salary and Other Allowances of an Assistant Surgeon

1991 Salary Scales(Scale: Tk. 1850-liO-2620-120-3220/-)

(a) Basic pay per month on average Tk. 2535(b) Medical allowance Tk. 100(c) House Rent at the rate of Tk. 1141

Tk. 45? of basic pay(d) Ad hoc I (pay increase) Tk. 254(e) Ad hoc II ( ) Tk. 254(f) Ad hoc III ( " ) Tk. 254

Total per month for Tk. 4538an Assistant Surgeon

Salary and allowance for an Assistant Surgeon per year is Tk.4538/- x 13 = Tk. 58,994/-

At 1991 exchange rates (1 US$ = Tk. 35) this would equalapproximately USS 1,685 a year, or a monthly salary of US$140.00.

- 97 -

Araex 14

BANGLADESH

FOtURTH POPULATION AND HEALTH PROJECT

Knowledge of and Visit by Female Workers

URBAN CHITTAGONG RURAL

URBAN DAM RURAL

URBAN KHULNA, RURAL

URBAN RAJSHAHI kJRAL

. .

* UNAWARE OF ANY FIELD WORKER* AWARE BUT NOT 'VISITED IN LAST 3 MONTHS

M VISITED BUT F P NOT DISCUSSEDVISITED AND F P DISCUSSED


- 98 -Annex 15

BANGLADESH

FOURTH POPULATION AND BEALTH PROJECT

Current Users of Specified Methods of Contrace2tio

RURAL URBAN TOTAL

NO CHILD 1 CHILD 2 CHILD

3 CHILD 4 CHILD 5 CHILD

- E~~~~~PILL

USTERILIZED

IUD

M CONDOM

O INJECTION

I OTHERS


-99 - Annex 16

BANGLADESE

FOURTH POPULAION AND HEALTH PROJECT

Percentage of Currently Married Women Who Want No

More Children or Have Been Sterilized

By Current Age

100,90,80.1700

60.

50 U STERILIZE

301 ~~~~~~~~~~~~~~~0WANT NO)

30., MORE

0 .

LESS 20-24 25-29 30-34 35-39 40-44 45-4920 CURRENT AGE

By Number of Living Children

100.90.80.70.60.

U STERILIZE40304 WANTt'NO

20 - MORE10.

0 1 2 3 4 5+NUMBER OF LIVING CHILDREN

By Number of Living Sons

CH1ILD 2 CHILD

-~~~~

4035 50

30 402s

20 ~~~~~~~~~~~~~~30

Is 20I0 15 t0 0

0 10 1 2NUMBER OF SONS NUMBER OF SONS

Source: NIPORT, Bangladesh Fertility Survey, 1989, March 1990.

- 100 -

Annex 17

BANGLADESH


Issues in the Population Sector

During implementation of the three previous projects, satisfactory

understandings were reached regarding some issues of concern to the GOB, IDA,

and other members of the Consortium of donors for the sector, i.e. regarding

demographic targets, the contraceptive mix, the FP and MCH service balance,

and incentives. The GOB used to establ.sh demographic targets during the

First and Second Five-Year Plans that were, by no means, attainable.

Discussions between the GOB and donors at the start of the Third Five-Year

Plan led, however, to a near consensus under which the aim would be to reach a

CPR of 392 or better by 1990 and of about 48-50? by 1995, as well as an NRR of

1 by 2000 or early thereafter, which would be maintained until a zero

population growth rate was reached. Consensus also has been reached that the

demographic realities of Bangladesh require all-out efforts to achieve early

demographic stabilization (NRR 1) and all avoidable delays and bottlenecks

should be avoided. In regard to the contraceptive mix, the early emphasis on

terminal methods has given way to a mix emphasizing temporary contraceptive

methods, particularly pills, condoms, injectable and implants for low parity

couples, and sterilization for those who have achieved the desired family size

and want to terminate childbearing. The need to keep the mix under constant

review and to adjust to changing circumstances has been agreed. The problem

of striking a balance between FP and MCH services has been addressed since

1985 and some progress has been made in correcting the imbalance. Efforts

will have to be continued for many years until the present infrastructure and

manpower levels, which are insufficient to tackle the problem of high maternal

morbidity and mortality, are strengthened considerably. The Fourth Five-Year

Plan addresses this issue in some depth. GOB's incentive system, developed

over the years, had also led to some controversy, particularly regarding

punishment of field workers who failed to achieve sterilization targets and

payments to agents who referred cases for sterilization. These components

were perceived as violating the principle of free choice in contraception and

led to malpractice, neglect of follow-up and withholding of information to

clients. After an extensive study in this connection, the GOB has abolished

the system of payment of referral fees to referral agents. They have also

withdrawn orders for punishing field workers who failed to meet their FP

ta-gets.

- 101 -

Annex 18Page 1 of 4

BANGLADESH


In-Patients at Health Facilities, 1981-89(Cumulative time trends)

800

700

So -

600-

~~~~~~i D_hc

200300

12~00

1981 1982 1963 1984 1985 198 1987 1988 1989

Year

Sources MOHFW Statistics, in Griffin, C., Mobilizing Resources for Health andFamily Planning--1987 Bangladesh Health Expenditure Study, SummaryReport, March 20, 1989. Updated by World Bank based on MOHFW data.

BANGLADESH

FOURTH POPULIATION AND HEALTH PROJECT

In-Patients at Health Facilities, 1981-89(Cumulative time trends)

8o0

600

0~~0

500

0~~0

0~~~

1981 1982 1983 1984 1985 1986 198T 1988 1989

YearRM Teaching Hospitals | District Hospitals Upazila Health Comp

200~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~0:

010Sore OF taitc,i rifn . 99 Udtdb oltBn ae0n OF aa l

- 103 -

Annex 18Page 3 of 4

BANGLADESH


Out-Patients at PP and Health Facilities, 1981-89(Cumulative time trends)

so

so -

40 -I

- ~ jX 40'

I 30 -

20-

.1~~0

10

1981 1982 1983 1984 1985 1986 1987 1988 1989

Yaw

Source: MOHFW Statistics, in Griffin, C., 1989. Updated by World Bank basedon MOHFW data.

BANGLADESH


Out-Patients at PP and Health Facilities, 1981-89(Cumulative time trends)

60

so _

a ~ ~ ~ ~ ~ ~ ~~~~~~~Ya

40 -

0~~~~~~~~~~~~~~~~~~~~S~ ~~~~~~~

SSti i1aWk30d

I.I

16 ~20E8

10-

0' _

1981 1982 1983 1984 1985 1986 1987 1988 1989

YearRM Teaching Hospital. Di.frict Hospital. Upazila Health Conrp Union HFP.W.C.

a.ISource: IDHPW Statistics, in Griffin, C., 1989. Updated by World Bank based on MOHFW data. aow

- 105 -

Annex 19

BANGLADESH

FOURTH POPULATION AND HEALTR PROJECT

CoEarative Indicators of FP and hlesth

FactorIndicator Bangladesh U.S. Difference

(approx.)

Infant Mortality Rate 110 10-15 x 10(per 1,000 live births)

Maternal Mortality Rate 700 7 s 100

(per 100,000 livebirths)

GNP (US$ per person) 170 23,500 > s 100

Expenditures for 2.3 2,350 x 1000Health/FP(US$ per person)

Expenditures for 0.11 >150 x 1300

Medicines(US$ per person)

- 106 -

Annex 20

BANGLADESH

FOURTH POPULATION AND HEALTH PROJECT 1991-1996

List of Low Priority Prolects

AllocationProject Title (in million Taka)

1. Further Development of RIHD 100.00

2. Furtner Development of Ophthalmological Institute, 50.00Dhaka

3. Establishment of Medical College at Khulna 80.00

4. Conversion of Sir Salimullah Medical College 10.00(condensed) into a full fledged Medical Collegefor regular MBBS Masters Courses

5. Establishment of National Institute of Kidney 70.00Diseases & Urology

6. Establishment of Institute of Cardiovascular 95.00Diseases at Dhaka

7. Establishment of 300 bed Shahid Suhrawardy Hospital 530.00

8. Conversion of Tejgaon Health Complex into 60 bed 9.40Hospital for treatment of Rehabilitation of DrugAddicts

9. Establishment of three (Dhaka, Kashinathpur and Feni) 110.00Casualty Hospitals

10. Establishment of two Dental Hospitals 100.00

11. Establishment of IPGMR 100.00

12. Establishment of an ICRH 80.00

13. Establishment of Shishu Hospital at Chakbazar, Dhala 24.00

14. Regional Institute of Research Training and 50.00Rehabilitation in Diabetes, Endocrine and Metabolicdisorders

15. Establishment of a National Institute of Health 200.00Services Planning and Management

16. Construction cf 64 Deputy Director Offices 630.00

- 107 -

Annex 21

BANGLADESH


Contraceptive Method Mix, 1990-95 /2(Government of Bangladesh Projections) /-

Method 1990 1991 1992 1993 1994 1995

Female/Male

Sterilization 36.0 35.5 35.0 35.0 34.0 33.0

Female

Oral Pill 26.0 24.5 23.0 22.0 21.2 20.0IUD 7.6 11.0 13.5 15.5 17.0 18.0Injectables 5.2 9.2 12.5 13.0 13.0 14.0

Subtotal 38.8 49.7 49.0 50.5 51.2 52.0

Male

Condom 10.0 12.8 13.0 13.0 13.5 13.5

Others 15.2 7.0 3.0 2.0 1.3 1.5

Total 100.0 100.0 100.0 100.0 100.0 100.0

'1 Excluding new contraceptive methods to be introduced during the project,e.g. implants, progesterone vaginal rings, etc.

To be revised every six months. Major revisions tend to occur and maychange the projections significantly over time (e.g. regarding oralcontraceptives, IUDs, etc.).

- 108 -Annex 22

IANGLhDESR

FOURTE POPULATION AND HEALTB PROJECT

Summary of Previous IDA-Assisted Population and Health Prolects

Dis-Name of Project/ Effective Closing Total IDA burseCredit No. Description Date Date Cost Credit ments

Appr. Actual

First Population Training and Service 01/75 04/80 45.7 45.7 15.0/1 15.0(Cr. 533-BD) Facilities

Increasing the Numberof Female Family WelfareWorkers by 3,700

Intersectoral Pilot Schemesto Disseminate FP Information

Program Support for PopulationActivities

Research, Evaluation andTechnical Assistance

Innovative and Private SectorActivities

Second Population Health Care, MCH and FP 01/80 04/86 110.0 89.9 32.0/1 30.8and Family Service DeliveryHealth Capacity Increases and(Cr. 921-BD) Improvements in the Quality

of Training of FP andHealth Personnel

IEM ActivitiesEvaluation and ResearchInnovative and Private SectorActivities

Administration, Managementand Project Implementation

Third Population FP/MCH Service Delivery 12/86 12/91 213.8 T.B.D./I 78.0 50.4/4and Family MCH ProgramsWelfare Communications(Cr. 1649-BD) Womens' Programs

NGO Support and InnovativePrograms

Evaluation and ResearchProject Management Support

/1 Other financers: GOB, Australia, Canada, Germany, Norway, Sweden, and United Kingdom.Other financiers: GOB, Australia, Canada, Germany, Netherlands, Norway, Sweden andUnited Kingdom.

/8 Other financierst GOB, Australia, Canada, Germany, Netherlands, Norway and United Kingdom./4 As of December 31, 1990.

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BANGLADESH

FOURTH POPULATION AND REALTH PROJECT

Bangladesht A High Point in Donor Coordination

1. There are over a dozen donors, bilateral and multilateral, who wantto assist in addressing the very urgent and very severe population problemswhich Bangladesh is facing. Some of these donors were providing assistance tothis end long before the Bank's arrival in 1972. Many of the problemsassociated with poorly coordinated donor relationships were present in theBangladesh case, as well. It took over a decade to work out the presentimpressive mechanisms that now govern the workings of the BangladeshPopulation and Health Consortium (a semi-formal grouping of the Bank, sevencofinanciers, and several UN agencies). Developing and maintaining theConsortium's financial and administrative relationships is one reason theBangladesh population projects have always had high coefficients.

2. The Bank's first project was able to mobilize more support frommore donors than had previously been involved, and linked six of them ir. aninitial cofinancing relationship. At that time, all but one of thecofinanciers preferred to have parallel financing agreements with thegovernment, with separate financial and operational reports, and separatesupervision missions. Thanks to the Bank's intervention on this front, donorcompetition and confusion was reduced, and external resources were increased;but it was to take years before the pn ties learned how to minimize theadministrative burdens which multiple donors often mean for a government.

3. The initial cofinancing arrangements were converted into a morestructured Population and Health Consortium in 1987. Membership is limited tothe Bank and its cofinancing partners, with WHO. UNFPA and UNICEF as executingagencies for a number of activities. Today, most members continue to signseparate agre-aments with the government and cross-agreements with the Bank(i.e. parallel financing remains the dominant mode, but under a master co-financing agreement between the Bank and the government). In time, mostConsortium members have agreed to turn over their funds to the Bank forcentralized disbursement under a Trust Fund arrangement, using Bankdisbursement rules. The government needs to submit reports only to the Bank,which then submits financial reports to each donor.

4. The Consortium members remain on good terms with each other, andwith the other donors who remain outside (e.g. ADB and USAID; USAID hasapplied for membership, but has not yet been incorporated). Donorcoordination does not stop az the borders of the financing Consortium; non-members often attend meetings of the Consortium as observers. Consortiunmembers have agreed to share the costs of a project administrator and, ince1986/87, three additional professionals in the Bank's Dhaka office. After afew years, as noted above, most Consortium members agreed to turn over theirfunds to the Bank for centralized disbursement, using common disbursementrules, centralized accounting, and consolidated financial reporting. This

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imposes so much additional administrative work on Bank headquarters that afour-person Project Support Unit had to be set up, much the largest and mostcomplex of the many Trust Funds for which the Bank acts as trustee. The Bankhad to be persuaded to take on these special arrangements, and to shoulder theadded costs (in effect, the interest earnings of the donors' trust funds arepaying these administrative costs). Consortium members agree to limit theirfield supervision to participation in two Bank-led annual missions: one is a50-60 person program-review-cum-field-visit mission in February/March, theother a smaller supervision mWssion in September/October. Relations with thegovernment today are actually so good that in early 1990 the government askedConsortium members for advice on its health and family welfare program for thenext Five Year Plan. The Bank arranged a three-day working meeting for thispurpose in May 1990, at WHO's Geneva 'headquarters.

5. Instead of falling victim to rivalries and administrativecomplexities, donor coordinatioi and co-financing continue to grow: a newpopulation and health project is under preparation that looks to be twice thesize of Population III; the Consortium is likely to expand from seven membersto 10 or 12 during the next fiscal year. The Bangladesh Population and HealthConsortium is probably the longest-lived, largest, most complex, and perhapsthe most successful example of donor coordination and cofinancing in thehistory of Bank operations.

6. Slowing population growth takes years, of course; but donors nowthink they see light at the end of the tunnel. The contraceptive prevalencerate (CPR) has risen from 7.7Z in 1975 to 33? in 1989. The total fertilityrate (TFR) has fallen from over 7.0 in 1977 to between 4.6 and 4.9 today.With only a slight increase in the age of marriage, active populationpolicies, family planning and MCH seems to deserve most of the credit forthese hopeful trends. The government deserves high marks on theseachievements, but it could never have made as much progress as it has withoutthe remarkably effective system of donor coordination and cofinancing whichhas been built up in the sector over the past 17 years. Some other countrieshave noted the success of the arrangements worked out over the years inBangladesh, and have expressed interest in Bank assistance in doing somethingsimilar to this arrangement.

Source: World Bank, Policy, Research and External Affairs Office,Annual Population, Health and Nutrition Review, 1990.

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BANGLADESH


Cofinancing for First, Second and Third Population Projects(US$ million)

Proiect Proiect Size IDA Credit Cofinanciers Amounts

First Population 45.7 15.0 Norway 8.5Germany 6.1Australia 2.6United Kingdom 3.2Canada 2.0Sweden 3.0

Total (Six bilateral agencies) 25.4

Second Population 110.0 32.1 Norway 20.0and Family Germany 18.2Health Australia 4.0

United Kingdom 4.0Canada 5.0Sweden 8.0Netherlands 7.9

Total (Seven bilateral agencies) 67.1

Third Population 233.3 97.5 Norway 29.5and Family KFW (Germany) 28.2Welfare GTZ (Germany) 16.9

Australia 9.0United Kingdom 13.7Canada 28.1Netherlands 10.0

Total (Seven bilateral agencies) l_5.4

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BANGLADESH


Indicators for Monitoring Women in Development Strategy

The following performance indicators are based on the genderconsideration guidelines identified by the Consortium during the AppraisalMission for the Fourth Population and Health Project. Some indicators are morecomplex than others and will require further elaboration to ensure appropriatedata collection, reporting, and analysis.

Guideline Indicator

The project focus should be broadened Special studies to assess the healthfrom female reproductive health impact and the efficiency andto all aspects of female health effectiveness of methods beingand the health facilities should be introduced on a pilot basis, i.e.,expanded to deliver the range of implants, and of methods alreadyservices required by females starting accepted, i.e., injectables given atfrom birth. This is most important the doorstep by FWAsin terms of program performance.It requires development of identification of at-riskindicators integrated into the pregnancies and number of referralMIS following baseline surveyF associated with maternal and infantand agreement on realistic mortalityperformance objectives for eachindicator. Nutrition profile of pregnant women

and breastfeeding women

Assessment of female adult healthstatus

Gender-disaggregated identificationof nutritional profile for childrenunder age five

Gender-disaggregated identificationof poverty-related disease patternsfor children under age five

Gender-disaggregated identificationof immunization patterns and theirimpact on the family health status

Gender-disaggregatet identificationof demand and use patterns forGOB's FP and health facilities andservices

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Guideline Indicator

A plan to be prepared by April 30,1992 for dedication of 70Z of bedsin district hospitals and UHCs forwomen and children

Women should be represented at all Baseline surveys should be carriedlevels of the FP and health system, out of female staffing patterns inin all committees, and in project the MOHFWimplementation units and should begiven increased access to training An annual report on progress inand to scholarship and fellowship this regard be prepared by the MOHFWprograms as part of the annual review process

Gender-equity should be considered An assessment should be made toin promotion decisions within the identify major constraints andDirectorates of Health and of FP appropriate areas for redress

Field level female workers should be Allowances for attending satelliteprovided with adequate transportation clinics should provide for the needarrangements of women to travel by special

conveyance such as rickshaws andfor accommodations

Personnel statistics, baseline surveys, The human resource development planand operational research undertaken to be prepared by March 31, 1994through the project should include should contain appropriategender-disaggregated data indicators for this purpose

Field level workers should not be Uniform appraisal techniquescompelled to meet acceptor targets should be developed for field workers

which exclude acceptor targets

Greater emphasis should be placed onFP/MCH information and counselling,including development of asupervisory reporting systembased on quality of service delivery

The IEM program focus should be Indicators for this critical area,broadened to address both men and related to such topics as the agewomen of marriage, birth spacing, maternal

and female nutrition, and contracep-tive methods, should be developedwhen GOB has an integratedFP/MCH/IDMstrategy, to be submitted to IDA byJanuary 31, 1992, with clearobjectives and means of achievement

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Guideline Indicamor

Gender awareness copics should be Prior to revision of the trainingincluded in basic and in-service curricula, seminars should be giventraining curricula of field workers on gender analysis; output should beof the Directorates of Health and identification of performanceand of FP indicators to assess the impact of

delivering gender componentsintegrated into curricula

Gender strategy should be included No indicators required - output canin all NGO activities supported be easily measured. Gender analysisby the Consortium workshops should preferably be

organized by NG0s supported by theConsortium prior to development oftheir strategies

Gender equity should be included as No indicators required - action cana topic in the terms of reference for be easily measured; screening measureslocal and international consultants should be put into placefinanced under the project

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BANGLADESH


Nursing Services

1. In 1977 the Directorate of Nursing Services (DNS) was establishedunder the Health Wing of the MOHFW within the Directorate of Health Services.The DNS is responsible for the planning, administration, organization,implementation, supervision, coordination and evaluation of nursing educationprograms and nursing services in health facilities throughout the country.The DNS advises the MOHFW, the Directorate of Health Services, otherDirectorates, and other institutions about nursing matters. It maintainsliaison with international nursing organizations.

2. The DNS is composed of a Director, two Deputy Directors, one eachfor Education and Administration, two Assistant Directors in the HeadquartersOffice and one Assistant Director in each of the four divisions. TheseDivisional Assistant Directors work with the Divisional Deputy Directors ofHealth Services and supervise nursing education and nursing services in theirdivision. There are currently over 7,000 nurses registered with theBangladesh Nursing Council. Almost 5,000 nurses are working in GOB hospitalsand other facilities. Approximately 2,000 are employed in the Middle East andother countries. The remainder work in private facilities or for NGOs.

3. Nursing in Bangladesh has traditionally been hospital-based andcurative-oriented. Now efforts are underway through changes in the basicnursing curriculum and development of the Nursing Institute to reorientnursing to be more community-based and prevention-oriented. A position forDistrict Public Health Nurse (DPHN) has been created in each of the 64Districts. In addition to working as members of the Civil Surgeon's staff,this nurse will work with Upazila Health Complex nurses, teach communityhealth nursing and primary care courses at Nurses' Training Institutes andsupervise student nurses community field experiences.

4. Standards for nursing education and nursing services are set andcontrolled by the Bangladesh Nursing Council. At present there are 43 NursingInstitutes in Bangladesh; 8 Government Nursing Institutes are attached toMedical College Hospitals and 30 to District Hospitals. Theoretically a totalof 1,138 seats are available for annual admission in the Government NursingInstitutes; around 800 students actually enroll and around 650 nurses pass theexaminations each year and are eligible for registration with the BangladeshNursing Council.

5. The basic nursing curriculum is four years in length. Three yearsare basic nursing. Almost all female student nurses take midwifery in thefourth year. Another one year diploma course exists for specialized nursing.

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6. Currently there are 4,087 sanctioned posts for nurses in Governmenthealth facilities with 26,913 beds, giving a nurse-to-bed ratio of 1 nurse forevery 6.6 Government hospital beds. Even if all sanctioned posts were filledand if all nurses were engaged in hospital nursing, which they are not, thiswould remain a very low nurse-bed ratio.

7. Internationally recommended minimum standards for nurse-bed ratiosares

1 nurse for every 4 general beds1 nurse for every 2 specialized beds1 nurse for every intensive care, OT, or labor bed.

8. Thus, many more sanctioned posts are needed to improve the nurse-bed ratio for acceptable quality of nursing care. In addition, approximately1,000 registered nurses are currently waiting for posting in Governmentservice. Sanctioned posts are also needed for nurses in public healthnursing, school health and occupation/industrial health services.

9. The College of Nursing, a Constituent College of Dhaka University,is the institution of higher education for nursing in Bangladesh. The Collegeoffers two-year post-basic courses in Nursing and in Public Health Nursing.Faculty for Nursing Institutes, District Public Health Nurses, and supervisorsfor health facilities receive post-basic training at the College.

10. The project will support posts for 10 nursing trainers, onelibrarian and two English teachers, consultants for curriculum development,library and other teaching materials, and renovation and repair of the NursingCollege. It also will finance technical assistance and refresher training,construction of four nursing institutes, repair and renovation of existingnursing institutes and provision of teaching materials.

11. The project will also support 573 senior nurse posts at NursingInstitutes and UHCs and a one month introduction course for new nursetrainers. It will support staff, construction and equipment for fourcontinuing education centers and four rural Health Care Training Centers aswell as 15 courses in each center per year, including technical assistance andsupplies.

12. Project implementation may be assisted by WHO, which would hire andsupport a Project Manager for the nursing component.

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BANGLADESH

FOURTH POPULATION AND HEALT! PROJECT

Institute for Mother and Child Health

1. In Bangladesh, 702 of the population are either children under 15years (50Z) or women of reproductive age (20S). These are also the"vulnerable groups" suffering high morbidity and mortality from usuallypreventable causes. The MOHFW has FP and health programs directed topreventing and treating the illnesses of this group through the MCH program.As yet this is still a weak program, a major reason being the shortage ofpersonnel with adequate combined clinical and preventive health care training.The project will establish an Institute with small clinical facilities locatedin a semi-rural area, with the objective of providing communW.ty and clinicbased training for all levels of service. The Institute is meant to establisha unique and leading position in the country to promote appropriate MCHstrategies and policies. This will be a community-oriented approach for thetraining of medical and nursing staff from an institution and clinical base,which is currently absent in the country. It will be both an institution toguide and lead the country in MCH and a model of combined clinical andcommunity-based services.

ObWectives

2. The project has been formulated in great detail and aims to:

(a) provide a base for community-based comprehensive training of healthpersonnel responsible for preventive, promotive and curative healthcare of children and mothers. Staff shall include pediatricians,obstetricians, undergraduate medical students, upazila medicalofficers, medical assistants, family welfare visitors and medicalsocial workers.

(b) conduct problem-oriented essential health services research.

(c) provide comprehensive preventive, promotive, and curative servicesin the community and the outpatient department, treat commonillnesses of children in the inpatient department, and care for atrisk-pregnant mothers.

Project Strategies

3. The outpatient and inpatient facilities and the community will bethe bases to fulfill the above objectives. Training and courses will runthroughout the year for the various level health workers. The surroundingvillages (300,000 population) will function as field practice area; health andnutrition services will be provided to the children and mothers and VPservices to the mothers in the villages in a package. Essential health

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services research and operational research will be conducted in the community.The outpatient department will deal with the health and nutrition problems ofchildren, pregnant and lactating mothers. It is expected that there shall bedaily attendance of 300-500 children and mothers. Risk pregnancies, which areidentified as contributing to maternal mortality, will be admitted asinpatients, either as referral from the field practice area or from medicalpractitioners. Prenatal and postnatal follow-up will be done at theoutpatient clinic and in the community. The components of child survival,such as growth monitoring, immunization, breastfeeding promotion andprotection, oral rehydration for diarrhea, nutrition education, distributionof Vitanin A capsules, deworming, and birth spacing wil) be practiced in theoutpatient clinic and in the community. Very sick children with commonproblems, such as diarrhea, acute respiratory infection, meningitis, severeprotein energy malnutrition, or infectious diseases, will be admitted fortreatment. The services will be such that the trainees are exposed to thecommon real life health problems of the children and mothers of the country.Community participation and leadership will be developed in the matters ofhealth and nutrition of children and mothers. Regular training courses willbe conducted for nurses in community and clinical pediatrics and obstetrics.

Position of the Institute

4. This will be a Government Institute. It will be responsible totrain Government health and FP personnel in child and maternal health. Thefacility will not pretend to remain the only institute of its kind but shouldlook like a model training base in the subjects appropriate for trainers. Itwill provide a base for training of Upazila medical officers and of trainees,such as MAs, family welfare workers, medical social workers and nurses. Thetrainers and trainees from institutes such as IPGMR, Dhaka Shishu Hospital,Dhaka Medical College, Salimullah Medical College, NIPSOM, School of Nursingand Upazilas will attend various moduled courses. In these courses, thecomprehensive community approach to health care will be highlighted, followitngthe Morley approach of the Child Health Institute in London. It will be aresource center providing a data base, teaching and audiovisual materials.The center will have ciose linkages on aspects of teaching, research andservices with the IPGMR, Dhaka Medical College, Salimullah Medical CollegeHospital, Azimpur Maternity Center, ICDDR,B., Bangladesh Institute ofDevelopment Studies, Save the Children Fund and other NGOs. The Institutewill make all efforts to change and develop an attitude in trainers andtrainees towards appropriate health care of children and mothers. Although aGovernment Institute under the Ministry of Health and Family Welfare, it willhave an autonomous status. The Institute's Board/Committee will thus selectand retain its own staff. All care will be taken to appoint motivatedcommitted staff who are fully oriented to the objectives of the center.

Components

5. The Government will purchase 12.62 acres of suitable land atMatuail. The Institute will have the following departments:

(a) Medical Units: for pediatrics and obstetrics, with outpatient and

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community services sections. Support units wvil be the units ofpharmacy, medical records, surgery, radiology and laboratoryservices.

(b) Nursing: a small school of nursing vill provide training for MCHnursing care in the community and at the clinic.

tc) Administration: for ancillary services of caumunication, stores,laundry, medical illustration, library, kitchen, transport andmaintenance.

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BANGLADESH


Technical Assistance Prolects

Training Health Personnel in Operational Management

1. The project will upgrade the ability of supervisory staff at alllevels to provide support and guidance for supervision through on-the-jobtraining and by identifying weaknesses of supervised MCH and FP staff. Itwill develop remedial measures, create better work environments, and formulatesolutions to problems experienced by staff in day-to-day operations.

2. The project will fund training of: (i) health workers inoperational management including MCH and FP, (ii) physicians in surgery,internal medicine, gynecology, and simple anesthesia to improve the quality ofcare in UHCs; (iii) 'emale volunteers in community health (selective); (iv)trainers to form training teams; and (v) local village leaders (selective) inPHC. It will also finance preparation and collection of training materialsand development of monitoring and coordination mechanism for trainingactivities.

3. The strategies will be: (i) assessment of training needs of thedifferent categories of health personnel at the different levels of the healthservices starting from ward to district level; (ii) development of a plan ofaction to implement the training programs; (iii) development of Core SupportGroups for organizing and implementing training programs; (iv) improvement ofthe existing training facilities available at the district and upazila level;(v) development of training modules, work manuals and other support materials;(vi) raising health volunteers from the Community to act as a supplementarywork force alongside the government salaried personnel (on an experimentalbasis); (vii) orientation training for Community leaders and mass media stafffor social mobilization in support of health promotion as an importantcomponent of community development (on an experimental basis); and (viii)development of a mechanism for coordinating training activities to avoidduplication of efforts and to promote efficient use of resources.

Control and Prevention of Sexually Transmitted Diseases

4. This component has been formulated to: (i) establish a surveillancesystem for STDs; (ii) facilitate diagnosis and treatment of STDs; (iii)arrange appropriate training to health workers in its control and prevention;(iv) improve laboratory facilities to help diagnose STDs; and tv) increasepublic awareness of the issue.

5. The proposal aims to combine the currently ongoing efforts in AIDScontrol (with WHO assistance) with an intensified drive to control othersexually transmitted diseases. Activities envisaged ares (i) a sentinelsurvey to obtain baseline information; (ii) supply of essential equipment to

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selected laboratoriest (iii) training of lab technicians; (iv) purchase of

essential drugs against STDs; (v) specialized training of physicians, nurses

and other staff; and (vi) and information campaign on STDs.

6. Implementation will be by the Directorate of Health Services, with

the specific executing agency being the IEDCR. 'WHO will assist the project

technically as well.

Control and Prevention of Cancer

7. Notwithstanding more pressing health priorities in Bangladesh,

cancer demands its share of attention. The annual incidence is estimated at

over 200,000 and this project component aims to meet the issue through

technical assistance to formulate a control strategy.

S. Stated objectives are to: (i) study behavioral factors related to

cancer, especially of the lung and the breast; (ii) development of cancer

professionals; (iii) creation of public awareness about prevention of cancer;

and (iv) coordination of interagency efforts in cancer control.

9. Proposed activities include the development of a cancer registry,

periodic surveys of prevalence of cancer and associated factors, staff

training, development of surveillance activities through a strong data

management system, establishment of linkages with other health and non-health

departments relevant to cancer control, and production of health education

materials (posters, slides and films). The implementing agency will be CIRH

in cooperation with IEDCR, NIPSOM and IEM/HEB. WHO will support this

component as well.

Establishment of a Pharmaceutical Production Unit at Khulna

10. The main objective of this component is to cater to the needs of

essential drugs in the public hospitals and clinics. GOB planned to establish

4 pharmaceutical production plants in 4 divisions of the country. GOB already

established 2 plants for drug manufacturing, one at Dhaka and one at Bogra.

These plants produce 32 of the 45 essential drugs and meet 752 of the public

sector's requirements. GOB's Fourth Five Year Plan proposes to produce 12 new

products in the proposed plant at Khulna. The proposed plant would adopt the

basic concept of GMP (Good manufacturing practice) and manufacture essential

drugs in the forms of tablets, sachets for ORS, sterile injections and dry

vials, and soft gelatine capsules of Vitamir. A (high potency). The plant

would have 5,609 sq m constructed building. The entire product of the plant,

when available, will be purchased by GOB out of its revenue budget.

11. The project will incorporate technical assistance to help GOB in

further scrutiny of proposals and development of detailed implementation

plans. The Essential Drug Unit will be consulted before finalizing the

composition of any proposed drug list. GOB has also agreed to employ females

under the project to the maximum possible extent and make provision for

women's facilities in the building. The project will also be coordinated with

the project component on 'Strengthening the Rational Use of DrugsR.

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12. The Fourth Project might support this component, preliminary costedat a total of Tk 4,320.53 lakhs or US$11.86 million, if funds would beavailable from other components not materializing, or from excess funds due toforeign currency exchange fluctuations. Support could be programmed throughthe existing R&R system, provided the outcome of the feasibility study wouldbe positive and subsequent GOB-Consortium agreement could be reached.

Establishment of a Condom Manufacturing Plant

13. The project endorses the need for developing local capacity for theproduction of condoms. Based on the sheer volume of commodity requirements by1992, Bangladesh is clearly a candidate for local production of condoms.Feasibility studies carried out in the past are not only outdated but alsolacking in comprehensiveness. GOB has agreed to have a fresh feasibilitystudy conducted with comprehensive terms o reference, addressing (i) economicand non-economic consideration of private and public sector production; (ii)the effect of various donor policies with regard to procurement of locallyproduced condoms; (iii) development of several price scenarios; (iv)implications of a public sector plant, fully or partially controlled by thegovernment; and (v) the environmental impact of the project. The study willbe conducted in conjunction with UNFPA. The results of the study will bediscussed with the IDA/Cofinanciers Consortium and subject to economicviability and other relevant considerations. The project may considerproviding funds towards setting-up of local condom production capabilityduring the project period. The same funding considerations as mentioned underthe sub-project above (pharmaceutical production plant at Rhulna) will apply.

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BANGLADESH


The Three Womenlls Prousm

1. Women in Bangladesh have only limited access to services that canequip them to acquire knowledge, obtain essential social services, andovercome gender-specific constraints on participation in the labor force.Since 1976, IDA and the Cofinanciers have been providing assistance to suchwomen through funding of three women's programs - Mothers' Centers, Women'sCooperative, and Women's Vocational Training. From a modest beginning, thethree programs have expanded to cover in 1989 about 2-8 upazilas, of whichsome are overlapping, the Mothers' Centers cover 80 upazilas, the Cooperativescover 100 upazilas, and the Vocational Training covers 58 upazilas.

2. The three programs have reached rany women over the past 15 years.Coverage has been in the range of 730,000 women (Mother's Centers - 540,000Cooperatives - 140,000, and Vocational Training - 50,000). These numbers m'ynot seem striking in the context of the size of the country's womenpopulation, but most members are innovators who serve as examples to others,both in self-employment and contraception; they are scattered widely in ruralareas; are now better informed; and facilitate a two-step flow of informationand innovation.

3. Evaluations by various agenc'es since 1979 have indicated thatthese programs were able to provide some gainful employment to women; thatproject women know more about contraception and practice contraception more;that members actively persuaded other women to use contraception; and thatagriculture-related income-generating activities wers more widely practiced,although these were not always the most profitable choices. The contraceptivepractice rate among women participating in the three programs ranges from 54Zto 60Z. The variations in monthly income among the participants of the threeprojects ranged from Tk 97 (Mothers' Centers), to Tk 111 (Women'sCooperatives) to Tk 201 (Women's Vocational Training). A larger proportion(66X) of members of Women's Cooperatives received loans than did members ofMothers' Centers (31Z) or Women's Vocational Training (12Z). Thesedifferences are attributable to a comparatively well-developed credit system,through local banks, for Women's Cooperatives. The other two projects dependon a small revolving fund provided by the projects although operated throughthe banking system.

4. The evaluations indicated common deficiencies in the threeprograms. Those deficiencies relate mainly to the: inadequacy of credit,particularly for the Mothers' Centers and Women's Vocational Training wherethe amount is small for individual credit (the maximum being Tk 500);difficulties experienced in access to contraceptive services; lack of marketsurveys as a guide to choice of goods to be produced; inadequate training;inadequate marketing facilities; and lack of quality control. Some of thesedeficiencies have been addressed, although not adequately. A quality control

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staff has been recruited for Mothers' Center projects; market surveys havebeen carried out recently for two of the three projects; and contraceptiveservice delivery has been strengthened. But the immense possibilities forusing the resources of organized groups in 100 upazilas to strengthen familyplanning, maternal and child health services have not been fully explored.

S. To strengthen the program in the future, the Fourth Project willsupport a thorough review of the three Women's programs, as described in paras2.85. Considering the importance accorded to enhancing the incomes of thewomen involved, the review will give particular attention to the programs oftraining in traditional products. The principal question to be addressed willbe whether the main trade of all projects should be tailoring (at least 45? ofactivity) and the second trade of two projects should be cane and bamboo orwhether comparative advantages of certain projects should determineappropriate specializations. In the course of the review, complementarysubjects will be addressed including skills levels of trainers, comontraining curricula and manuals, joint training facilities, adequacy ofequipment and materials, procurement arrangements for inputs, quality ofproducts, market development, supervision, credit and seed money, and accessto share deposits held in banks.to share deposits held in banks.

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BANGLADESH


Population and the Environment

1. The environmental setting in Bangladesh poses obvious challenges tothe population. Powerful rivers dominate the geography, cutting the landvertically and laterally into a deltaic plain of temporary land and rising inthe monsoon into a rushing sea. Without elevated land to define theircourses, rivers flood half of the arable land in the peak of annual floods andcalamities recur when annual rainfall shifts subtly. About 202 of people liveon land that i, inaccessible in the monsoon season and not consideredpermanent. Clusters of artificially raised land serve as the basis forsettlements that are widely dispersed, without permanence or geographicboundaries. Most of the 66,000 villages in the country cannot be reached byroad or scheduled river transport. These fundamental ecological insecuritiespermeate all social systems and constrain effective communications, includingoutreach services, in the country.

2. Population pressure (averaging 813 persons per sq. km. and risingon agricultural land to 1,199 persons per sq. km.) has resulted in intense useof forests, fisheries, and land. Moreover, with rising demand for fuelwood.biomass, and land for agriculture and housing, high population density iscontributing to an overharvesting of homestead and other accessible forestarea. The country has less than 0.02 ha of forest land per person, one of thelowest ratios in the world, whereas it had 0.035 ha in 1968-69. Fragmentationof land holdings is a serious problem. Half of all families own less than 0.5acre. The number of landless families is rising as productively sized plotsof agricultural land become increasingly scarce. Growing landlessness iscausing particular hardship for female-headed households. The sheer force ofpopulation pressure no doubt is the most basic cause of the country'senvironmental degradation. According to FAO, the total area of degradedland' is estimated to be 989,000 ha (7.42 of total land area). Up to 1985,some 128,000 ha had reportedly been rehabilitated or protected to some degree.Treatment of a further JO,000 ha was planned during 1986-90.

3. Population pressure will continue to grow. While the GOB's FPprogram has succeeded in increasing the CPR from under 82 in 1975 to around33Z in 1989 and in reducing the TFR from over 7 in the mid-1970s to just under5 in 1990, sustained rapid decline in fertility will be needed tosignificantly slow population growth. An immediate concern is the present age

1 In FAO Regional Office for Asia and the Pacific, Environment andAgriculture, 1989 the term land degradation is defined as "the process wherebyland deteriorates through a reduction in soil depth or quality as a result of theactions of water, wind, gravity and temperature which may be reflected in reducedproductivity in current or future periods by its impact on the quality orquantity of vegetation which the land supports."

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Annex 29Page 2 of 2

structure of the population. With about 50 million children now below age 15(43Z of the population), many will not be able to find productive work inrural areas. This will be a major factor contributing to the projecteddoubling of the urban population in the country over the next 10-15 years.For example, the populations of Dhaka (3 million) and Chittagong (1.5 million)are expected to triple within the next nine years. Host urban populationgrowth will occur in t)he poorest and most deprived areas of the cities. Rapidpopulation growth already has led to severe shortfalls in basicinfrastructure, developed land, social services like education and healthcare, and shelter. Further population growth will result in critical shortagein roads, drainage, solid waste collection, electricity, transport; watersupply, and sanitation facilities.

4. To begin addressing these problems IDA is supporting the FourthPopulation and Health Project, in conjunction with many donors. It alsosupports an Urban Development Project that is improving storm water drainage,solid waste collection and disposal and sanitation in Dhaka and Chittagong.In addition, three low-income settlements in Dhaka area are being upgradedwith new roads, footpaths, water supply, gas distribution, surface drainage,solid waste collection, low-cost sanitation, land filling and more secure landleases. The project also is supporting development of a 100 acre sites andservices component in Chittagong to provide affordable housing to lower incomegroups. IDA is also, under the ongoing Dhaka Water Supply and SanitationProject, supporting a study of the availability and quality of the water inthe aquifer under Dhaka; a similar study is proposed as part of the FY92Chittagong Water Supply and Sanitation Project. The Chittagong Project alsowill introduce waterborne sewerage in priority industrial, residential andcommercial areas, and will provide assistance to strengthen the Department ofEnvi'onment in Chittagong. Overall, IDA has assisted the water supply andsewerage sector in Dhaka and Chittagong since the late 1960s.

- 127 - Annexc 30

FOUR'Al FOPiitAIION 4AN0 ' ItACii PRU,$itCI Table 1PRO,fCt COS' iiJLMARI

1011, I'll E, A,q. ~~Co19 0A

AFPP/MCi- SEAVICE OELIVER'

$ CEST ' ACti 4451 2$2 6 575I' 32 33 91220 SR $ '0 $ 32 333 REG OFet ER8S 29139'.;35 41)9 8I 7 1I5 SI 386 $I

3 CINICAi EqCS C o 854d 92 so '02 25 6 235 8I0 3$ 5 24f94UVI(f IRAlAii

NIPOiFI ~~~~ ~~~~~ ~~~~~394 5499 454 - 2 $0a B I6 1$25 l3 2IDA IRAINING i 21i4 77 6I i 4 a 0 0 493$

S,,-',nIoIa INSERIFoCE 'AAAING SI,3 6 3 632 3 10 3 '6 A $7 7'3 9Sf FAM I" iANNI NCFiA. ItI T C S

(,T at J9VCs & 490440O ADs $ 25 4 I)9 i 39 3 $ 6 30 A 0 4 392$ 6RENAOVATION a9V9 Al 796 6 6 33 02 93 2 A I 023 3 2LOGISITIS 660 supiUIES SO30 26 4 76 A 35 0 $ 4 0I1 I3 35 0

Suli-lolel iAMIII PLANiASI. -ACIL:TicS 1.472 0 46 .594 6 3 0 3 $ 349 6 3 86 PRIVAT 498CiIA.CONLAEIIVS 458 4 l4584 90( 2 - 26 1 00

SUo-o94I PP/ItCH SE1vICfQEIE' 7 629 4.716 8I$ 7449 25 59, 308 9 '$2 832397 36 69

I MAT 6 NEON'.ATALHNEAL" CART 363 49 4 77 53 0 $ 0 9 21 $ 3 02 MD64 R IiSINO. f2UCATION

STREN NURS,ING EDUCATION1 419 9 27 494 A 2 $'3 0 994 I 3ST8E8 MED CIUcAII,CS 308 8 '0I 48 a9 38 3 f 5 S.2 93 7 38 3MEDICAL SIJALITV 9SSURANCE 319 0 - 39 0 - 0 II 9 0 INST F 8010CR 6 CHILD HEALrT.3$ 3988 2 A 8 7 - 2EXPANSION & CEV N195DM 199$9 8 68 263 - 24 I 5 3 I7 69 24 9

Su0-Total NED AND IAiJRSING EDUCATION 9 270 3 264 6 1.6249 T7 a 34 81 70 49 8 7 82 DEV RESEABCN IN BUANG9.AOS 38 7I9 55 2 39 0 90 0S6 9 I 2 0

A4OISCASE PREVENT ION B CONTROL

TUBER AND LAPROSIC COTQTL 624 8 3869 .020 7 38 S $7I 9 908 280 39 5EXPANDED PRDGRAM DF IMMU.II

CONTR"OL OF DIARROEAL Dist '322 '07 2 238 4 45 3A 2 9 66 46 IVIT AMI N A IC, D. &AR41 220 4 3975 5379 S9 3 680 8 794 7 69 2

CONTROL OF VECTOR-BORNE,DISEASE 360 '0 0 4AR0 22 0 I 0 0 3 92 22 0INTESTI"At PARAsItErCCR I30 36A 65 22 0 04 0.9I 05 22 0INS' OF PUBLIC HEALTH $3 3 23I9 364 63 0 0 4 0 B I 0 62 0MODERNA8 EORG DRUG 'ES 90$I 99 300 A9 0 03 03 06 A9 0

Sub-Total DISCASE PRSVFNTION & CCNrROL i.34819 0887 0 -9998 49 '0 2857 23 7 52 5 46 $0

S EST & TBCNG UB8RN HEALTH 79 90 9 0 2 0 0 2 2 2 06 SC HOOL HEALTH PROGRAM 390 - 20 - 0 99 - 07 IMPROVING HEALTH FACILETIES

RENOV & FUNCT IMPQOV OH 3072 84 9 392 9 22 2 8 4 232 0 7 22 2EStABLISHMENT OF 90 UHCR 3B654 39 2 4046 £ 0 2 90 0 I 9 II 9 0 2

SuDITo9al IMPROVING HEALTH FACILITIES 67 8 2 9 6 4 9 4 a2 8 B & IMPB UTILIZATION OF UNCe 8i787 194 9 77236 26 4 99a 8 32 292 25

S.D-To tal HEALTH SERVICE OELIVERV 2.7956 6.S06 2 5,26919 29 27 90298 49 3944 9 29 27C SUPPORTING ACTIVITIES

I INFORMATION 5SISERS

STRENIG OP MIS FOR PP 94.7 7 7 72 4 24 0 1 5 0 R 2 0 24 0MI SFO8 HEALTH 62 0 28 9 87 9 29 0 9 7 0 7 2 4 29 0HE.ALTH 8 DEMOG SU94 l -E99 89- 0 0 B 0 6 * 0ST RENG OF EPID SUODA SYS 94 9 3 7 2 98 0 0 4 0 9 0 8 98 0

SUb-Totaf INFORMATION SISTERMS 980 5 465B 988 23 4 9 .3 ;84 23' 92 ORGANZN . MANAGMIA. 6 FINANCING

NI 0 U SUPPORT 99768 0S8 99 43 9 22 00 32 9 REiOBOAN HEALTH &FPP PR3G B1a 8 4 8 00 0 - 9.S I9 B 00 POP 0EV A EVALu UN IT 2654 B32 4237 99 0 9 0 02 92 I90 0MCH COOROINATION CELL 386I 95 327 5 A 0 9 0 0 0 90 4 0HEALTH ECON A F1NANC PROj 12 4 25 1 49 97 0 02 0.' 04 I7 0PROJECT FI NANCECCELL 90 32.23 9, 23 0 02 0.9 03 27 0PROJECT MOANAGEMENT SUPRORT 904 9 72 9 76 6 49 2 0 4 8 $

CONSTR HEALTH& POP BLDG 299 5 291I 320 97 2 08 8 7 2MAINT 6 CONS518 MANSAMT UNIt 89 9 99 - 0 95 9 - 9 - 0

SubSyotaI ORGAMNI. MANAGMt. & FINANCING. 670 0 984 2 824 20 4 98 4 A 922 9 20 A23COMMUNICATION PROGRAM

IEM PROGQAM FOP FP &MOM '90 4 9 2914 9 28 9 8 2 9 9 7 0 265MASS MAEOEA ACT IVIT IES 96B A8 I 29 2 22 1 2 7 0aB 3 4 23 9

COMMIU PABTIC FOR PP/MOM '78 2 3 9 79a8 2 9 4 9 Q 1 4 9 2 9

S. -Total COMMVNICATION PROORAM 4 969 R8 869 87 927I 7 993 7 34.oNON-GOVT ORGANIZAIIOkN 2863 - 288 - 9 7 8 - 7 8 I9 INNOVATIJE PROJECTS $43232 6 179787 20 9 39 910 4 8 20

6 I1A PROJ ECTS 298 $ 7I 3 6233 99 2 8I 9 I810 0 IA 2

Sub-Tota1SSUPPORTING ACTIVItIES 2.009 2 40 72.4199 9 ; 92, 89 0 99 26863 97 920 WOMEN SAND NUTRITION 98008RAM6

9WOMEN'S -PROG'RAMS

WOMEN'S COOP ERATIVES ''B 6 6 9 922 8 6 9 2 3 02 32 4 6 9MOTH4ERS CENTRES 90o6 4 7 e883 S 0 2 B 0I9 2 6 9 0WOMtEN'S VOCATIONAL TRNO $99 2 4.0 999 2 4 9 3 0 0 9 322

Sub-Total WOMEM'S P~~ROOAMS 298 4 98.9 334.0 8 2 8a7 0.4 8. 8 22 COOflINATEO NUTRITION PROOBaAM 87 2 I9 $I 99 2 0 2 4 0 0 2 4 I 13

Sub-Total WOMEN'S AND NUtRItION PROGRAMS 405 9 987 422 3 4 2 9; I 0 5 196 4 2

Total BASELINE COSTS 13 ;'9 4 6.09 984I.8489 2 9O00 277 9 969 7 9437 3D 900toP9sye'ca I CorntIngancias $60 5 208 4 368 8 S58 2 4 4 5 7 I90 ' 8 3P.9:cecConItinQAnc.ee 2,66'2 '.940 $ 3,609.3 20 98 33 B $3 B 477 29 B

To I PROJECT COSTS 98.620;97.298 924.099 0 3' 929 4'6 2 989 2 609 4 2$ 999

May 8. 0989 99 27

-128 - Table 2-

tl3.jRIr VpopUAt IION A41 40 I4f..t PRO.,ECT

.992 19J93 ;994 1999 "996 t ~tl 19 1 1993 94 'I.99 1996l t

ota

A FPII4CI SE,ICLc O6Lv,IV

ACCfS3 T0 -I SEPol 'f~ ?28 C. 4 sb 96t C.1.91r2 2 348 a .0900 1lB9 37 94at .549 49 200 9

"R IIANG OF "I', '~6I1 0 396 326 346 379 2 .74. 9 Bo 91 I IT 90 4

3 CLINICAL I'lavc'. St at~,- 9 2 6 2 3226A 339 2 2 a3 3920 9t I aI 334 7

4 INSTRVICE 'RAI'.;,,,

NIPORT ''289 36 94 9 104 2 tO 5 36 3 0 2 9 24 259 2 6 13

TOa IRAINI.t1' A41 40 3 44 2 4659 45 4 212a0 09 It I I I I 5 3

'tt,ttT ltt.tl INSEOOFt RAI'..t4t. '.417 '94 6 39 I 1907 960 749 4 0 4 0 3 9 3 7 37 la 9

9 fAUl 0.AI4IN, 'A~ I ;S

19rOf '.aCl G6 P 6l3AO2999 297 2 t 9 3 309 3t32A 1.433 2 80 77 55 7 4 7 436 0RINO-6'ICt, 01 -01 ' .ZC - 196 2 74 A544t 3 7 t - 3 9 4 3 t 9 2

L3GI STICS 0N4) StIPP If'. 26 22 14A4 3 3 2 t 993 0 7 3 6 0 4 0 3 0 3 2 2

S..aloo Y 1401. N"P6 ING46 ACILIT(lfS 429, 0 319 6 3900 492 t 3692 1.,996 9 7 a9 3 9 ITI a99 47

6 PQ oall IE.CT7 CONTAAC(P'lIo1 '0 t '07 6 146 l2t I267 972 9 2 7 2a9 2 9 30 3I14 4

Sub- '0141 IP.tlCrt SF9916' EWER' t 1~~~9.o27 745;13lb'603 3.4289 93 946 14 423 9 49 070 779 I 93'7798435999

B HEALTH. 99CC E `197

AT67&NECIT" EATO.'(.j CARE t6 A 2t 7 '7 9 0 t6 91 6 04a 0 6 04 0S9 04 2 3

2 MEO ANO NURSING EOLCaION

STRENI N.l.RSIIG EO2UCATON 99 99g16 5 to9 0 ' It A 14 0 2 4 259 269 2 7 2829 ?9

STREN 60 EOUCAT:CN 07 I t 6 010 71 t26 t327 902 3 2 9 30 30 3I 3 2 1

MEDICAL OUALITI ASSOAt.CE 9 89I 9 3 9 6 I104 4964 0 2 02 023 02 0 2 2INST OF OTtlER &, 2,It 116T 69 6 73 9 7 32 9 9

EXPANS ION & 09f.NIPSOt 935 5 72 60 1 64 I 67 7 303 3 1 4 I I A I I7

S.b-Total 960 AND NURSI1NG ACUCArION 321 9 390 9 372 I 39289 414 7199 i I a 9 0 93 9 6 99466

30Ev OE EAOCr. IN. 9AtAK.ADS IA 9 I 7 O I7 OA It0 643 0 4 0 4 0 3 03 03 I6

4 OTSEMS PREVETION A CONTROL

T URER AND LEPROStCCNtOL 226 4 272 236 9 250I 70 9 1.21 4 6I 59 S99 6 I 6 4 30 4

EXPANOES PROGRAM OF IalMaICONTSOL OF OIAR900AL OISE 51 6 593 96 3 SO96 60 7 29839 I4 I4 t4 I t4 7

VITAM4IN At1 0 0 . 6 T0 I9 4 164 2 I029 99 2 I03 6241 4 2 423 2 6 24 2 9 19

CONTROL. OF VECTO9-9tCRNE 015EASE a9 1III 90 90 93 St 0 9 0 3 0 2 02 0 I 3I1NTESTINALU PARASI' CB. 4 3 3 3 7 3 9 4 I 1

INST OF PU9LIC ALT.t 21 7 3 0 3 90 73 42 2 069 0 1 0 0 023 023

MOOERB APEORG 0DRUG6 47 A 49 S92 44 42 234 0I 0 01 01I 01 06

S5.0-TOTSO ISEASE PREVENT:O14 A CONIROL 492 0 49I 41 43 3 490 3.9 9 129 12 It 0. 10 996a9

9 EST & TRENG URBAN HIEALTHI I7 6 29 I 4 9 T 9 67 933 059 0 7 04 04 0 4 2 4

6 S9CHOOL IEALrT-,P9OGRAM aI 7 93 9 t4 4364 02 02 02 02 03 12

7 IMPROVING HEALTH FACILITIES

RENO0 & FUNCT IUPROV Oml 93 3 tOO9 :0.4 172 3 297 4589 1 4 2 6 237 4 2 0 9 IT

ESTABLISHMENT OF tO UNCI 72a I 31 I 10623 153 9 69 47C06 I9 34 2 7 3 7 0.2 IT 9

960-Total IM4PROVING HEALrH FACILITIES I26 I 2322 0 2t26 229 9 326 929 et 3 4 6 0 3 90 0 B 23 049a [upRUTILIZATION OF U4CS I6I 9 I73 I I193 3 I193 3 203 9 919 4 3 45 4 4 7 49 230

Stab-Tota1 HEALTm SERv,cf OELI,,EQT 1.196671.2996 1,234 B 1.401 2t.162 2 6,25423 3 0 335320 9 34 227 7 1572

C SUPPORTING ACTIVITIES

I IfN-F-OBIMA,tIO-N --SYS-T,EMS

STR ENG of.MI CoR FP 17 4 isB 9 l 6 3 4 142 64 I 0 9 0 9 0 B 03 0 3 2

MIS FOR HEALTH I6 9 252 3 7 2 4 109 102 0 0 9 06A 0.6 06A 0 3 2 6HEALTHt A E.10 SUB,VEV 4 9 4 0 4 3 4 9 593 23 04 0I 0 t 1 0 I 0:1 0 I 06

STBENG OF EPEO SuRvVS 99 69a 2 3 29 26 200 02 02 01 001 t 09

Rob-Total I(Nl,OBMArIOI4 SYSTEMS 4950 9 4 S90 0 49 33 0 22959 I2 I4 I3 I I 0a9 a2 ORGANN . MANAG"' 9 FINANC!NG

MO u SuPPORT 2412 29.0 1399 2912 I299 1410 096 07 07 07 07 3IREORGAN HEAL TM A FP P900 II 4 I22 3 12.0 13 1 14 6 6SI1 0 . 03 03 032 03 I6

Pop OEV 6 EVAL U UNIT II2 IT4 10 B 100 7 4 O90 9 03 03 0 3 02 02 I3

MCI. COOBOItNATION CEL.,I 12 7 9 7 9B4 O96 440 03 02 02 02 02 I IHEALTH ECOF. & EIN"AINC PROa 2 142 7 17 2 0 t 0 I 0 I 0 I 0 I 0

PROJECT FINANICE CELL 3 3 41 2 3 2 2I 3 14 2 01 0 I 0 I 0 I 0 I 04

PBOJECT WaNAGEME NT SUPPORT 39 0 39 2 41 7 44 2 499 210tI I0 10 I 0 I I I 93CONISTR FHALTH &' POP BLOG 4359 A6I 97 9 3S9 109 6 294 I I2 I4 2 4 20 26 B

MAINT A CONSTB MdANAOI4T uNIT It 9 12 4 13 2 14 0 14a9 66 0 0 3 0 3 0 3 03 04 t7

SUb-Total 0O0GAN2N . MAN4AOMT. 6 FINANCING 199 4 179 9 21900 207 (I 2339 9 e9976 4 3 4 9 9 I 925 0

23COMMUNICATION PROGRAM

IC. .OBMFOFPaUCI 90469 37 6944 927 33 3 1 A l 7

MARS MEDIA ACTIVITIES 43 I 43 7 1a6I6 7 B lg6 Il4 0 ;I2 I 0 4 0 4 05 3 6

COI4I4. PARTIC. FOR FP/MCI. 3665 42 9 4259 44 4 47 I 213 6 10 I tI I I 9

Sob-Total COMMUUNICATION PROGRAM t3" 147 4 123 126 B 304A 9 4 32 3 9 3 I 3I 3 I AG4 NON-GOVT ORGANIZATION 99 694.0 `9982 72 2 76 6 2406 I I 17 I1II I. 9

B INNOVATIVE PROJECTS 372 29 9 2 I 44 3 46 7 210 I 1 0 I0 1 11 1 I S 939 T. A PRO4ECTS lt12a 734 7123 932 999 4264 30 B 19 20 20109

Ru0-Total SUPRING ACTIVIT its 544 I 9559 92. 90. 09 ,917 1. 143 14.3 4.2 IA5 71 90. WOMEN'S AMO F9T RITIO PRGRAMS

1. WOMEN'S PROGRAMS

woMEN S COOPERATIVES 46 3 46 6 49 7 - 142 6 I 3 2 I 2 - - 3 7

MO0THERS CENTRES 340 294 343- 1096 6 09 10 09 -29

WOMEN'S VOCATIONAL TRNG 390 651 445 9 i 29 6 I 0 I23 1"Ia-- 33

Su-Total WOMJEN'S PROGRAMS I1 10I 129 4 - - 37789 323 34 32 - - 9 a

2' COOROINATED NUTRITION PROGRAM tB 4 19 B 20 7 22 0 233 10489 0 9 05B 0 5 059 0 6 2G

Sob-Total WOMEN'S 6140 NUTRITION PROGRAMS 138 7 t49 6 l4B 22 0 23 3 492 A6 3 7 3 9 3 7 0 5 0 6 Q1 4

Total PROJECT COSTS 3.63; 4.790 9 .116 5 .432 4 9.09 9 24.090 73 2419012A122AO 4

May S. 1991 II 27

Annex 31Table .

- 129 -

BANGLADESHFOURTH POPULATION AND HEALTH PROdECT

Summary Accounts by Year(TAKA Million)

Base Costs Foreign Exchange

1992 1993 1994 1995 1996 Total % Amount

I. INVESTMENT COSTS

A. CIVIL WORKS 571.7 576.5 649.4 703.1 440.9 2,941.6 2.3 66.8B. EQUIPMENT

OFFICE EQUIPMENT 5.9 - - - - 5.9 63.9 3.8OTHER EQUIPMENT 312.Z 449.6 270.9 277.0 182.1 1,491.9 38.5 573.8FURNITURE 44 7 56.1 44.6 55.6 23.9 225.0 5.4 12.1

Sub-Total EOUIPMENT 362.9 505.8 315.5 332.7 206.0 1,722.8 34.2 589.7C. VEHICLES 154.5 161.9 67.2 33.3 15.3 432.3 55.2 238.4D. MEDICAL & BIOLOGICAL

SUPPLIES

CONTRACEPTIVES 219.7 568.2 555.3 612.7 580.6 2,536.6 100.0 2,536.6DDS KITS 230.7 214.9 210.5 208.4 211.7 1.076.2 100.0 1,076.2OTHERS 201.8 187.2 189.3 200.8 198.0 977.1 56.8 554.6

Sub-Total MEDICAL & BIOLOGICALSUPPLIES 652.2 97C.4 955.0 1.021.9 990.3 4.589.8 90.8 4,167.4

E. TECHNICAL ASSISTANCE

LOCAL CONSULTANTS 141.8 129.5 117.2 417.4 111.2 617.1 2.8 17.2EXPATRIATE CONSULTANTS 167.5 175.5 155.7 140.1 134.1 772.9 97.0 749.9

Sub-Total TECHNICAL ASSISTANCE 309.3 305.0 272.9 257.5 245.3 1,390.0 55.2 767.1F. TRAINING

FELLOWSHIPS ABROAD 18.3 23.3 18.2 11.2 11.2 82.1 58.1 47.7IN COUNTRY 332.3 334.9 334.3 332.6 323.8 1,658.0 5.7 94.4

Sub-Total TRAINING 350.6 358.2 352.5 343.8 335.0 1.740.1 8.2 142.1G. INNOVATIVE AND NGO

ACTIVITIES 93.2 93.2 93.2 93.2 93.2 466.0 7.8 36.5

Total INVESTMENT COSTS 2.494.4 2.970.9 2,705.7 2,785.5 2,326.0 13,282.6 45.2 6,008.0

II. RECURRENT COSTS

A. SALARIES & ALLOWANCES 731.4 978.6 1.307.7 1,269.2 1,229.9 5,516.7 0.0 0.0B. ADMINISTRATIVE EXPENSES 152.1 175.3 165.9 148.0 146.2 787.6 0.5 4.1C. PRODECT OPERATING COSTS 54.8 55.0 60.0 46.2 46.0 262.0 14.7 38.4

Total RECURRENT COSTS 938.4 1,208.8 1.533.6 1,463.4 1,422.1 6,566.3 0.6 42.5Total BASELINE COSTS 3,432.7 4,179.8 4.239.3 4,248.9 3,748.1 19,848.9 30.5 6,050.4

Physical Contingencies 61.8 83.6 72.7 78.9 71.8 368.8 56.5 208.4Price Contingencies 136.6 487.4 804.2 1,104.6 1,268.5 3,801.3 30.0 1,140.1

Total PROJECT COSTS 3,631.1 4,750.8 5,116.2 5,432.4 5,088.5 24,019.0 30.8 7.398.9...... ....... ....... ....... ....... ........ ....... ........

Taxes 194.9 233.2 152.1 187.9 137.3 905.4 0.0 0.0Foreign Exchange 1,064.3 1,595.4 1.509.2 1,639.6 1,590.5 7,398.9 0.0 0.0

May 8. 1991 11:27

fUURIII POPUIAIWIU AN1W 111A11H PRO0.3311S.muuwy Account by P,ojict Conp~,ne

11101A Mg Ilwr.1

IP/FICII SIFFVICI D3 1 lYfR

INFSfRVICE IRAININGSIRING OF ClINICAl LSI OF MAI

ACCISS FO 91CF SRVlILI 1BA UFIWCs & RINFUVAIION Of I0CGISIIr& IleIVAIE .3i IDI? N F.NFIAISFP I,IRVICFS SlRVlflS Dil 1V1RY NIPORI ;IIIAININIC UPGIIAI RD~. MtIIAll A NU611 SiI'PP IIIS 161411IfLbHIVI, 116A1 III 8AH1

INV(SNIHFFI COSIS

A. CIVIl WO0RKS 1 7 1.033 8 204 4 2IIEQIIPHIFI4

Of111.1 foIJIPNI II 2 6O11411 EQUIPFIIII Is 0 114b0 443 9 8 8 13 2 14 7 5 47 8 2 IfURNIIIIRI 17 2 I? 0 3b 8 . i U

Sub1oala fQUIPNINI 33 2 129 2 443 9 8 8 13 2 "I b 8 / 8 1I' VIIIICIIS IS? 4 0 0 71b 43 3 0 5 F I 6 I 13 I 0 9110I1.8 £ 11IO1DGIC*ISUPPII S

CONIIRACIPI1VFS 1.962 5 - 115 7 4511 4DOS 8115 1.076 20111614 13 I

Sub~-Total P1101CAt 8 BIOIOGICAtsuppklLS 1.962.5 1.076 2 128 8 4'58 4I 1CNN4141.t ASSISIANCE

tOCAL CONISUITANIS 10 6 - 30.0 40 7 6 0 41 9 lXPAIRIAIL CONSULiANIS 41.6 8.6 43.8 35.3 4? i 140

SwbhIotal 1(CNNICA1 ASSISIANCE 52 2 8 6 74 4 7b 0 6 0 41 9 4 2 18 1)F IRAIFIIIG

F11ILOIISIIPS ABROAO0 13 3 ..- .28 2IN CO131NIRY 1.0 151 6 150 9 -53 4

Sub4citalIRAINI141G 13 .3 - 0 151 6 150 9 53 4 2-l 2G IIUOVAIIVi AND NGOACIIVIIIIS-

lolal INVESIm14OI COSIS 2.2185 l.?214. 0 675. 9 279 7 470 6 1. 139 3 27? L. ifi 345114 !455t11 RECURRENT C0S1S

A SA181R1f5 £ AIIOIINCES 4.324 9 33 8 353 0 175.0 7 0 IS 3 21 6 7 38 ADMINISIRAIFVF EAPINSIS 3? 5 109 0 121 3 V)3 9C PROMlCI OPlRAIING COSIS 57 a It) 1.0 I 5 14 alotal RICURRINI C0STS 4.357 4 195 6 414 3 175.0 7 0 30 3 45 I 22 1total BASElINE COSIS 6.575 9 1.409 6 1.15!0 2 45,4 7 177 6 1. 139 3 30? 8 76~4 458B 4 *77 Physical CoftiIngencues 998 60 3 28 8 04 0 7 7473 ?80 I CDPrice Contungencies 1.404 3 271 6 203 I Al 0 33 7 219 2 i1 8 Ii I 91 2 13 8 80l-8

total P140.1(C. COSIS 8.080 0 1.741 5 1,382 0 _536 I 212 0 1.433 2 375j I 88 3 157? 5 81 6

0 lla-es 32.0 47 1 175.1 26 2 5? 22228 b 8 8 0 28aFor-eign F.change 2.690 8 1.409 0 347.3 08.7 IS5 15 3 7 6 298 572 5 48 8

NY8 8. 1891 10 55

BANGt AD[ SNlOhiRIll POPULAI ION AND liIIAllII PROJFCISuymary Acco,,ri by Project Cosponent

liAIIA NilI ior.)

MIAIMII SKRVICI 0li11VERT

DISEASf PNLV[NIION 8CONtROtMiD AND NURSING EDUCAT ION..............

. .... .... .... .. ~~EXPANDEDINST OF PRlOGRAM Of

SIRIN BEOICAI NUIHERIT Of Dv IJBER AND iNNUI NIIANiN A. EDIIIRLI Of MNI of HODLNN aNUNSING SIREN MEO QUALIFY ChiliD EXPANSION R ISFARCII IN I.EPNOSY CONt IROL OF I DO0 . 8 VMCtR 801RN1 LNIISTIIAI PUBl IC REOkii DRUGLOUCAIION OIDUCAIIIIN ASSUIRANCE HtfAitil DIV NIPSO HIANGtADS I3ININI DIANUDIAL 015 ANt DIII9ASt PARASIII tIRt NEAt Il Its

INVI¶dItNlN (0515

A LNItI WORKS 251 4 190 7 159 5 44 2 -- Ia8 3 9 I 0It IQIIII'NILNI

iltlif.I IQUIPNINI 05 28-(l1INR IQIIII'MNI IIItAO4 lb7 17 0 13 5 'IO 1 12. I ltt 21I 0 0 8. I 14 0IUNNIItJNI -. .I? 003

%,A) total EQUIiPMENT 180 4 IS 7 17 0 14 0 52.9 ;I t:u15 22 3 01 a I 15 3C VtI oitiI s 83.9 32 Isb 1.04 EQU mUICAI IT BIOIOGICAl

CON tRACI PIt N I S

RS .477.1, 1381 ' 2479 SJ1I 174

S., bloat MEDICAL S ISEOOGICAIsIAPPItis -. 477 6 138 7 297 5 9 I 17 4I 111,t1NitAl ASSIStANCE

1(OCA1 CONSULIANIS - 8 9 93 A 50.0 II 0 58 7 2 8 4 5 4 IFxPAINIAII COIISULIANIS 70 5 7 3 224 t 14

5.8. ltlal I(CNNICAI AISSISEANC1 10 5 a 9 93 8 so 0 18 3 28? 8 2a8 4 5 4 I I4ItRAINING

II I NDSII IPS ABROAD 4 2 -210 -IN COUNIRY 157 2 52 4 14 3 65 5 128 5 - 25 8

S,,h total IRAINING 161 4 5? 4 14 3 65 5 128 5 21 0 25 8Ii INNOVAIIVI AND NGO

AtIlVIltIS -~~~~~~~~~....... ..... ........... ... .-

bloal INtvISIMINI CO515 412.8 494.0 39 0 318 8 239 7 53 3 891 I 15b.8 472 8 39 Li 1.1 30 9 It 3

It RICURRINI COSIS

A SAIURIfS ITAttO)ANCES .140 119b1 255 283 a9i 04 55 27N AiININISIRAIINE FI,P(NSfS I 8 4 9 .I9 41 7 2 36 9 1 5C: PRlJItA (~I PERAIING OSIS 00 IS 5I

fatal 111CURRINI COSISS I 8 4 9 14 0 I 9 123 5 82 6 65I 5 3 lb 4 5 5 2 7lolal BAS11IIN1 COSIS 414 6 496 9 33 0 318 a 25 37 95 2 1. 020 7 239 4 53/ 9 49 0 Ilb. 36 4 200Phays.cal Con.tingenctes 17.6& 224 It 2 3 9 0 7 -03 09 08Pri.ceCot nl.gec es 81 9 el0 74 625 49 6 89 190 7 440 862 62 30 49 26Iota

tPNojEclCO £05 514_0 602.3 464 3924 3033 bit3 1.211 4 2835 624 I 514 195 422 234 9 W

Ia.es 48.0 98 7 30 4 14 I 4 5 51 4 4 4 0 9 5 2 4 " Foreign f.change 3 2 220 8 7? 7 19 5 468 7 126 b 376 3 It 2 4 2 26 6 II A to

0

.a .....9 ..10 - - - - - - - - - - - - - - -- - - - - - - - - - - - - - - - - -- - - - - - - - - - - - --Sb- - - - - - - - - - - - - -- - - - - - - - - - - - - -

BANGi k0l %I2I UURI*tb $13P'Il All 18 AND IllIAlIIH P9Q.2111

Aczcountl by I'mievi Cotpwd4.n.11A8A Hll BsonS

IMPROVING HEAkLTH FACILITIES INfI0RMI~ lowl SIS1ENS

Fs) & sLHooI RNB J1u aMP rn.tAti" a SI~REN. orSIRkNG URBAN IIEAI If BUIIci ISIARtISHINII Of tUiilAIIAION W3 SIRING Of1 HIS IOR DfNGO (p20lit Al Iti PROI4.RAM IMPRUIV OHI SO uIIcs UIILS MIS FOR IP HI'AIllu SUIRVIf SURV SYS

INVI%IMINI COSISl

A 11711 NOUNs i 225 7 299i2 262s 7 3722 I QIIIPMLRI

WHIR11 IQUlISISKI4 45 157 48? 53 2 142.5 519 1 5 09liki 218 URF 22b 1s6.0 97 5 04 08Sol IoSo I 101222'INI 4.5 IS 57 70 3 69g 2 240 0 ii 9 1. 5 I 2 0a&2' R,It ?Ci:I s 10 2 0.8 1I6 28I)MIDIIAI 9 6IO01I21CAI

IIINIRAUIPIIVI¶.. (22% Kits

S.A6 Iota) MIDIC:AI A BIOIOOICAISIIPP'IIf s 10. 2 - -U

1I tlI:NtCAl 0SSISIANCE tQ

lOCA( CONSUl FANIS 01 a 9 2S 0 I 7 22 2 - 4lXl'AiRIAil COSISUIIANIS94 b 2203

Sub. lotal fiCtINICaI ASSISIANICF 01 8 9 jig1 q a 3 44 8 I 7I 18A181MG

fIiOSEIIPS AIIROAB . 4IN COUIRSII 03 14 3 -136 0 300 2 9

uh, bloal IRAINIIBO 03 143 -13b 0 30 0 a 9 I 4C. INNOVAtiVI AND MO0

totla IVIVSFMINI COSIS 268 B 39 0 2960 378.6 764 6 21 0 77 9 3 I 10 4

11 1111:l114R11.1I COSTS

A SAIARICS 8 AtIOWANCtS 52 3 - 75 5 - I 2 IA 3 5 9 A8a b6622 AANBNISIRAIIVI EUI'INSFS 20 6 25 9 7 A 34 3 3 0 21: P'U(ld(Cl UVE2A1 IWG CUSIS ... . 79

losul RII2JRRFSII COSS 52 3 - 96 I 25 9 9 0 SI 4 9 2 16 7 6 Alo2la 228522181 fOSIS 79 0 39 0 392 I 404 6 773 6 32 4 871 24 8 17 2P'l7S*ldLoot C .qefCKO)M $ 0 8 2 4 2.7 II2 0 3P-,.v ConS sgen, .es 13 15 7 4 64 0 63 4 234 9 II 7 24 9 3 C 25 5

bloat IBIUJICI £O515 93 3 .6 4 458.5 470 6 9 15 6 84 I 102 0 23 4 20 0 0) o*

I a.o'. 57~~~~~~~~~~~~~~~~~3 17 0 22 2 3.1 0 0o. 09 27 I.,e,gn fzchange 8J~ ~~~ 94 3 45 3 227 4 19 2 28 8 'I4 Nw

Ray A 149 1 20 5

igtgin POPULATIO AtN O H(IIIa inPoouiStamry Accountl bY PeOject COOeeut

llAMA HIIII#on,

SUPPGRi 11G ACJIViIIES

POP oiv KRt Pn.JfC; PROJIC) COuSIR LjuNiaN 0 U REORGAN.HAIMIN £ S V'AkU COORDOINATION HFA8111 ICON8 IINANCE M11AI.(Nrli 1IA1111 S ANAHAUISUPPORT IIP PROG UNii cliI I IINAC I'R0J ctiI 1.1pliali pop BLDG UNIt

INViSIMNiI costS

A LIVII MnORs 230 2

t QIPRIIMi (UP

(111111 iQUIpmNSN 0 Is I 0 1 I 2 9 49 IluRNutluili 44

SA, lolal ioUIlPIIN 5.0 m 5I 0 *3 2 9 - 55.54 ViII ic s I b 2b4 3 0 0 7 I 3

.UPI II 1

9DS RIlS

Su8 lotal NIOiCAL IT BIOtOGICAISUPPI115 -I.

I ICKiNICAt ASSISIANCV

lOCAl COlNSUI8ANIS 7 21 0 6 0 39 - 86fiPAIRIAIl CONSUIiANIS 54. 8 4 1 Ia 8 '12 I.

Su,~ Total 1(01111CM aSSSISIAUCR 7 548 2- 3 6 0 3 6 91 2 6 I 28 I,

I IlmI IlO"I PS *890*IN COUNiRT 820 3 5 19 0 97 06

Suh lolal IRAINING 820 - 35 19. 0 9 7 06G. IuNOVbIIVI AND NW0

ICIIVIIIIS-

total liWVEIISHNl COSIS 90 4 54.8 32 7 28 9 14 4 4 2 9?25 291a 8 8 4.

11 R1CUR0131 COSIS

8 SAIARIES aAIIONaNCiS 20 8 2 5 I 58 0 9S ADNuNISIRATIVI IXPIUSIS 2 3 8a5 7 2 0 5 84 I 27 7 21, 8L PRUJICI WERIP*IKNG COSIS

ioIal RiCURIDNlI COSIS 281 3 i 0 8 7 0 5 8 I 841 i 87 26 8loila 8SEIIiNI COsis 118 4 54 8 43 7 3? t5 14 12 3 IlL .b 320 53 55 5j1Physical Eontlngenies 0 5 03 25,pr.ceo COnI morqnce:se 22 I 104 7 2 65 22 I 9 333 4.62 lOS5 m I- 0lolal PNUJIECOSI0S1 141. 0 65 3 5109 44 0 i 72 14. 2 2101 3 89 I 6 0. I8

la.ej 93 50 0 I-aiore,go fachangs 0 9 65I3 9 I I 5 2 7 3 . 8as7 25.0

may S. M e9 10 ~55 - - - - -- --. . .. ....

BAIGtADI SF4lOUlaIt F'OPUIAIILIN AN) "11*11)31 P9031(

.wiasry Ac..Cn.a by PrtojectF r.(31910aM'43A6* MilItonil

... ... .... .. ... .. . ... .... .... ... .... .. . ... UM.3 N'S AND NUIRII 301 PROGRANSCOM1IUICAIION PROGRAM----.................

-- - - --- ---- - ------ NOMI~~~~~~~~~1071 N' S PROGRAMIS

PROGRAM C(0111 MUFFIN'S COOROINAFID Coot'n9ernciesfUR IP A PASS MEDIA PARIIC 140N-GOVI )NNOVAIIV& I A IIMIN'S MOFIFIRS VOCAl tONAl ,eUIF3lruNMCi ACIIVIIIL5. FOR IP/MCFF ORGANIIIAFIJO PEO.FtCFS P3)031C15 COUPtRAII9LS C:tNIFFS 4141G PROGRAM*1 lotal 3 mDn

I NVIS1M1N11 c051s

A LIVIF WORKS14 0 3 3 9 .2.941 6 43 1 3.9 744 ouJPRINI

IliFFiE IQUIPHINI . -. 59 2 6 0 2u11111 IQUIF'mINI 414 6 0 2 8I0 4 3 3 3 I 0 6 1. 491 9 3 9 by7 IIUItNiIUF4 55 05. 23 06 00 225.0 5. 3 4

5,b total IQIIIPHINI 5. 5. 46 6 0 2 - 830 9 5.3 A 0 6 3. 722 6 3 6 61 3I' vFFFiIll,S 163 8 . I5. 23 39 24 06 432 3 00 013 iflhlAI S1 61161

I.3FNFRACIII 1V1S 2.531.b 5.0 4768

DOS11 K S 1.016? 2 50 5. 38Ol Ill RS ~~~~~~~~~~~~~~~~~17 4 97/3I 0? 20

S..b total MIDICAI A aIDtOGICALSUPI'I'I IS 17 4 4.5189 5 40 1826 I II.IINICAI ASSISIANCE

10181 F01111S31IFANS -133 4 617 1 00 00 4IIPAIRIAlt CONSUIFLANIS -.- 36 3 -- 172 3 0 0 0 0

SIh loala 11(1114E(8 ASSISlANCE 169. 7 .. 1.390 0 00 00I IIAINING

lIFIOIISIIPS ABROAD 2 6 2 0 . 2 6 2 6 4 3 82 3 0 6 0 5In (01114314 75.0 2 1 176 0 131 9 42 2 2 8 45.4 84 3 1. 65.80 0 3 4 5.

Sob Fotal IRAINFNG 75 0 51 1 781 131 9 44 8 5.3 49 7 84 3 1. 740 I 0 3 5 0G I"NNVAIIVI AND 1460AliIVilIFS 286 3 179.7 466 0 00 00

I.tal INVIS11iNN COSIS 968 60 3 179 6 286.3 379 7 331 I 48.0 14 8 5.5.9 8s55 13.282 6 2. 8 348 8

If RICURRINI COSIS

A 58AIARIF5 A AIIW4NI:IS 480 239 5.5 ~ .0 373 20 5.5.S16 7 00 0 0M AOMINISIRAFIVI t&P1NS15 41 0 26 7 76 0 787 6 0 0 0 0I. PAO.FICF UPIRAIIN6 COSIS 110I Ila4 45. 220 08 21420 00 00

lola) RI CURRINI COSIS 5.8I 3 149 32 2 7 5. 80 5 5.9 3 2 8 b.56b I 0 0 0 0Iola$ WIA'IIIN COSIS 25. 49 I125.2 119 8 2814 3 179 7 b3133 123 t- 95 3 F15. 2 88 3 114.848 9 F 9 368 8Phy.cal Eoal 'ngencies o 0 0to45 05 34OA00a Pr,ce Conllingence.e1 479 isa8 338 54?2 30 4 622 146 108 1334 165. 3.80)3 18 1477M

lolal PR40JFCI COSIS 302 9 341 0 233. 6 340.6 210 1 4264 142 6 106 6 128 6 104 8 24.0)9 0 1 A 43145 FiJ:;z: .... m ... ..::- :. .... ... - . .: --- : - _-: -:: .. . .~ ~ ~~~~~~~~~'~FIsms I a 243 0 2 - 5.3 3 2 2.1 OF1 0 0 905 4 4 5 407 0 3Foreig, (.change 76 I 30 2 4 0 39 A 77 3 7 93 5. 4 5. 2 ?.39N 9 3 3 2478 8f

Ray B. 119 1 I 55.

BANGLADESH


Costs at Azoraisal of the First, Second. Third and Fourth Bangeladesh Poputation and Health Projects

First Project Second Project Third Project Fourth Project

.------- USS (MitIion) ---------- -------- USS (Nillion) ---------- --------- USS (Million) ---------- -------- US$ (Million) ----------GOB GOB GOB GOBCofin- Count- Cofin- Count- Cofin- Count- Cofin- Count-Category of IDA anced erpart IDA anced erpart IDA anced erpart IDA anced erpartExpenditure Credit Grants Funds Total Credit Grants Funds Total Credit Grants Funds Total Credit Grants Funds Total

Civil Works 4.2 7.3 2.4 13.8 18.6 24.6 3.1 46.4 41.2 0.0 3.9 45.1 62.9 19.5 8.6 91.0t X ) (27.9) (28.6) (44.5) (30.2) (58.1) (36.7) (28.5) (42.1) (52.8) (0.0) (10.8) (21.1) (34.9) (7.6) (5.2) (15.1)Equipment 2.6 3.4 0.2 6.2 5.5 7.8 3.3 16.6 31.3 23.0 5.6 59.9 32.8 14.2 16.4 63.4C X ) (17.6) (13.2) (3.9) (13.6) (17.2) (11.7) (30.0) (15.1) (40.1) (23.2) (15.3) (28.0) (18.2) (5.5) (9.9) (10.5)Training 0.4 0.3 0.0 0.7 0.1 1.8 0.4 2.3 0.6 18.6 1.0 20.2 37.8 54.5 1.0 93.3( X ) (2.9) (1.1) (0.0) (1.5) (0.3) (2.7) (3.4) (2.0) (0.7) (18.7) (2.8) (9.4) (21.0) (21.3) (0.6) (15.5)Salaries _/ 1.8 5.5 0.0 7.4 0.7 21.1 2.5 24.3 0.0 35.9 15.7 51.6 15.7 45.7 135.6 197.0X ) (12.2) (21.7) (0.4) (16.1) (2.3) (31.4) (22.7) (22.1) (0.0) (36.1) (43.1) (24.1) (8.7) (17.8) (82.1) (32.8)

Special WActivities 0.3 0.1 0.0 0.4 1.5 0.5 0.0 2.0 5.0 22.0 10.2 37.2 30.8 122.4 3.5 156.7( X ) (2.0) (0.2) (0.0) (0.8) (4.6) (0.8) (0.0) (1.8) (6.4) (22.1) (28.0) (17.4) (17.1) (47.8) (2.1) (26.1)

Unallocated SJ 5.6 8.9 2.7 17.3 5.6 11.2 1.7 18.5 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0( X ) (37.5) (35.2) (51.1) (37.8) (17.5) (16.7) (15.4) (16.8) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0) (0.0)

Total 15.0 25.4 5.3 45.7 32.0 67.0 11.0 110.0 78.0 99.4 36.5 213.9 180.0 256.3 165.1 601.4( X ) (1000.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0) (100.0)

X of Total (32.8) (55.5) (11.6) (100.0) (29.1) (60.9) (10.0) (100.0) (36.5) (46.5) (17.0) (100.0) (29.9) (42.6) (27.5) (100.0)

_/ Public Sector Sataries and related operating costs.

b/ Research, Innovative Activities, and special NGO projects.

c/ Physical and price contingencies unallocated at appraisal, but assigned to specific components during implementation.

'I

wW

- 136 - ~~~Annex 33-AO 136S- Table 1

FOURTH .'OP'UL%EI ON INC HEALTH PRO-JECTPlnencinv, Play. 3v Project Components

'USE 1 IttIIon)

A,' BEO CIDA EEC r GrZ APw

A F/IMCIl !AvICE' OR. IVEtU

IALCL.s t TP i SEAvICfS 0a00 4 20 7 l4 A id B 6 4 26 51I3 27SIRE'j OF SCM SETwICFS 0 40 9 - - - - -ii426 2

2 CtINICA SER1"ZVICE, O(cA"R- 05 I A'I NSERVICE tRAINING

NIFOQT 1289 4 9irA IRAINING -

S.0O-ToaI INSEAVICE TRAINING-12A60 1P AMIL' PIANNINCt FACILItlIES

ESI or UFL3 S UPGRAAOI OAENOVATION OF MCMI AZ:D

LOGISTIC' ANG SUPPLIES

Sut 7Iota FAIAII/ PLANNING FACILITIES A PRI VATE SECTOR CON'TRACEPTIVES- - - - 12 A406 I

Su 1AA IFAM EVICE OELIvERY I80 5 - - 2978A2 25 2 7 0 12 A2 6 a2 0 t 6B .501IN ARACTDELIVERY

AIMAT A NEON.ATAL HE'A'LTH CARLt 2 MAO ANt NuRSI1NG ADuLATION

SrREN NURSING EDUCATIONSTREN MEO EGUCAT ION- 2 7 II? NEOICAL QUALITY ASSURANCE INSTOF MOTHER &. CHILDCHEALtH

EXPANION01 a OEV NIP$ON 6aBas

Sub-Total MEO AND NURSING EDUCATION 6 014 2 7 0B3 0EV RESE ARCH IN BANGLAPS 0 84AR

GOISEASE PREVENTtON & CONTROL

TUBERANOLEPROSY CONTRIEAPANOEDn PROGRAM OF IMMUI

CONTROL OF DIABROEAL OISEVITAM'IN A. I 0 0, & ARICONTROL OF VECTOR-BO0RNE ofISEASEINTES TINAL PARASITE CTRLINSTrOFPUBL IC HEALTH

MODERN A REORG DRUG TEE

EuDTrGtaI OISEA SE PRE VENTION 6 CONTROLS' EST B STRENO URBAN HEALTH.6 SCHOOL HEALTH PROGRAM7IIMPROVING HiEALTH FACILITIES

RENOV & UNcTrIPROVOESTABLISH'MENT OF 10 UNCA

Suo-TotAf IMPROVING HEALTH FACILITIES a IMPR UTIL IZATION OF UHCs-- - - 21 0 00 2- - -

SuR-To0tal HEALTH SERVICE DELIVERY 7 64A B 2 7 1 7 21 S B912.9 - -C SUP PORT ING ACTIVITIES

I INFORMATION SYSTEMS

STRERNO OP 45FRPMIS FOR HEALTH - - - 2.3 sB 2 - - -HEALTH 6DEMOG SURVEYSTRENG OF EPID SuR 55SY

Sub-Total INFORMAATION SYSTEMS- - - - 2 2 2302 - - - - - -2. OROANZN . MAANAaMT. 8 FINANCING

5 0 UISUPPORTRIEORGAMN HEALTH & PP PROGPOP OEV & EVALU UNITMCM COOROINATION CELLHEALTH ECONA &SINANC.PRO.IPROJECT FINANCE CELL,

PRJCT MANAGEMENT SUPPORT 0.2 4.0 0t IO .22 .8 10.4 .01.CONSTR HEALTH & POP BLDGSAINT & CONSTR N4ANAGMT UI

Sub-Total ORGANZN .MANAGNT. 6, FINANCIN 0.2 008 0.1 0.5 I 2 4 0.0 2.2 0.0 2232 COMMNUNICATION PROGRAM

IRS PROGRAM FOR VP & MCII4 - - 4.1 54.5 - - - - - -MAS$S MACIA ACTIV ITIESCO.II PABTIC FORFP/MCH

5ubO-Ttal COMMUNICATION PROGBAM - - 4.! 20.0 - - - - - -A. NON-GOVT ORGANIZATION -S INNOVIAT IVE PROJECTS - - I225.0 O TA. PROJECTS - - 1 715 0 - - -

SbD-Total SUPPORTING ACrtIVITIES 0.2 0.2 0.I 02 IOB a4 7 0 a I - - 0 1.1

0. WOMEN'S_AND_FRATRITION PROGRAMS

I. WOMEN'S PROGRAMS

WOMEN'S COOPERATIVESMOTHEIRS' CE4LTRESWOMEN'S VOCATIONAL TRNO

SI-taWOEN'S PROGRAMS2COOROINATEO NUTRIriON PROGRAM

Sub-Total WOMAN'S MAO NUATRITtGIN PROGRAMS

total Olourselsent 0. 2 6 0.5 40.23 7 47 B B 12 B 2 I B 65

May A. 1001 It 27

- 137 - Annex 33

FOURTI- POPVLAtlo AND M6ALTI 88R.JECT Table 1Floancl.q Plan by

8r.oIect Co. ,non,a

(US$ Million)

'JAPAN NI' NO01AD SIOA IDA G69 OVERNMENT Total Loc81

A.uont Ao..nl aa ~n1 ¶ Al~ AtImo.1nl ¶ moont V. A-O.nl ¶4 A...n_: Ecl A.a ¶aoc

I 7631 6.3 09 U2 - 16(4 S9. 00 60 0 200 9 33 4 669 1332 08a- 'II3 8a3 3 7 016 0 70 1 7 i 6 , 43 7 1 3 364 7I 2

- - - ~~~~~~3 0a95 - 2 6 6 13 6 302 lb14 44 2 34 7 8 8 a97 21 9 4 4

- 07 1 I 136 3.2 ia iI 0 713249 37997 - - - 036 4 563 0 D0 81 0

* I3 7 0 3 719S 4 -I 056 toa 9 I Ia 162 0 a

304 944 6is166 360 90 01 300 .6.9199g5.. -01 19 92 16 02 a9 0.1

12543 10457 22 04 08 3 0 2

9 I 19 I 3 6 696 6 8 4 3 47 79 I3 40 2 6 0- ~~~~~~~- 2 0136 - - 000 0 14 4 234 144 -

9 1 2 5 -3 8a38 207 a3 0 90 I 9 32 6 6986 19 30'6 36 3 36"9 9 9a8 120 6 218 2 3 2

- . 1~~~~ ~ ~~1494 Ide 1 484 -0131 23 04 12 10 0 1

- - - 96969 312317 1296 129 21 01 16 1 2- - - - - ~~~~~~~~~I 912 6 -a-80562a8 2 51689 1 I 258 6 7 i 2.5

* - - ~~~~~096s00 06600 - 0000 12 02 - 12 -* -. - - ~~~~~~ ~~~20I99 - - I71 724 08 78 98a 16 - 9I 08a

-09101 76 13 8 84 0 4

- . ~~~~~~016I2 12 626 1 0 6 I '2 39 0 a83"I 3 446 6 77 7 4 34 4 48- ~~~~~~~~~~09 46.3 01 7 4 16 0.3 00 I0 0.'

- 60 16A4 - * 17 9s6oa8 7524 8 30 4 I 118a la6 -

* - 3.0 422 22306 - -- 02 26 1724 7I 12 32 2.6 i 3- - - - -- 06 33 - 1408896 3 8.1 166a 2 6 94 6.4

I 1 8710 02 18 0 I3 0 2 03 0 8 0.0103677 02323 0901 01 0 4 000S8 2 3 0327 7 II 0.2 0.7 0 3 0 I

- - - 04716 - - - -~7i 0t1181 0 1 10 4' 06 01 03 02 0

* 8 014 1 2 6 4 6 0 6 0 9 - - 34 4 60.9 II .3 19.9 96 8a 94 26 8 29 4 6* - - - ~~~- - 1 3663 - 0 9 37.6 01 6.1 24 0.4 02 220 01I

1.2 100 0 - 1.2 02 - 12 -

8.6 74 8 2.9 2562 118 I 2 4 a8 I 04

10 6 894 1310.6 11.9 2.0 1.1 10.2 06

19 22 82 2 4.2 17 8 . 23.4 3. 9 3.95 1 9 0

02 10 0 .93 8 23 0 3.8 7 14 09

- - 8 0 I 4 3 2.7 14 3 9 1 I 7 1.1 74.8 47'.6- 22.0' 140 157 2 26.1 44 4 10g 3 8.6,

- - ~~~~1.2 56.8 0 9436 2.1 0 4 0.6 1.6 0.0

- 03it7 2 6 04 0.7 1.8 0 00.2 40.9 0.3688 06 0.1 - 0603 49 4 0.3906 08 5 0.1 0.1 0.4 0.1

- .- ~~~~~~~1.7 29.2 1I8 31.6 8.8 1.0 1.3 4.4 0.1

* - 09824 8 1.6 44 7 I I 289 - - - 0 00 7 3.9 0 6 0.0 3.5 0.0- - - -- - l.t 70 0 - 08 530.0 - 16 03 I-.6 -

- ~~~~~~~~I I 84.1 0218. 1.3 0.2 02 10 0.- - - - ~~~~~0648.1 - - 0.8 48.1 0.0 3.7 1.1 0.2 0.0 1.0 0 0

- - - - - - ~~~~~~~ ~~0280.0 - - 02 80 0 - - 0.4 0It 0.; 0.40.1 29.8 307 2 04 0.1 0. 0.3 0.

- - 099.6 0919.4 0,s 9.6 038.8 - 0 00 0 83 0.9 2 2 3.I 9286.8 0 338 97 16 0 6 9.10.9 81.6 0.8 48 4 I7 0.3 - 1 7

1 4 8.8 2 911.7 2.9 ItI7 0 3 1.2 12 8 80 6 1.7' 6 6 285 4 2 4.9 20. 0 0I

- - 0.7 8.8 - -- - 0.3 4.9 2.8 321 76 13 1 9 56 0.0(.I6 43 3 2.0 86.7 3.6 0.8 0.8 2.2 0.6

- - 07 4 t 3 43.8 4 9 27 6. 2 8 3 0.7- - 1 0:2.0 - 60700 1' 518 0 - - 00 0.0 9.8 1 4 - 8.8- - - - 2.9880 -~-I : - - .; 20.0 0 00.0 9.3 09 1.0 4 3-- - - - ~~~~~2.4' 22.02 - 06 8 2 59.? 92 9 0.9 4 9 '0.8 I 8 2 0 8.7 0 1

- - 3 1 4 3 8 2 11.4 8 9 2 4 2 432.3 28 3 39 3 8.8 Ia8 71.9 12 0 12 0 58.8 I 0

1.9 2.2 1.: .4? I .7 0.6 0.2 3.4 0.01. 72 0.922 a8 059 0 I 2.6 0I

20 889 1.34. 3 .5 3 06 0I 3.2 0 0

8.8 88.9, 4041.61 98 6 0 5 982, 0 12 6 97.4 01 6 2 6 04 0.0 2.6 00~

8 3 67 1 4 1 32 9 12 4 2 I 0 9 I 8a 0 1

9.1 I 9 24.8 4 1 33 2 8.9 23 7 3 9 13 4 2.2 190 029.9 165 I 27 4 801 4 100.0 185.3 393 3 22 9

Annex 33- 138 - Table 2

BANOL.ADESHFOURTH POPULATION AND HEALTH PROiJECT

Financong Plan by Summry Accounts(Us$ M1ilion)

AUS BELG CIDA EEC GTZ KFW

Amount % Amount % Amount % Amount % Amount % Amount %...... .o.. .... .an .. a.. soo. ..... .... .o.... c..a. . ....

1. *NVESTMENT COSTS

A. CIVIL WORKS 1 2 1.3 - _ 8.0 8.8 - - -

S. EQUIPMENT

OFFICE EQUIPMENT 0 0 3.1 - - - - -_ _OTHER EQUIPMENT 0 5 1 1 1.8 4.0 0 0 0.1 3.3 7.5 0.2 0.4 - -

FURNITURE - - - - - 2.9 43.2 - - -

Sub-Total EQUIPMENT 0.5 0.9 1.8 3.5 0.0 0.1 6.2 12.2 0 2 0.4C VEHICLES 0.0 0.0 0.0 0.0 0 5 3 7 0.0 0.0 0.6 4.9 0.0 0.00 MEDICAL 8 BIOLOGICAL

SUPPLIES

CONTRACEPTIVES - - - - 10.5 13.1 25.2 31.4 - - 18.6 23.3DOS KITS 0.4 1.2 - - - - - - - - 11.5 34.1OTHERS

Sub-Total MEDICAL & BIOLOGICALSUPPLIES 0 4 0 3 - - 10.6 7.3 25.2 17.6 - - 30.1 21.1

E. TECHNICAL ASSISTANCE

LOCAL CONSULTANTS 2.2 11.9 _ - 1.1 6.0 0.7 4.1 1.2 6.7 -

EXPATRIATE CONSULTANTS 0.2 1.0 0.4 1.7 2.2 9.5 3.2 14. 2 1.0 4.6 0.4 1.

Sub-Total TECHNICAL ASSISTANCE 2.4 5.8 0.4 1.0 3.3 7.9 -.0 9.7 2.3 5.5 0.4 1.0F. TRAINING

FELLOWSHIPS A8ROAD 0.3 12.8 _- -_ _ _ _ _IN COUNTRY 3 8 7.8 0.6 1.2 2.2 4.5 4.1 8.2 4.5 9.1 -

Sub-Total TRAINING 4.2 8.0 0.6 1.2 2.2 4.3 4.1 7,8 4.5 8.7G. INNOVATIVE AND NGO

ACTIVITIES - - - - 1.3 9.5 - - - -

Total INVESTMENT COSTS 8.6 2.1 2.8 0.7 17.8 4.4 47.4 11.7 7.6 1.9 30.5 7.6

II. RECURRENT COSTS

A. SALARIES & ALLOWANCES 0.8 0.5 * - 19.2 11.6 - - 5.2 3.1 7.9 4.783. ADMINISTRATIVE EXPENSES 0.1 0.5 C 1 0.3 0.9 3.8 0.4 1.6 - - 0.4 1.6C. PROJECT OPERATING COSTS - - _ - 2.4 30.S - - - -- -

Total RECURRENT COSTS 1.0 0.5 0.1 0.0 22.5 11.4 0.4 0.2 5.2 2.6 8.3 4.2Total DOsbursement 9.6 1.6 2.8 0.5 40.3 6.7 47.8 8.0 12.8 2.1 38.8 6.5

sums.. .... ...... . ......... . ......... .... .... ....

May 8. 1991 11.27

- 139 - Antnez 33Table 2

BANGLAPR5NFOURTH POPULA? ION AW) HEALTH4 PROJECT

Financing Plan by Summnary AcoOunts(US$ Million)

JAPAN NET NORAD ODA SIDA IDA GOVERNMENT Total LoCal-------- --------- For. (Excl. DutiesAmount % Amout % Amount % Amount % mout % Amount % Aount % Amount % mh Tx) Txo

MSb.....e. . ... .... . a..P. 500960... ..... ..... ..... ..... . ... 58 5....... ...

6.2 6.8 - 0.0 0.0 4.1 4.6 0.0 0.0 62 9 69.1 6.6 9.4 91.0 15.1 1.9 80.9 S.

- - -- - - - - - - 0.1 67.6 0.0 29 4 0.2 0.0 0.1 0.0 0.0.1 0.3 0.3 0.7 1.3 3.0 1.6 3.5 0.3 0.6 23.3 63.0 11.4 26.8 44.0 7.3 16.4 17.7 O.0.1 1.5 - 0.0 0.6 - - 0.0 0.1 2.8 42.6 0.8 11.7 6 7 1.1 0.3 6.8 0.

0. . .0 .6 1326 1- . . 0.6- 26.3- 61. ;- 12 2 24;.0 60.9 8.6 16.9 23.6 10.60.1 0.8 0.0 0.3 0.6 3.9 0.0 0.1 0.1 0.6 5.7 45.6 5.0 40.1 12.6 2.1 6.9 3.1 2.5

- - 7.5 9.4 8.3 10.3 0.6 0.6 1.2 1.6 8.4 10.6 0.0 0.0 80.2 13.3 80.2 -- - 6.0 14.7 6.65 116.3 -7.0 20.7 4.4 13.0 0.0 0.0 33 6 6 6 33.6 -- - 6.7 22.8 1.2 4.2 0.7 2.2 0.3 1.0 16.9 67.9 3.5 11.8 29.2 4.9 16.6 10.9 1.7

- - 19.1 13.4 16.0 10.6 1.2 0.8 6.4 5.9 29.7 20.8 3.6 2.4 143.0 23.8 130.4 10.9 1.7

- - 0.1 0.3 0.6 3.4 0.0 0.2 0.8 4.3 10.7 68.4 0.9 4.7 18.3 3.0 0.6 17.8 -- - 0.3 1.1 2.0 8.7 1.4 6.2 0.5 2.2 11.2 48.9 0.0 0.2 22.9 3.8 22.3 0.7-

- - 0.3 0.8 2.6 6.3 1.5 3.6 1.3 3.1 21.9 63.1 0.9 2.2 41.3 6.9 22.7 1.5.-

-- - - 0.4 17.3 - - 0.4 17.3 1.3 52.6 0.0 0.0 2.4 0.4 1.4 1.0-1.7 3.4 2.5 5.0 7.3 14.7 8.0 16.2 0.2 0.4 14.6 29.5 0.0 0.0 49.6 8.2 2.8 46.7-

1.7 3.2 2.6 4.8 7.7 14.8 8.0 115.4 0.6 1.2 1S.9 30 6 0.0 0.0 62.0 8.6 4.2 47.68

- - 1.0 7.4 2.9 21.0 6.0 43.3 1.6 11.1 I1I 7.6 0.0 0.0 13.8 2.3 1.0, 12.8-

8.1 2.0 23.3 5.8 30.1 7.4 22.3 6.5 12.3 3.0 163.4 40 4 30.2 7.5 404.4 67.2 184.0 197.6 22.9

0.6 0.3 0.4 0.2 0.6 0.4 1.1 0.7 0.7 0.4 6.1 3.7 123 2 74.3 165.7 27.6 - 165 7 -- - 1.2 6.1 2.3 9.9 0.3 1 3 0.1 0.6 8.0 34.3 9.6 41.0 23.4 3 9 0.1 23.3-

0.5 5.9 - 0.2 2.8 - - 0.2 2.8 2.4 31.4 2.1 26.5 7.8 1.3 1.1 6.6-

0.9 0.6 1.6 0.8 3.2 1.6 1.4 0.7 1.1 0.5 16.6 8.4 134.9 68.6 197.0 32.8 1.3 195.7 -9.1 1.6 24.8 4.1 33.2 6.5 23 7 3.9 13.4 2.2 180.0 29.9 165.1 27.4 601.4 100.0 185.3 393.3 22.9...... ... ........ ...5..... .. .........0..SU............5.......

- 140 - Annex 34

RANGLADESH


Forecast of Annual Expenditures and Disbursements

IDA Fiscal Year Amount Cumulative Cumulativeand Semester Disbursed Disbursements Disbursements

----- US$ Million…--------…

FY92

2nd (January 92 - June 92) 17.8 17.8 10

FY93

1st (July 92 - December 92) 17.8 35.6 202nd (January 93 - June 93) 20.6 56.2 31

FY94


FY95


FY96


FY97

1st (July 96 - December 96) 14.9 180.0 100

Closing Date: December 31, 1996.

AL ~~~~~AAAA AL LAA A LAAALA A A AA hA AA A AL A A A A A

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1-4 L~~~~A A A A AA ALLA AA A AL LA AALL A AA AAA A AL A A AL

L ALA A ALAAL A LA ALA A

L A A A ALAL AAA A A ALA ALAALA A AA ALA A ALALAAL A A AL ALAL A

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46 L~~~~~~~~ AAAA A ALL AA AL A A A ALALA A L A AuAA A ALLALA ALAAAL AAAA AL AAA A ALA A A AL LAA

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00 f244 * - E4 * 1 * 4) - ) > e 0* *4 0 *4la S d OO'. E-4 4 .- 4 1 > J'- 4 -4 .-40000 '4 1 0 10 '4. 0 4 >. .4 4 01400--0 Al20M~o V 1 a- 0.40to~ 0~ 0tg4464o a. 0 0 3 4 460~4- r mu C w() 46446 6~ 4U E00 fd g:~4114i22O4 C4c 14 Su 03

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* 10toId U.4 - 46U t J .14A0 1Q >'o 46 C4 0 0~ .OI j4 -44)0 4464 J4 Z $0 : 0 1~~~~~~~~ .4i )QW04iudo Mi $ J1 0064J > .14 c oacu 1404co ua

43 > 4 to0.14D .4 4p 0.13 4 0- 4 U 46 0 0 r2 4 4 46'Id40M0 0a . 4 -f%

> a4 46014$0$ 0 iJUJ- -4 0 4.144-A 0 $4 C4: I * 0% 0 p460I:r. 3 .4-4 00.14 *4 64 -446 0 0 0 0 * 0 ^ u * * 00a 4 * - 0- or 4 0z E E) 04 z m U) O4 * - - - - * g *- 2 z

X 0-4H.D~0.~i *a.a~O~~ z -i*W * *

a * - - * ^- - * - * ^ - * * *^ - * qpr

- 142 - Chart 1

DANGLADESH

FOURTH POPULATION AND PATI PROJECT

Organization of the Ministry, Health and Family Welfare Program

| IUnlXr of H alfh and ftn0y Wdtuee

.~~~~~ -

. | 8~~~fecroty of Heaanh and Famlly Wslfare

Addtlnal Soetuy

. ASeoretly ann. r - t eW - SCtS

Dy. Sec. Dy. Sec. Dy. Sec. DY. Sec. DY. 8ec. DY. 8ec. Dv 8ec. DY~e8e. DY.Seo.General Personnel DlasM"ne Health ealt"h Health 0iN l673Admn. Adnn. Admn.-2 Admn.-3

Jt. Sereay, Helth, Education and Manpower Devlopmnt

I I IDY. See. DV.Sec. DvSeo.

-eh du. rfinng Oodand HumanResource

Devebopment Jt. Sectbso Planning and Development

I III Dv. Chte~~~~~~~~~~~~f Dy. Chief Dvhb

D aesthi FWPlanning MoLnLongandPlanning Development Construction

Development

(1) Director General of Health ServIces

I I I I I I I I IDirector Director Director Director DIr,otor Dlrector DIrector Chief ChiefAdmn. PHC Hospital Med. Health Drug Health Healkh Heath

Edu. Planning Admn. Med. Edu. IntomatlonStores Bureau UnIt

(2) Director General, Family Planning Services

I I I I I IDirector Director Director Director Director DirectorAdmn. iEM MIS MCH Logistis Finance

Services and Supplies

Supervision Directorateand Regional Dlrectors

(3) ODrector General, NIPORT

I IDirector DIrectorTraining Research

(4) Directorate of Nurding Services

Director Nursing Services

Dy. Dlrector NursIng Services

Asst. Director Nursing Servicessa&4855

- 143 - Chart 2

BANGLADESH

FOtJRTH POPULATION AND HEALTH PROJECT

Organization of the Rural Health and Family Welfare Program

1s.'rict Level MCovi eon(64~~~~~~~~~~~~~~~~~~~~~~~~~~~~ela Offce) icOlecorOeputvOlredors Clvil Surgeon's

(64 Offices) FP (;4) MedOica 'Jnce

Asst. Directors Surgeon's Office (26)(64)

UpazRla Level(397 Rural ' H

MO MCH FPO UHFPO

SFWV FWV

4, 4 I I I I

UInion Level \%FV A O (4,403 Unions) ,

\^ Pharrn~~~~~~acists r MA M ecss((MAs Pharmacists e

4~~~~~~~~~~~~~~~~~~~~~~~ 4',

t~~~~~~~~~~~~~~~~~~~~~~ \'

Wnion Level FWAs MA.

(13,500 Wards) L 2: Ws00 21 BOO

(4-3 : AdmlniUoasve Supervi)on

. -* . * *.*: Technical Supervison

sM.dshw4ai5ss

- 144 - Chart 3

BANGLADESH


NIPORT Organization For Traini4

Director General of NIPORT

Director DirectorTraining Research

Curriculum Specialist

t I - I I - - l Dy Director,I I ~~~~~~~~~Adronn

Evaluation Deputy Dretor DeputI Director S ifStJ OtI AudioSpecialist Training ~ ~ (Traning) (8)wst

Admn. Officer

instr ors(5)

Asst. Director Asst. Director Asst. Director Asst. DirectorDhaka Chitagong Khulna Rajehahi

eadshv4864Sd

- 145 - Chart 4

BANGLADESH

FOURTH POPULATION AND EALTH PROJECT

MCH Program Organization

Secretary of Health and Family Welfare - Natlonal MCH Coordination Committee

Additional Secretary

mcII Jt. Secretary it. SecretaryJt. Secretary Jt. Secretary Jt. Secretary Coordinatlon- FW HeadhCell He

Director General Director General Director GeneralHealth Services (FP/ CH) (NIPORT)

Addn. Dlrector General IHealth Services Director Project Director

MCH TBA Training ProjectServices

Director Director DirectorPHO Ho Ital Admn.

Project DirectorDirector Diarrhoeal 8 MedIcal College Hospitals Divisinal DirectorEPI Disease (Providing Obstetrical and (F

Control Paediatric ServicesProJect

I Deputsr Director -O t. MCHCordI (F ') Committee

Deputy DirectorDivision

CiilSurgeon Diet. HospitalI ?Providln Asst. Director

Services Up ziaUpasilas MC" FPOCoordination UpazlaCommittee Health

and FamilyPlanningOttice upZn Asat.

FPO

MOs EPI MOe Obgn. ParmeicalCOD s2yllst' Speclaists I

SFWVs FWVs

FVWs MAs

FWVs TBAs

eads&4S54Sc

MAP SECTION

4

<~~~~~9 90 9?. .9?

BANGLADESHft )nX A T FOURTH POPULATION AND HEALTH PROJECT

* District Headquorters District BoundariesA-1 PA-1;JD Division Headquarters Division Boundaries 62b' @& f; National Capitol International Boundaries

~~~~~> \ -;-- .. '...

~~~~ / .I INDIA

25' 4 :5:f ~ ~ ~ ~ ~ . ( *u I__- rv<4s5 ~ t #

/ > ?1.' - ,t _

24' S S ,r,N59f-f )+4' > ',>K a ^ I|N D I 24% s . <,3>F- f

yN, JRAI C.Kl S iS~~ARIATpuR hADR.,/

I SSOR~A Nj f 7RAJ>I"

23 INDIA K .

I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~N A ., xS+Sa)L \4 '\

(T~~~~~~> ) z J?H:] (S Ch1rr?$ PGA FrAf

~~ j~~BHOLA htgn@

rtI e m0 has of fie w|The ods ,s,d -0-St for V-J RGUNA ,o8d0,0 ?nds e,o& toB/ PATTYA- tle/so IterOtla V?? ~ 1 / A Y , ene fhe ?r nF- Aqnet r( } C,04ot o0&,' The denoOwW,o,,s / V22° usd atd VWe howof O St-OlO

f?rt fO Tle ;00r 0 Worl d 8* lIt.

o? anr M- Ce?ro ay. cox's LA-MA

BANGLAOER ( BAZA

INDiA MYANMAAR o Swa,

') '0 10 20 30 40 50 MLES MYANMAR

210 I I ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~210--21° o 20 40 60 80 KILOMETERS

>\

I SRI LANKA 900 9o 9l-_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _9_ NI

World Bank Document...This report Is based on the findings of an approloal mission which visited Bangladosh In November 1990 comprising 47 msmbers of the Bangladesh Population and

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