Introduction

 

Currently, around 30% people of Bangladesh reside in urban areas. As a result of rapid urbanization, this percentage is projected to increase to 60% by 2030(CIA World Bank Fact Book, accurate as of July 2011).  This rapid expansion has placed significant pressure on health services and facilities in urban areas. Although Bangladesh has a strong public sector primary health care network system in the rural areas, there is significant lacking of similar arrangement in the urban areas. Urban local bodies have been mandated to provide public health and primary health care service delivery to the residents within their administrative jurisdiction. Considering limitations and scopes, the Local Government Division of the Government of Bangladesh had taken initiative to provide primary health care services to the urban people through partnership among urban local bodies and Non-Government Organizations and with the financial support of Asian Development Bank and other co-financers. The Local Government Division had been implemented two projects namely Urban Primary Health Care Project (1998-2005) and Second Urban Primary Health Care Project (2005-2001). Evolving from previous two projects, the Local Government Division has been implementing Urban Primary Health Care Services Delivery Project (July 2012 to June 2017) with the financial support of Asian Development Bank, Swedish International Development Cooperation Agency and the United Nations Population Fund.   

 

Goal
 

The goal of the project is to improve the health status of the urban population, especially the poor, through improved access to and utilization of efficient, effective and sustainable Primary Health Care (PHC) Services.

 

Objectives 

 

Objectives of the project is to improve 


1.    Access to and use of urban PHC services in the project area, with a particular focus on services provision for free to the poor; 

2.    The quality of urban PHC services in the project area; and 

3.    The cost-effectiveness, efficiency, and institutional and financial sustainability for the urban primary health care delivery    system to meet the needs of the urban poor. 

 

Location of the project

 

The project area is comprised with City Corporations of Dhaka South, Dhaka North, Rajshahi, Khulna, Barisal, Sylhet, Comilla, Narayangonj, Gazipur and four district municipalities of Sirajgonj, Kushtia, Gopalgonj and Kishoregonj. Total population of the project catchment area is around 10 million.

 

Project Components and outputs

 

Components

Subcomponents

Outputs

A

Strengthening institutional governance and capacity of local governments

1.       Strengthening strategy and coordination framework for urban PHC

§  Implementation of urban health strategy

2.       Strengthening institutions and management capacity of LGD and ULBs for urban PHC

§  Institutional support to LGD

§  Administrative capacities of ULBs

3.       Strengthening local ownership and commitment for urban PHC

§  PHC advocacy and awareness building

§  Improved planning and budgeting for basic social services

4.       Management systems, learning and innovations on urban PHC

 

§  Urban Health Management Information System

§  Facility mapping

§  Operations research

B

Improving urban PHC service delivery system through PPP

1.       Urban PHC services delivery, including health education and behavior change communication

§  Partnership agreements

§  Behavior change communication program

2.       Effective reaching of the urban poor

§  Poverty targeting

§  Mobile services

§  Collaboration agreements

3.       Ensuring quality of PHC services

§  Health workers training

§  Equipment and drugs

§  Quality monitoring assurance

§  Performance management of NGOs 

4.       Access to urban PHC through improved infrastructure network

§  Construction of 12 new CRHCC and 26 PHCC   

§  Green clinics

C.

Project Management Support

1.       Core project management

§  Appropriate staffing and training for PMU and PIU

2.       Technical support for project management

§  Utilization of consultancy services

3.       Project financial management system

§  Modernization of FMS through computerized FMIS

4.       Training Coordination

§  Established Training Coordination Unit

§  E-learning and assessment

5.       Monitoring and evaluation

§  Household survey, health facility survey, qualitative survey  and end line survey

 

Implementation Arrangement

 

The Local Government Division of the Ministry of Local Government, Rural Development, and Cooperatives is the executing agency of the project. A Project Management Unit(PMU) headed by Project Director provides technical, administrative and logistical leadership for project implementation. PMU has been assisted by National and International Individual Consultants and Consulting Firms. A National Project Steering Committee chaired by the Secretary, Local Government Division provides guidance to the PMU. Director General of Monitoring, Inspection and Evaluation Wing of the Local Government Division is the Chief Coordinator of the project. The Health Department of the City Corporations and selected municipalities are the implementing agencies in their respective project areas through a Project Implementation Unit (PIU). The PIUs are assisted by Partnership NGOs to deliver primary health care services to the people of the project areas. Each city corporation and municipality has a Partnership Committee chaired by the Mayor. There is a Ward Primary Health Care Coordination Committee (WPHCCC) chaired by the respective local Ward Councilor and co-chaired by the female Ward Councilor and Zonal Health Officer.

 

Partnership Areas and PANGOs

 

The service delivery area of the project has been divided into number of partnership areas. One NGO has been selected through competitive bidding for delivering services in a PA Area. Each selected PA NGO has been delivering services through one Comprehensive Reproductive Health Care Centre (CRHCC), numbers of Primary Health Care Centers (PHCCs) and Satellite or Mini Clinics. The partner NGOs are: Population Services and Training Center (PSTC), Khulna Mukti Seba Sangstha (KMSS), Association for Prevention of Septic Abortion, Bangladesh (BAPSA), Nari Maitree, Unity Through Population Services (UTPS), Dhaka Ahsania Mission (DAM), Simantik, Progoti Samaj Kallyan Prothisthan and Poribar Porikalpana Sangstha (PSKP & PPS), Srizony Bangladesh, Christian Services Society (CSS) and Resource Intregation Center (RIC).

Consultants  

 

The project has provision for Consultancy Firms and Individual Consultants to provide management and technical support to the project. The firms are: Project Performance Monitoring & Evaluation (PPM&E) Firm, Behavior Change and Communication Marketing (BCCM) Firm, ICT Solution and HMIS Firm, and Operations Research Firms. Individual Consultants are : Urban Health Strategy Expert, Resource Management Specialist, PPP Transaction Specialist, Urban PHC Specialist, Procurement Specialist, Quality Assurance Specialist, Gender Specialist, Environment Specialist, Financial Management Specialist, Human Resource Development Specialist, and Training Management Specialist.

 

Logical Framework

 

Narrative Summary

Objectively Verifiable Indicators (OVI)

Means of Verification

Important Assumptions (IA)

1. Impact

Sustainable improvement in health, nutrition and family planning status of population in urban areas, particularly for the poor and women and children

By 2020, for urban population: 

·      Maternal Mortality Ratio (MMR) reduced by 26% from 194 to 143 per 100,000 live births

·      Under-Five Mortality Rate (U5MR) reduced by 24% from 63 to 48 per 1,000 live births and gender disparities eliminated (<5% difference)

·      Proportion of underweight reduced by 25% (from 46% to 35%) and stunted children reduced by 25% (from 36% to 27%) and gender disparities eliminated (<5% difference)

·      Total fertility rate (TFR) reduced by 12.5% from 2.4 to 2.1

·      Differentials in MMR, U5MR, TFR, and child malnutrition between the lowest wealth quintile and the highest wealth quintile in urban areas reduced by 15%

Bangladesh Maternal Mortality Survey (BMMS) 

Bangladesh Demographic Health Survey (BDHS)

Bangladesh MDG reports

Urban Health Survey

Assumption

Government and partner institutions remain committed to inclusive growth and reducing poverty.

 

 

2. Outcome

Strengthened delivery system and organizational capacity for sustainable provision of pro-poor urban primary health care services, focused on women and children.

 

 

 

 

 

By 2017, in project areas: 

·      At least 60% of births in project areas are attended by skilled health personnel

·      Prevalence of underweight and stunted children reduced by 20% (<5% difference between sexes)

·      At least 60% of eligible couples use modern contraceptives

·      At least 80% of poor households are properly identified  as eligible for ‘red-cards’ and access UPHCP health services when needed 

·      Increased commitment of urban local bolides (ULBs) to urban primary health care, as evidenced by (i) at least 50% increase in overall allocation to the Urban Health Sustainability Fund, compared to UPHCP II, and (ii) at least 10% of ULB development block grants are allocated for primary health care and public health related services

Project Baseline and End-line surveys (collected household, facility-based, and qualitative)

Integrated Survey Instrument (ISI) results

Urban Health Surveys

Status report of Urban Health Sustainability Fund

ULB Annual Development Plans

 

Assumption

GOB effectively implements investment programs and strategies for strengthening the delivery of pro-poor urban primary health care services.

Risks

CCs and municipalities have insufficient funds to implement programs and strategies for strengthening pro-poor urban primary health care delivery services

Competing needs/ politically-driven interests in allocating resources in the ULBs

3. Outputs

 

 

 

3.1  Improved accessibility, quality, and utilization of urban PHC services through public-private partnership focused on the poor and women and children

By project mid-term and sustained until completion:

Accessibility and utilization

·      At least 30% of each major UPHCP healthcare services (including Caesarian section) are provided free-of-charge to identified poor (‘red card’ holders)

·      At least 60% of identified new pregnant women in project areas have skilled birth attendants

·      At least 80% of planned construction and upgrading of facilities are functioning normally within 3 years of loan effectiveness

Quality

·      At least 80% of children consulting for acute respiratory infection receive correct treatment

·      At least 90% of UPHCP clients express satisfaction with project services 

PPP performance and accountability

·      100% of PA-NGOs achieve internal quality compliance (financial management, updated clinical registers, clinical waste management, inventory management)

Project baseline, midline, and endline surveys (household, facility-based, qualitative)

Integrated Supervisory Instrument (ISI)

Patient satisfaction survey (as part of project baseline and end-line survey)

Project Health Management Information System (HMIS)

 

Assumptions

Turnover of PA-NGO management and clinical staff is minimal, and that trained staff are retained for longer term

NGOs and Government are committed to accountability and performance in PPP contract management

Risk

Social and cultural factors(including gender) prohibiting the poor and women from accessing facility-based services

3.2                Strengthened institutional governance and local government capacity to sustainably deliver urban PHC services

Governance and capacity

·      Permanent and functional inter-agency  coordination structure for urban health established by December 2013

·      All project ULBs have a functioning health department with at least 1 staff trained in PPP contract management and core project management skills by 31 December 2013

·      Data collection and analysis are computerized through HMIS in 80% of partnership areas by 31 Dec 2014

Sustainability

·      ULBs increase their allocations by 5% per annum for basic social services (including primary health care) in their Annual Development Plans and block allocations

 

Project baseline, midline, and end-line surveys (household, facility-based, qualitative)

Project Joint Review Missions

ULB Annual Development Plans

Project training program evaluation

Project quarterly progress reports (QPRs)

Assumption

Government and LGD remains committed to strengthening local government institutions for efficient delivery of public services

All participating ULBs are adequately funded and are committed to delivering urban PHC services.

Risk

Political pressures at the ULB level divert resources and efforts away from the delivery of PHC services.

3.3                Effective project management

·      Fully-functional PMU established by loan effectiveness and PIUs in ULBs established within 3 months of loan effectiveness

·      24 partnership agreements (PAs) signed within 6 months of loan effectiveness, and the remaining 6 within 1 year of loan effectiveness

·      Fully-functional computerized financial management system (FMIS) in PAs by 31 Dec 2014

·      Timely implementation of project monitoring and evaluation surveys, follow-up of findings, data collection, and quarterly progress reporting

Project Joint Review Missions

Project QPRs 

Project HMIS

 

 

Assumption

Continuity in PMU and PIU staff and retention of capacities built overtime

Timely availability of qualified counterpart staff and government counterpart funding

Risk

Rapid turnover of counterpart technical staff due to resignation, promotion, or assignment to other government/private offices.

 

Services

 

The Project provides following services, based on the national expanded Essential Services Delivery (ESD+) package of the government:

1.       Antenatal Care

2.       Delivery Care (NVD & CS)

3.        Postnatal Care

4.       Menstrual Regulation

5.       Post Abortion Care

6.       Family Planning Services

7.       Neonatal Care

8.       Child Health Care

9.       Reproductive Health Care

10.     Adolescent Health Care

11.     Nutrition

12.     Communicable Disease Control

13.     Non-Communicable Diseases Control

14.     Limited Curative Care

15.     Behavior Change Communication

16.     Diagnostic Service

17.     Violence Against Women

18.     Emergency Transportation Service

 

Conclusion

With more than 150 multistoried constructed health care centers, largest workforce and population, the project is one of the largest projects in urban areas in the region. It is also a unique model of Public Private Partnership for providing primary health care to the urban poor, especially to the mother and children. The project does not only provide services, it also contributes to scaling up standard of the PHC services delivery system in the urban areas. With the ownership of Urban Local Bodies for implementing the project and engagement of Non-government Organization for delivering the services, the project’s ultimate goal is to establish a sustainable primary health care system for the urban population of Bangladesh.   

 

Urban Primary Health Care Services Delivery Project.
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