Forty-four years ago, it would have been hard to imagine that today, Bangladesh would be a $130 billion economy, producing sufficient food to feed 160 million people, almost reaching replacement-level fertility rates, and poised to achieve many of the Millennium Development Goals. Despite difficult odds, the country has made considerable progress -- overcoming floods, cyclones, and drought, and achieving progress in the health sector.
Part of the success in the health sector is due to a change in approach. Moving away from many independent health projects based on a disease (HIV, malaria) or an issue (maternal health, nutrition), Bangladesh introduced a sector-wide approach in 1998.
This approach integrates an essential package of health services. It began with a health and population program led by the government and funded jointly by the government and development partners.
This was followed by an integrated health, nutrition, and population program and a similarly-focused follow-on program. A retrospective evaluation of these three sector-wide approach programs reveals considerable progress as well as areas that have been less successful.
These successes are quickly recapped here:
• Successful improvements in financial management and funding available for health services, from $80 million to $1.8 billion from 1998 to 2011, enabling the ministry to plan and implement essential health, nutrition, and population services at scale
• Improvements in program design and implementation
• Strengthened capacities for monitoring and evaluation (M&E) at the Ministry of Health and Family Welfare (MoHFW) compared with previous single-sector programs
• An improved procurement and supply chain management system
• An increased leadership role for MOHFW in planning, administration, and monitoring and co-ordinating activities with and among various development partners.
However, despite these successes, some aspects of the health sector and the sector-wide approach were less successful:
Hybrid modality
The sector-wide approach in Bangladesh’s health sector can be considered a hybrid between a project approach and a sector-wide approach. Whilst the choice of the sector-wide approach achieved desired results, there were (and still are) parallel projects (mostly construction of medical colleges and hospitals) running under MOHFW, diverting resources from the sector program.
Also, a number of development activities are being implemented by non-state actors and funded and supervised directly by development partners. These projects and activities have contributed to achieving progress in the sector-wide approach, but aren’t formally accounted for by the ministry.
Human resources and training
The number of trained health care providers increased substantially and vacancy rates decreased. However, retention of physicians in rural areas is still a major problem and there have been challenges with supervision and governance.
In addition, training for managers to efficiently lead processes under a sector-wide approach needs to be strengthened to reflect appropriate skills training.
Decentralisation
The centralised planning processes inherent to the government’s systems made it difficult to achieve some reform initiatives related to decentralisation and autonomy in the ministry. Several innovations of outsourcing private agencies to provide support to the ministry were unsuccessful at delivering expected results.
Performance-based financing
With a sector-wide approach, the ministry is able to use a greater share of its assistance credit from the World Bank each year to finance eligible expenses once agreed-upon targets are met. However, different performance-based financing modalities were adopted, and none which were effective in leveraging planned changes/reforms.
Were anticipated benefits realised? In one word, yes. The sector-wide approach in Bangladesh started as a means to improve service delivery and health outcomes through better planning and co-ordination. It has helped the country to focus on critical development objectives such as service coverage and access, and has also led to efficiency gains.
It has also enabled the government to establish links between objectives, strategies, activities, resources, and outcomes and has reduced costs in terms of engaging development partners and designing programs.
