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MOHFW <strong>and</strong> NGOs, <strong>and</strong> separately for SMC. However,about half of <strong>the</strong> upazilas still do not have proper storagefacilities, <strong>and</strong> generally keep <strong>the</strong>ir supplies <strong>in</strong> a smallroom <strong>in</strong> Upazila Health Complexes or at Upazila ParisadBuild<strong>in</strong>gs (subdistrict adm<strong>in</strong>istrative complex), where it isnot possible to follow basic storage pr<strong>in</strong>ciples. Fur<strong>the</strong>r, <strong>the</strong><strong>in</strong>crease <strong>in</strong> contraceptive requirements could result <strong>in</strong> <strong>the</strong>warehous<strong>in</strong>g system experienc<strong>in</strong>g a shortage of space.The government undertook a number of measures tosimplify <strong>and</strong> modernize <strong>the</strong> public procurement policy<strong>and</strong> procedures <strong>in</strong> order to m<strong>in</strong>imize delays. Despite thoseefforts, delays cont<strong>in</strong>ue to hamper <strong>the</strong> procurement process.Delays arise largely due to: (a) limited technical capacity of<strong>the</strong> DGFP <strong>and</strong> MOHFW officials <strong>and</strong> Tender EvaluationCommittee (TEC) members; (b) high staff turnover atDGFP <strong>and</strong> MOHFW; (c) considerable time <strong>in</strong>volvementfor <strong>the</strong> MOHFW <strong>and</strong> World Bank Review Process; <strong>and</strong>(d) lengthy time for decision-mak<strong>in</strong>g by MOHFW <strong>and</strong>World Bank officials.The high turnover of tra<strong>in</strong>ed procurement staff <strong>and</strong> seniormanagement staff creates a knowledge <strong>and</strong> experience gap,limit<strong>in</strong>g <strong>the</strong> capacity of <strong>the</strong> MOHFW/DGFP to carry outtimely <strong>and</strong> effective procurement. Also, <strong>the</strong> TEC membersdo not have <strong>the</strong> requisite knowledge for prepar<strong>in</strong>gacceptable bid evaluation reports.Lack of adequate supportfor behavioural changecommunicationCommunication is an <strong>in</strong>tegral part of <strong>the</strong> FP programme,facilitat<strong>in</strong>g exchange of <strong>in</strong>formation <strong>and</strong> ideas to promote<strong>and</strong> susta<strong>in</strong> behavioural changes among differentpopulation groups towards <strong>the</strong> small family size norm <strong>and</strong>promote <strong>the</strong> use of contraception.The Information, Education <strong>and</strong> Motivation Unit of DGFPprepares various types of communication materials, suchas posters, h<strong>and</strong>bills, billboards, short television serials,dramas, radio j<strong>in</strong>gles <strong>and</strong> advertisements; however, mostsuch materials are outdated <strong>and</strong> not tailored to meet <strong>the</strong>specific needs of different client groups. Also, <strong>the</strong>re is noseparate cadre of officials at <strong>the</strong> district level for behaviouralchange communication activities.The major behavioural change communication objectivesunder HNPSP <strong>in</strong>clude: (a) encourag<strong>in</strong>g users not todiscont<strong>in</strong>ue FP use without valid reasons <strong>and</strong> to cont<strong>in</strong>uewith <strong>the</strong> option to use o<strong>the</strong>r FP methods; (b) develop<strong>in</strong>gpositive attitudes among people about longer-act<strong>in</strong>g <strong>and</strong>permanent methods <strong>and</strong> promot<strong>in</strong>g male participation;(c) extend<strong>in</strong>g behavioural change communicationactivities to hard-to-reach areas, urban slum dwellers<strong>and</strong> disadvantaged population groups; <strong>and</strong> (d) <strong>in</strong>creas<strong>in</strong>gbehavioural change communication knowledge amongservice providers for better counsel<strong>in</strong>g <strong>and</strong> good-qualitycare services. The key strategies <strong>in</strong>clude: (a) streng<strong>the</strong>n<strong>in</strong>gbehavioural change communication <strong>in</strong>terventionsat service centres, (b) improv<strong>in</strong>g <strong>the</strong> <strong>in</strong>terpersonalcommunication skills of service providers, (c) develop<strong>in</strong>g<strong>and</strong> dissem<strong>in</strong>at<strong>in</strong>g appropriate messages us<strong>in</strong>g a media mix,(d) develop<strong>in</strong>g advocacy programmes for policymakers<strong>and</strong> o<strong>the</strong>r stakeholders, <strong>and</strong> (e) promot<strong>in</strong>g longer-act<strong>in</strong>g<strong>and</strong> permanent methods (GOB, 2008a). To achieve <strong>the</strong>goals <strong>and</strong> objectives outl<strong>in</strong>ed <strong>in</strong> HNPSP, <strong>the</strong> governmentdeveloped its Adolescent Reproductive Health Strategy(GOB, 2006b) <strong>and</strong> National Communication Strategy for<strong>Family</strong> <strong>Plann<strong>in</strong>g</strong> <strong>and</strong> Reproductive Health (GOB, 2008b).Although such strategy documents, as well as <strong>the</strong> previousstrategy documents (for example, see Khuda et al., 1993a),are quite comprehensive, <strong>the</strong>ir implementation has hardlybegun. Accord<strong>in</strong>g to <strong>the</strong> DGFP officials concerned, <strong>the</strong>major constra<strong>in</strong>ts to implementation of such strategies<strong>in</strong>clude: (a) lack of adequate support from <strong>the</strong> higherlevel decision-makers, (b) <strong>in</strong>adequate fund<strong>in</strong>g, (c) lackof adequate numbers of tra<strong>in</strong>ed staff, <strong>and</strong> (d) <strong>the</strong> limitedcapacity of <strong>the</strong> DGFP pr<strong>in</strong>t<strong>in</strong>g press to pr<strong>in</strong>t differenttypes of behavioural change communication materials. Asa result, both FP users <strong>and</strong> service providers have not beenable to ga<strong>in</strong> access to relevant <strong>in</strong>formation from a coherentnational behavioural change communication programme,which promotes small family size norms, counters clients’mis<strong>in</strong>formation <strong>and</strong> misconceptions, provides clients with<strong>in</strong>formation regard<strong>in</strong>g where services are available, <strong>and</strong><strong>in</strong>forms couples about <strong>the</strong>ir FP options. Consequently,basic knowledge of FP methods is low. Provider knowledgeis relatively low, result<strong>in</strong>g <strong>in</strong> poor quality of service, which,<strong>in</strong> turn, leads to <strong>in</strong>effective use of FP methods, unwantedpregnancies <strong>and</strong> <strong>in</strong>creased use of menstrual regulation <strong>and</strong>abortion (see also Alaudd<strong>in</strong> et al., 2010).Limited fund<strong>in</strong>g <strong>and</strong> actualexpenditureTotal health expenditure (THE) was estimated at Tk.159.91 billion (US$ 2.32 billion) <strong>in</strong> 2007, up from Tk.73.8 billion (US$ 1.4 billion) <strong>in</strong> 2001 <strong>and</strong> Tk. 48.47billion (US$ 1.1 billion) <strong>in</strong> 1997. THE as a percentageof GDP was 2.7 per cent dur<strong>in</strong>g <strong>the</strong> period 1997-2000;it <strong>in</strong>creased to 3.4 per cent <strong>in</strong> 2007. Per capita spend<strong>in</strong>gon health <strong>in</strong>creased from Tk. 391 (US$ 9) <strong>in</strong> 1997 toTk. 1,111 (US$ 16) <strong>in</strong> 2007, one of <strong>the</strong> lowest levels <strong>in</strong><strong>the</strong> world. Bangladesh’s public expenditure constitutes 26per cent of THE, which is similar to that of India (25%).Private expenditure as a percentage of THE account for 74per cent <strong>in</strong> Bangladesh, 83 per cent <strong>in</strong> Pakistan <strong>and</strong> 52 percent <strong>in</strong> Sri Lanka (GOB, 2010d).116
Households pay <strong>the</strong> major share of health expenditures<strong>in</strong> Bangladesh; <strong>the</strong>ir relative share has <strong>in</strong>creased from57 per cent of THE <strong>in</strong> 1997 to 65 per cent <strong>in</strong> 2007.The government is <strong>the</strong> second largest f<strong>in</strong>anc<strong>in</strong>g agent,account<strong>in</strong>g for 26 per cent of THE <strong>in</strong> 2007, with its sharedecl<strong>in</strong><strong>in</strong>g from 36 per cent <strong>in</strong> 1997.For public sector f<strong>in</strong>anc<strong>in</strong>g, MOHFW serves as <strong>the</strong> primaryf<strong>in</strong>ancial <strong>in</strong>termediary of <strong>the</strong> government, receiv<strong>in</strong>g fundsfrom <strong>the</strong> M<strong>in</strong>istry of F<strong>in</strong>ance. Of <strong>the</strong> total amount ofpublic sector health f<strong>in</strong>anc<strong>in</strong>g, MOHFW’s share was Tk.40.1 billion (US$ 581 million), which is 97 per cent of <strong>the</strong>total public f<strong>in</strong>anc<strong>in</strong>g <strong>in</strong> 2007. MOHFW uses <strong>the</strong>se fundsprimarily by disburs<strong>in</strong>g <strong>the</strong>m to those units provid<strong>in</strong>ghealth care. In addition to its own providers, throughtransfers <strong>and</strong> grants-<strong>in</strong>-aid to NGOs, MOHFW supports<strong>the</strong> health, FP <strong>and</strong> maternal <strong>and</strong> child health activities ofNGOs (GOB, 2010d).The estimated budget for HNPSP (2003-2011) is Tk.3,738,411.05 lacs 5 , of which Tk. 2,081,764.52 lacs (56%)is from <strong>the</strong> government revenue budget, Tk. 629,911.82lacs (17%) from <strong>the</strong> government development budget,<strong>and</strong> Tk. 1,026,734.71 lacs (27%) from project aid. For<strong>the</strong> development budget, <strong>the</strong> government’s share is 38per cent <strong>and</strong> that of development partners is 62 per cent.Out of <strong>the</strong> development budget of Tk. 1,656,647, <strong>the</strong>share of <strong>the</strong> FP <strong>and</strong> maternal, child <strong>and</strong> RH programmeis Tk. 357,129 (22%) of <strong>the</strong> total development budget –Tk. 98,662 lacs (16%) from <strong>the</strong> government developmentbudget <strong>and</strong> Tk. 258,467 (25%) from project aid. Of <strong>the</strong>total amount allocated to <strong>the</strong> FP <strong>and</strong> maternal, child <strong>and</strong>RH programme, FP service delivery accounts for 56 percent, while it accounts for only 12 per cent of <strong>the</strong> totaldevelopment budget allocated to <strong>the</strong> health, population<strong>and</strong> nutrition sector (GOB, 2008a).Dur<strong>in</strong>g 2003/04 <strong>and</strong> 2009/10, actual expenditure from <strong>the</strong>revenue budget was over 90 per cent <strong>in</strong> most years, exceptfor 2005/06 <strong>and</strong> 2008/09. However, expenditure from<strong>the</strong> development budget did not follow any clear pattern,rang<strong>in</strong>g between 62 per cent <strong>in</strong> 2008/09 <strong>and</strong> 89 per cent <strong>in</strong>2004/05 (see Table 2). Thus, <strong>the</strong> allocation to <strong>the</strong> FP <strong>and</strong>maternal, child <strong>and</strong> RH programme is <strong>in</strong>adequate, <strong>and</strong> <strong>the</strong>programme is unable to spend <strong>the</strong> funds allocated to it,<strong>the</strong>reby not be<strong>in</strong>g able to achieve <strong>the</strong> desired programmeobjectives. Inefficiencies <strong>in</strong> public spend<strong>in</strong>g rema<strong>in</strong> <strong>the</strong>health sector’s most immediate challenge. Widespreadsystem <strong>in</strong>efficiencies, weak plann<strong>in</strong>g capacity <strong>and</strong> anoverly centralized approval process lead to underspend<strong>in</strong>gof available funds. Fur<strong>the</strong>r, weak accountability, limitedimplementation capacity <strong>and</strong> weak governance <strong>in</strong>evitablylead to underperformance <strong>in</strong> <strong>the</strong> delivery of public services(World Bank, 2010).The way forwardGiven <strong>the</strong> major gaps faced by <strong>the</strong> Bangladesh <strong>Family</strong><strong>Plann<strong>in</strong>g</strong> Programme discussed <strong>in</strong> <strong>the</strong> preced<strong>in</strong>g sectionof <strong>the</strong> present paper 6 <strong>and</strong> identification of <strong>the</strong> major<strong>in</strong>terventions of HPNSSP, <strong>the</strong>re is a need to adopt <strong>and</strong>effectively implement <strong>the</strong> follow<strong>in</strong>g strategies to reverse<strong>the</strong> slow<strong>in</strong>g down <strong>in</strong> <strong>the</strong> rate of <strong>in</strong>crease <strong>in</strong> CPR <strong>and</strong> <strong>the</strong>consequent stall<strong>in</strong>g <strong>and</strong>/or near stagnation <strong>in</strong> fertilitydecl<strong>in</strong>e.Need to develop a supportive <strong>and</strong>proactive policy environmentThere is no doubt <strong>the</strong> Bangladesh <strong>Family</strong> <strong>Plann<strong>in</strong>g</strong>Programme has lost much of <strong>the</strong> focus <strong>and</strong> priority ithad received until <strong>the</strong> mid-1990s. To fully achieve itsdevelopment objectives <strong>and</strong> br<strong>in</strong>g about <strong>the</strong> desiredreduction <strong>in</strong> poverty levels, <strong>the</strong> government should givehigh priority to <strong>the</strong> FP <strong>and</strong> RH programme <strong>and</strong> makeit an <strong>in</strong>tegral part of its overall development agenda;o<strong>the</strong>rwise, <strong>the</strong> demographic challenges it faces will impedeits overall development goals <strong>and</strong> objectives. Hence, <strong>the</strong>reis clearly a need to develop a supportive <strong>and</strong> proactivepolicy environment by sensitiz<strong>in</strong>g <strong>the</strong> political leadership<strong>and</strong> o<strong>the</strong>r stakeholders about <strong>the</strong> grave dangers of <strong>the</strong>cont<strong>in</strong>ued relatively high population growth rate <strong>in</strong> <strong>the</strong>country. Also, <strong>the</strong>re is a need for a more <strong>in</strong>clusive strategy,<strong>in</strong>volv<strong>in</strong>g greater <strong>in</strong>volvement <strong>and</strong> participation of allo<strong>the</strong>r m<strong>in</strong>istries concerned, NGOs, <strong>the</strong> private sector <strong>and</strong>professional groups. The political leadership should renewits commitment to conta<strong>in</strong> <strong>the</strong> rate of population growth,as it had until <strong>the</strong> mid-1990s, <strong>in</strong>stead of putt<strong>in</strong>g <strong>the</strong> issueon <strong>the</strong> backburner.With <strong>the</strong> end<strong>in</strong>g of HNPSP <strong>in</strong> June 2011, <strong>the</strong>government was <strong>in</strong>volved <strong>in</strong> design<strong>in</strong>g its next five-yearHealth, Population <strong>and</strong> Nutrition Sector Strategic Plan(HPNSSP), which would conclude <strong>in</strong> 2016. That Planrecognizes <strong>the</strong> demographic challenges faced by <strong>the</strong>country. The overall objective is to achieve replacementlevel fertility by 2016. The Plan is aimed at rais<strong>in</strong>g CPR to75 per cent from 56 per cent <strong>in</strong> 2007 (GOB, 2010e). Thetarget appears ambitious, imply<strong>in</strong>g a 2 per cent <strong>in</strong>crease <strong>in</strong>CPR annually. However, given <strong>the</strong> considerable unmet needfor contraception, <strong>the</strong> target can be achieved, though withmajor modifications <strong>and</strong> overhaul<strong>in</strong>g of <strong>the</strong> programme.HPNSSP has identified a number of <strong>in</strong>terventions <strong>and</strong>modifications to <strong>the</strong> FP programme aimed at facilitat<strong>in</strong>ga fur<strong>the</strong>r decl<strong>in</strong>e <strong>in</strong> fertility. These <strong>in</strong>clude <strong>the</strong> need to:(a) promote <strong>in</strong>creased use of FP before <strong>the</strong> first birth; (b)provide better counsel<strong>in</strong>g on side effects; (c) hire additionalfieldworkers <strong>in</strong> low-perform<strong>in</strong>g regions; (d) hire, tra<strong>in</strong> <strong>and</strong>update programme personnel; (e) improve delivery ofFP as part of post-abortion care; (f ) use different servicedelivery approaches for different geographic regions; (g)117
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Family Pla
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ForewordThe Asia <
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Part 1Part 1Asia <
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Ensuring that <str
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of methods for all, in</str
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and undertake <str
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Report on the Regi
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SESSION 1: Changin
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that improving <st
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at a hospital would be offered post
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Bounkoung Phichit, Deputy M
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medicines
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Thus, while knowledge of modern met
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Hon. Mr. Malakai Tabar, Chairman, P
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curricula. If the
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dialogue as well as regional <stron
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BackgroundGlobal development effort
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TableTable1EventNational policyYear
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A third observation is that reporte
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TableTable2Current Contraceptive Pr
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Figure(-1.2), Cook Island</
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FigureTableTable3Trends in<
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Nam. Nearly all economies i
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2008 2009% Bilateral % Multilateral
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family planning wi
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IntroductionFamily
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Page 77 and 78: FigureFigure1Oceania and</s
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Page 96 and 97: The concept of “unmet need” has
Page 98 and 99: TableTable8Percentage of th
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Page 110 and 111: 15 Tests of statistical significanc
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Page 131 and 132: ConclusionThe Bangladesh Fa
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Page 139: IntroductionThe use of contraceptiv
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Page 154 and 155: the north
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Page 158 and 159: TableTable11 Total fertility rate <
Page 160 and 161: End Note1The first camp was success
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Page 166 and 167: Figure1980s and ex
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in development has
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__________ (2007). Population <stro
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170
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TableTable2What has the</st
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174
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per cent of women reported us<stron
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is provider bias that such methods
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TableTable7skewed distribution of h
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TableTable8TableTable9182
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that of the nation
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TableTable12 7some policies that ex
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The system guides the</stro
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FigureFigure4Total donor expenditur
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FigureFigureagain
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Impact of family plannin</s
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marketing of contr
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United States Agency for In
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200
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acceptable. From an NGO perspective
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FigureThis trend of limited donor f
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Figureto have the
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FigureFigure5Percentage change <str
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FigureFigure6Desire to limit childb
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coordination betwe
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the 1980s
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Policy Management.__________ (n.d.,
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218
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Population Activities (UNFPA) for a
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where family plannin</stron
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Thus an objective assessment of <st
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226
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Figureeconomic growth durin
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TableTable1TableTable2For spac<stro
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eflect a provider bias (e.g., <stro
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The Indonesian delegation was very
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than in ensur<stro
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in-country <strong
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(Ministry of Healt
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242
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244
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FigureTrends and p
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TableTable3Unmet need for contracep
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TableTable5TableTable6TableTable725
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TableTable8TableTable9Malaysia, abo
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previously mentioned is based on fo
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TableTable16births and</str
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FigureFigure3TRF54.5Scatter plots o
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ReferencesAng, Eng Suan (2007). Stu
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Demographic data sheet: population
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population size, with just 336,000
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NuptialityIn Myanmar nuptiality is
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FigureIn Myanmar, birth-spac<strong
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Scope of coverage and</stro
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FigureIn Myanmar, out of six select
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equirements. The Min</stron
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according to <stro
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Adolescent sexual and</stro
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FigureHIV/AIDS. An HIV-positive wom
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National Population PolicyMyanmar i
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Linkages with o<st
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TableTable4Achievements of Myanmar
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monitoring <strong
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Nay Pyi Taw, 26 October 2010.53 Sit
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292
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294
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TableTableA296
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dispense and adm<s
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(1) I am against a
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FigureFigureFigure3Use of modern co
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FigureFigure7Traditional method use
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Figureprojection, and</stro
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Figure 11 summarizes the</s
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correlating <stron
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Figurethe use of c
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FigureFigure15Sexual behaviour <str
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track the distribu
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Figureservices, which should <stron
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FigureFigureFigure18 Population <st
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National Statistics Office, <strong
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TableTable11326
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TableTable19Laws and</stron
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worker and hours w
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334
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336
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includin</
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TableTable1Contraceptive prevalence
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These results suggest that about 70
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2 The (period) TFR is the</
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346
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FigureThe existence of traditional
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Guinea case by <st
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The establishment of provin
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provide family plannin</str
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Figurelegal requirement nor a condi
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FigureTableTable5TableTable6Figure4
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modern method and
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married or in unio
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Figureolder. Both the</stro
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TableTable15The immediate past Nati
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out that the “ne
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Commodity securitySupply cha<strong
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is able to achieve. In Papua New Gu
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Qualitative assessments by a number
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increasin<
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service delivery poin</stro
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Population: Views from Men
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1545-1730Day 2: December 9Session 2
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Day 3, December 10Session 50830-100
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15Mr. Tong Sithen1
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54Ms. Shadiya IbrahimAssistant Repr
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93Mr. Melkie AntonProject OfficerUn
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131Dr. John P. SkibiakDirectorRepro
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International <str
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