Attachments
Executive summary
Bangladesh is affected by a critical under-nutrition rate. According to the Bangladesh Demographic Health Survey (2011) global acute malnutrition has increased from below emergency thresholds in 2009 (13.5%) to above the threshold 15.6% for global acute malnutrition (GAM) and severe acute malnutrition is above alert levels: (SAM) 3.5% in 2009, increasing to 4.0 % in 2011.
Action contre la Faim (ACF) has been working in Bangladesh since 2007 and in Satkhira district since 2011. The SMART Survey conducted in 2014 revealed that the district has a GAM rate of 13.8% (10.8 - 17.3 95% C.I.) and 29.0% (23.8 – 34.8 95% CI) chronic malnutrition. Since 2011 ACF has been supporting the District Health Management Team to integrate management of acute malnutrition as routine activity in health facilities. Despite the improvement, challenges still exist with regard to the integration of the treatment of acute malnutrition within the health system.
The management of acute malnutrition has recently shifted from an intervention through the government health facilities via a local NGO toward a broader approach aiming at mainstreaming the treatment within the health system directly. Before mainstreaming the management of acute malnutrition in a horizontal approach, the health system needed to be reinforced as a whole.
In this context ACF International has developed the methodology Health System Strengthening (HSS) from diagnosis to programming – A step by step approach to conduct the diagnosis of the health system to identify strengths and weaknesses as well as address them through a programming exercise.
In consideration to ACF’s engagement in the Satkhira district, and the challenges identified in the health system, the district health authorities with the collaboration of ACF initiated this analysis in April 2014. The main objective of the exercise is to have a better understanding of the overall health system, according to the six building blocks (Governance, Finance, Service Delivery, Health Workforce, Supply and Health Information System). The community aspect was also assessed.
The process, led by a technical committee that encompassed Government and ACF representatives, involved the analysis of secondary and primary data regarding each building block. It also involved two stakeholder workshops: in one, participants, divided in groups (1 group per building block) were requested to evaluate the system against pre-defined benchmarks adapted to the national context and in another workshop, to design objectives and activities to address the diagnosed bottlenecks.
The overall diagnosis has revealed that the health system in Satkhira Districts has some adequate areas, particularly with regard to governance, and supply. However, weaknesses were identified namely the health workforce, finance, HIS and service delivery pillars. The health workforce pillar was pinpointed as the weakest pillar.
Weaknesses were also identified in each building block and these were addressed over the second phase of the health system strengthening exercise, the programming phase.
The supply pillar scored the highest. Major bottlenecks were nonetheless pointed out during the assessment: it seems that the facilities receive a fixed amount of drugs and medicine every three months and this amount is not based on requisition. Subsequently, certain drugs were out of stock too soon or the center would receive certain drugs in excess. The stock at facility level was neither properly managed (equipment and supplies not functioning or out of date) nor maintained in proper conditions (roof of the store needing reparation), the capacity of the store was also found to be small. It seemed that although facility staff alerted about the nonfunctioning equipment, no follow up action ensued. The integration in the supply chain of drugs and treatment needed for the management of acute malnutrition is still missing.
Although the governance pillar scored as one of the strong pillars in Satkhira, it was weak in certain areas.
Coordination mechanism chaired by District focal person for Health and Nutrition activities involving all partners were found to be non-existent or non-functional. At policy level, many activities exist but there is no plan to roll out the policy and the implementation of the policy is weak, for example: the district strategy and standards are set up for Nutrition services but they are not implemented.
The service delivery pillar was diagnosed borderline to weak. It seems that facilities are not providing the services according to the guidelines. Also, acute malnutrition management is not integrated in the delivery system at the community facility level. On the job training or supervision is almost inexistent. According to the assessment, the data collected at the health facility is not analyzed nor used for planning and budgeting. Moreso, there was both a lack of human resource, capacity and commitment in recording the data. Overall, no monitoring and evaluation plan exists for the district; interviewed key informants mentioned a lack of supervision. Another important finding was the lack of registers for case management at facility level and the absence of nutrition indicators in the overall reporting system.
The analysis of the health financing building block has disclosed that both at national and district level the investment in the health system needs to be increased. Bangladesh only spends 8% (countdown to 2015 report, see Annex1) of the total budget on health, this percentage is not enough to ensure a well-functioning health system.
The assessment also showed that the budget allocated for the totality of the Health and Family Planning activities for Satkhira in the government planning is insufficient. It was also pointed out that there was an inadequate financial support to CCs, FWCs from government side for running health facilities, small rehabilitation or maintenance such as fixing the roof of the store. During the primary data collection, 68% of the facilities did not have electricity, 40% had nonfunctional latrines and had no clean water available on site.
The human resource pillar was diagnosed to be the weakest among the pillars. Facilities do not have adequate numbers of staff and there is no scale up and down of staff according to the season and livelihood zones. The compensation and benefits system is not adequate or used in a consistent manner to determine salary upgrades and merit awards. It was also pinpointed that the job description of the health staff is neither up to date nor clear.
From the community side, from the focus group discussions, it seemed that the Community Support Groups CSGs exist but are not functional. The community was not involved in decision making nor were they asked about whether their needs are addressed. Most of the people present in the focus groups said they do not know about existing community mechanisms.
In the second phase of the HSS exercise, a programming workshop took place. Groups working in the government health structures and NGOs working in the health system in Satkhira were asked to come up with an objective and activities to address the diagnosed gaps. The groups work is embedded in the report.
In summary the objectives aimed at reinforcing the coordination mechanisms for the governance pillar, increasing the health budget allocated for the district for the finance pillar, increasing the health workforce for the HR pillar, integrating acute malnutrition management in the service delivery, training health staff for data recording and ensuring on demand supply for the health facilities of Satkhira. As the groups only had two hours to complete the work, the objectives and activities need fine tuning in the next steps before the start of the implementation.
The objectives and activities of each group will be shared with all the participants. Participants were asked to go back to their respective organizations and discuss which objectives or activities they can finance or take part in. A meeting will be held in a month by the district health authorities with the support of ACF to follow up on the district wide action plan designed with all stakeholder during this HSS exercise to reinforce the health system in Satkhira.