WHO COUNTRY COOPERATION STRATEGY,

BANGLADESH

WHO COUNTRY OFFICE, BANGLADESH OCTOBER 2000

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TABLE OF CONTENTS

1. INTRODUCTION...............................................................................................................1

2. COUNTRY SITUATION ....................................................................................................2

2.1 AN OVERVIEW OF DEVELOPMENT ............................................................ 2 2.2 HEALTH SITUATION ................................................................................ 3 2.3 HEALTH POLICY ..................................................................................... 4 2.4 HEALTH CARE FINANCING....................................................................... 6 2.5 MAJOR HEALTH PROBLEMS AND ISSUES: .................................................. 7 3. PARTNERSHIPS FOR HEALTH......................................................................................9

4. WHO’S COLLABORATION FOR WHO.........................................................................13

5. ROLE OF WHO IN HEALTH AND POPULATION SECTOR PROGRAMME (HPSP)..15

6. STRATEGIC INTERVENTION ON THE PRIORTY AREA ............................................16

7. OPERATIONAL STRATEGY .........................................................................................16

8. CONCLUSION ................................................................................................................23

1. Introduction

WHO needs to continue its contribution to global health development in the context of the

ongoing significant political, socio-economic, and demographic changes. This has called for

some fundamental reforms in the ways in which WHO conducts its business. In recognition

of this need, the Director General presented the WHO Corporate Strategy to the 105th

Session of the Executive Board (EB) as the basis for strengthening the capacity of the

Organization in the changing global environment. The Corporate Strategy as endorsed by

the EB, inter alia, provides a strategic framework for the WHO to collaborate with the

Member States more effectively and efficiently through collective and partnership action.

The Corporate Strategy identifies four strategic directions and outlines how the different tiers

of the organization can work in unison, particularly at the country level. Based on the

Corporate Strategy, each WHO Country Office in SEAR, in close liaison with the Regional

Office and HQ, is developing a Country Cooperation Strategy (CCS). Detailed strategic

directions and WHO core functions are shown in Annex 3.

The CCS is the country version of Corporate Strategy and is a strategic agenda of the WHO

Secretariat at the country level cooperation. The main emphasis of the WHO Corporate

Strategy is how to work together as One WHO, redefining the way WHO works and a priority

shift in line with the strategic directions. The challenge is a resource shift - how to align

efficiently between the corporate priorities and resource allocation. The strategic intent of the

Corporate Strategy is to engage the secretariat more in upstream policy work and

knowledge management. This is spelled out as six core functions in the Corporate Strategy.

The CCS articulates a vision and selective priorities for the work of WHO for health

development that are based on systematic assessment of country needs and expectations

as well as the country’s commitment and capacity. It reflects the values and principles and

corporate directions of WHO as one organization. It is developed in a spirit of partnership

and mutual respect with all partners in health in Bangladesh and in the context of the

country’s overall efforts for health development. CCS in turn will translate into operational

plans that are linked to regular budget and extra budgetary funding for Bangladesh in the

forthcoming biennia 2002-2003 and 2004-2005.

The Regional Office worked closely with the Bangladesh Country Office during the process

of preparation and formulation of the CCS for Bangladesh. Two background documents,

one proposed by the country team and the other by the Regional office team. The MOH&FW

also presented a document whole discussion the CCS.

The Objectives of the Mission were to:

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•= Understand the key health and development issues

•= Make and overview of the areas and magnitude of support by other development

partners

•= Study WHO’s current strategies and programme of work

•= To delineate the priorities and strategies for WHO Collaboration in the next two biennia.

During the CCS Mission to Bangladesh (Annex1 & 2), consultations were held with the

officials of the Ministry of Health, Country Office Staff, the UN Agencies and the partners.

Their contribution provided critical information for the work of the mission.

2. Country Situation

2.1 An Overview of Development

The 1997 estimated population was about 126 million. The population growth rate has

shown a marked decline in the decade of the nineties, falling from 2.0 in 1991 to 1.8 in 1996.

Male:female life expectancy ratio has shown positive trends, rising from 56.6:55.7 in 1991 to

58.1:57.6 in 1996. The fertility rate dropped from 4.3 in 1991 to 3.4 in 1996. The infant

mortality rate also dropped from 92/1000 live births in 1992 to 78 in 1996. The contraceptive

prevalence rate increased from 40% in 1991 to 49% in 1997.

The Human Development Index (HDI) value for Bangladesh in 1997 is 0.438, well below the

average of the developing countries. However, considering the HDI value in 1992 of only

0.309, the country has made significant progress in road to human development over the

past decade. Gross Domestic Product (GDP) growth rate has seen an increase from 1990-

91's 3.4 percent to almost 6 percent between 1996 and 1998. Per capita GDP also shows a

rising trend, increasing from US$277 in 1990-91 to US$337 in 1997-98. The economic

improvements are partly the result of an improved macro-economic management and a

steady increase in exports as a result of increasing private sector investment. Donor

funding has been declining over the past decade from about 8 percent in the early 90's to

about 4 percent towards the end of the decade. Most of the donor funds are project aids.

The steady economic growth has improved the poverty situation substantially. The recent

estimates of the Human Poverty Index (HPI) for Bangladesh shows that the HPI has

declined from more than 61 in 1981-83 to about 40 in 1995-97. While poverty remains

endemic in Bangladesh at above 50 percent, the situation has been gradually improving over

the years. Aggregate poverty has declined from 59 percent in 1983-84 to between 45 - 53

percent in 1995-96. The picture looks quite gloomy if we consider that some 60 million

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people remained below the poverty line of 2100 Kcal. energy intake in 1995-96 and of them

nearly 40 million people were extremely poor, with a daily energy intake of less than 1,800

calories.

2.2 Health Situation

Bangladesh's health situation is in transition. The Government has been successfully in

improving the health status of its citizens by bringing down fertility, mortality and morbidity.

Some of the communicable and tropical diseases that were once major killers have been

either eradicated or put under control. However the country is still plagued by poverty and

communicable diseases. Rapid social change and urbanization in recent years have

changed the health behavior and the life style.

Although with the improvement of some health indicators, overall health status remains very

poor. Over all life expectancy at birth is 60.8 years (1998). About 55% of children under 5

years of age are malnourished or stunt. About 70% of mothers suffer from nutritional

deficiency anaemia and 75% of pregnant women do not receive appropriate antenatal care.

Bangladesh, therefore, has a highest maternal mortality rate in the Region (390 per 100,000

live births in 1996-97).

The main causes of under-five mortality are diarrhoea, acute respiratory infections,

malnutrition, neonatal conditions, accidents and injuries. Other preventable communicable

diseases, like diarrhoea, malaria, kala azar, tuberculosis, particularly in rural areas are still

prevalent. The threat of new disease such as HIV/AIDS and the appearance of Dengue fever

are serious. Bangladesh has also a great challenge to make the country meet the target of

poliomyelitis eradication and leprosy elimination.

The aging of the population as a result of decreasing fertility and improved life expectancy

has exacerbated the current situation of rising degenerative diseases such as cardiovascular

diseases, hypertension, cancer and diabetes mellitus have also emerged as important

causes of adult morbidity and mortality, in addition to communicable diseases. Bangladesh

now therefore, faces with double burden of diseases. Besides general environmental

problems, like water and air pollution, arsenic contamination in water affects very large

number of population.

The Government is the main provider of the health services in the country, with the private

sector playing an increasingly larger role. NGOs are also involved in the provision of primary

health care in both urban and rural areas .However, with less than 40% of the population

receiving basic health care, availability and accessibility to health services continue to be a

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bottleneck in the country .Although morbidity rates improved in recent years, the disease

pattern has unchanged , infectious and parasitic diseases arising from malnutrition, lack of

hygiene and poor living conditions .Pregnancy and childbirth related illness continue to be

major threats to women's health. The reason for high maternal mortality rate include the low

nutritional status of pregnant women, the lack of access to or utilization of health care

services and domestic violence.

2.3 Health Policy

After a detailed and in-depth discussion with all the major stakeholders in the health sector

the National Health Policy has been formulated and approved by the Council of Ministers on

10 May 1999.It is being envisaged that the newly developed national health policy will

provide strategic directives to the MOH&FW for addressing the major health issues in the

country and indicate mechanism for exploiting available resources to realize the

Government’s vision within a stipulated period. The government has accepted the primary

health care (PHC) approach as a strategy to achieve the goal of HFA. PHc services will be

delivered through a four tier system, namely; a) community level through community health

workers, b) ward level through satellite clinics/health posts, c) union level through union

health and family welfare centers (HFWC) and d) Upazila level through the Upazila Health

Complex.

Aims and Objectives the National Health Policy are:

•= To improve health of the people through providing basic health -care facilities.

•= To formulate affordable and cost-effective health care strategy for the hard core rural

population in Bangladesh.

•= To improve the quality of service of domicilary as well as institutional health care at the

thana and union level.

•= To improve the nutritional status of the population, particularly of women and children.

•= To reduce the current level of infant and maternal mortality rate and initiate appropriate

actions for improving the present rate to an acceptable level within the next 5 years.

•= To ensure universal access to safe and healthy delivery practice for pregnant mothers,

particularly at the rural level.

•= To improve the present service and treatment facility for reproductive health in the

country.

•= To ensure the availability of doctors, nurses and paramedics and ensure the supply and

distribution of essential drugs, vaccines and other diagnostic and therapeutic equipment

at the Thana health Complexes and at all union health and family welfare centres across

the country.

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•= To strengthen the planning and management capabilities of the health system for

utilization and maintenance of the existing facilities to the fullest extent.

•= To introduce adequate policy framework and regulatory affairs for improving quality of

care in all Medical College Hospitals and Private Clinics.

•= To strengthen the family planning services of the country towards attaining the

replacement level of fertility by the year 2005.

•= To make available the methods of contraception of their choice to all couples of

reproductive age, irrespective of income and race through ensuring the services of

delivery at all levels.

•= To ensure and make available specialized health-care and services for the disabled and

mentally handicapped people.

•= To introduce transparency and accountability at all management levels of health care in

the country and develop appropriate and effective human resource for health in the

country.

•= To ensure advanced, adequate and appropriate treatment facilities for all types of

illnesses in the country and limit the tendency of the affluent people to go abroad for

treatment and medi-care purposes.

Fifth Five-Year Plan (1997-2002)

The Fifth Five Year Plan has set the following strategies:

•= Develop human resources through improving medical, nursing and paramedical

education on the basis of latest concepts and conventions of medical sciences

emphasizing on advanced studies/training of doctors and other health professionals

both abroad and in country and in-service training.

•= Promote adequate production, supply and distribution of essential drugs, vaccines

and other diagnostic and therapeutic equipment, etc within the country.

•= Reduce avoidable disabilities through appropriate preventive and rehabilitative

measures.

•= Provide universal access to safe drinking water and sanitation.

•= Create safe and healthy environments through prevention and control of

environmental and occupational hazards.

•= Encourage private sector to invest and participate in health care facilities.

•= Expand cost recovery process for overall sustainability while keeping the safety net

for the poor.

•= Decentralize management system and promote people's participation at all levels of

health care delivery.

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The Health and Population Sector Programme (HPSP)

The MOH&FW has launched the Health and Population Sector Programme (HPSP) in

Bangladesh in July 1998 which was formulated within the framework of the Fifth Five Year

Plan through wide range of consultation with the developmental partners.

The goal of HPSP is to improve and health and family welfare of the population in

Bangladesh, particularly of the most vulnerable women, children and hardcore poor section

of the population in Bangladesh.

The HPSP is expected to guide reforms of the health and population sector. The entire

HPSP will cost Bangladesh around US $ 3.2 billion over the next 5 years and represents a

major step forward for the health and population sector reform in Bangladesh. Out of this,

the MOHFW will contribute approximately 70% of the proposed budgetary outlay of the

HPSP (approximately US $ 2.3 billion) while the World Bank and its co-financiers will

contribute the rest 30%. The HPSP is providing a sector-wide framework for the MOHFW

for implementing major health-care reforms in Bangladesh.

The vision outlined in the HPSP include: Priority in the allocation of public-sector

expenditures to support services for the poor, vulnerable groups, especially the poor women

and children; provision of an Essential Services Package (ESP); Gender sensitive, pro-poor

and client-focussed services; Ensuring stakeholders participation; Programme management

based on a sector-wide approach and decentralization; and re-structuring of an existing

bifurcated health and family planning service provision through a unified structure.

2.4 Health Care Financing

Health care financing system is operated through Governments revenue and development

budget. Estimated expenditure amounts to 6% of the total government budget. Large part of

revenue expenditure is incurred for salary support of the government employees and

development expenditure is utilized for health developmental activity. A significant part of

development budget comes from the external sources which includes World Bank and co-

financiers, bilateral donor agencies as well as UN agencies like WHO, UNICEF, UNDP.

The amount of external assistance from external sources to the health sector was Tk.674

crores or $168.5 million (assuming $1=Tk.40) during 1997-1998. Thus foreign assistance

accounted for 61.00 percent of the development expenditure of the health sector.

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Expenditure for health and population sector has been growing steadily. The major part of

funding was channeled through HPSP. Which is supported by a consortium of World Bank

and ten bilateral donors. WHO plays a key role as a technical agency as well as executing

some of the components of HPSP.

Although there is a clear government policy that all citizens will get free services in all

government facilities, informal and unofficial charging is widely practiced. The Baseline

Service Delivery Survey for HPSP was conducted in 1999. It was found that 22% of people

make an extra payment to the workers when they visit government health services and 27%

pay an unofficial registration fee. However, over half of people surveyed responded that they

are willing to pay for improved government health services.

2.5 Major health problems and Issues:

Eradication of Poliomyelitis

Bangladesh is one of the 6 countries in the world where there are large reservoirs of

poliomyelitis. 29 wild poliovirus has been detected in the year 1999.

STOP Tuberculosis and Elimination of Leprosy

Tuberculosis is a major public health problem in Bangladesh. About 50% of the population

in Bangladesh have chances of getting contact with the causative agent and nearly 300,000

new cases are reported every year and approximately 60,000 deaths are attributed due to

TB in Bangladesh every year.

However, following the introduction of DOTS strategy for detection and cure of Tuberculosis,

Bangladesh has achieved a cure rate of over 80% for TB. More than 85% of the population

in the country has been brought under this initiative through successful partnership between

the GOB, WHO, NGOs other stakeholders and the community. It is also expected to

achieve.

Bangladesh has also targeted for leprosy elimination by the year 2000 and has launched the

National Leprosy Elimination Campaign (N' LEC) in order to strengthen Early Detection and

Treatment of cases with Multi-Drug Therapy (MDT) and raising awareness of the community.

Nutrition

The latest survey conducted by the Bangladesh Bureau of Statistics in 1996 indicated that

•= About 95 % of children under the age of 6 years are suffering from various grades

of malnutrition.

•= About 42-50% babies are born with less than the minimum weight of 2.5 kg.

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•= More than half of the under-5 are stunted.

•= More than half of mothers have been found to be acutely malnourished.

Under the National Plan of Action on Nutrition (NPAN), the MOH&FW has initiated a pilot

project entitled Bangladesh Integrated Nutrition Programme (BINP) with a view to reducing

malnutrition in Bangladesh, particularly amongst the women and children under 2 years of

age. The programme includes ensuring of house-hold food security, behaviour change

related to food intake, infant feeding, growth monitoring, caring practices, etc, aiming at the

attainment of the goals stated at the International Conference on Nutrition (ICN).

Building upon the achievements and successes of BINP, the MOH&FW has also formulated

a National Nutrition Programme (NNP) with an investment cost of around US $ 1 billion to be

implemented in the next 10 years which will cover entire Bangladesh.

Reproductive Health Maternal mortality in Bangladesh is in the range of 3.0 deaths per 1,000 live births, making it

one of the highest in Asia. Associated with this high ratio, the health of Bangladesh women

is compromised by anemia, reproductive tract infections, unsafe abortions and many other

obstetric complications. Contributing factors are poor nutrition, women's low status and lack

of access to services. Over two thirds of pregnant women do not receive antenatal care and

are not assisted by a trained person during delivery.

On the basis of pilot programmes undertaken by MOH&FW with assistance from UNICEF,

VVHO and UNFPA and learning from international experience, a new system for maternal

health has been developed which are being gradually put into place in the next five years

under the HPSP.

Emerging and Re-Emerging Diseases

The spectrum of infectious disease is changing rapidly in conjunction with dramatic scio-

economic and ecological change. While the age old disease, such as cholera and

tuberculosis continue to dominate the disease pattern in the country, others like malaria,

plague and kala-azar, which were on the verge of eradication, have re-appeared. At the

same time Cholera 0139 and HIV infection are being reported in the country. In view of this

current trend in health situation, efforts are being made to develop a new strategy for

prevention and control of emerging and re-emerging diseases including dengue and other

diseases with high health impact.

HIV/AIDS and Sexually Transmitted Disease

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With globalization, trade and economic liberalization and rapid urbanization, the country can

experience a large epidemic of HIV /AIDS cases and other STDs in the future. A total of 119

persons have been detected with HIV virus and out of this, 10 persons have been diagnosed

as suffering from AIDS. Out of these AIDS patients, 6 have died . The remaining four are

alive but are suffering from tuberculosis. However the UN estimate of HIV infection is about

100,000.

Arsenic contamination of ground water

Intensive use of land due to population pressure, excessive extraction of ground water for

irrigation, drinking and cooking purpose have been considered as the main factors for

contamination of ground water with arsenic.

The latest statistics indicate that:

•= Arsenic contamination of ground water has become an alarming public health

problem in Bangladesh in recent years. Nearly 70 million people in 59 districts (out

of a total of 64 districts) in Bangladesh are at risk of being affected by this emerging

public health problem.

•= 80,000 tubewells have been tested across the country and 63% of them have been

found to be contaminated by unacceptable concentration of arsenic (above the level

of O.lmg/litre).

•= To date, 7,000 cases of arsenicosis have been detected across the country out of

which 10 deaths have been reported due to arsenicosis. Many more are presumed

to be at risk.

3. Partnerships for Health

Overall Trends in Aid

In 1997-1998, the total expenditure (allocated) of the Government was Tk. 27347 crores, the

amount of total revenue expected from the domestic sources was Tk. 19624 crores, and the

amount expected from the external sources was Tk. 6817 crores (24% of total

expenditure).The amount of total revenue expenditure was Tk. 14544 crores and the amount

of development expenditure Tk. 12890 crores. The Government met about 52 percent of the

development expenditures out of his own revenue. The expenditure of the health sector

constituted 6.00 percent of the total government expenditure, and the revenue budget

expenditure of the health sector accounted for 2.00 percent of the total expenditure and 3.00

percent of the total revenue(Expected).

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The amount of external assistance from external sources to the health sector was Tk.674

crores or $168.5 million (assuming $1=Tk.40) in 1997-1998. Thus foreign assistance

account for 36.00 percent of the total expenditure and 61.00 percent of the development

expenditure of the health sector. The Government allocated a total of Tk.1233 crores or 6.28

percent of its total revenue to the health sector.

UN Agencies (Other than WHO)

The UN Agencies, other than the WHO, which are active in the areas of health and which

are extending technical co-operation to the Ministry of Health and Family Welfare include:

• United Nations Children's Emergency Fund (UNICEF)

• United Nations Development Programme (UNDP)

• The United Nations Population Fund (UNFPA)

• United Nations High Commissioner for Refugees (UNHCR) and

• The World Bank

In addition, there are a number of bilateral agencies such as the USAID, European Union,

the Canadian International Development Agency the Department of International

Development of UK, JICA, SIDA and other agencies.

United Nations Children’s Emergency Fund

UNICEF has contributed significantly to the tremendous progress which Bangladesh has

achieved for its children’s health over the past 25 years, despite many odds, with much of its

dense population living in absolute poverty and burdened with a high child mortality rate and

low literacy rate.

Universal salt iodization, baby friendly hospital initiative, oral rehydration therapy, vitamin A

supplementation, universal immunization and nutritional supplements are some of the areas

where UNICEF and the MOH&FW have joined hands together for meeting the basic health

needs of the children of Bangladesh.

The 1996-2000 Bangladesh Country Programme of Cooperation seeks to bring all activities

of UNICEF in line with the convention on the Rights of the Child, the Declaration and Plan of

Action of the 1990 World Summit for Children, and the Convention on the Elimination of All

Forms of Discrimination Against Women.

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In the areas of health and nutrition, UNICEF's focus is on improving the quality of services

for maternal and child health care, including building the capacity of some 60,000 health

workers and 108,000 health outreach sites. UNICEF is running three projects : Control of

Major Childhood Diseases -covering the Expanded Programme on Immunization reaching

over 19 million children, Control of Diarrhoeal Diseases, and Acute Respiratory Infections.

The Women and Maternal Health project upgrades and decentralizes Emergency Obstetric

Care facilities for some 3.8 million.

United Nations Development Proglamme: (Synergistic role for health)

UNDP is actively involved in Bangladesh, providing support to the Government for the

preparation of national programmes aimed at poverty alleviation through sustainable human

development. In the health sector, technical collaboration between WHO and UNDP has

resulted in the emergence of UNAIDS whose mandate is to strengthen the Bangladesh’s

ability to respond effectively to AIDS epidemic and to coordinate the UN systems activities in

support of the national response. Through the UNAIDS, the Government of Bangladesh is

following a multi-level, multi-sectoral approach to HIV/AIDS related issues. UNDP through

its AIDS Prevention and Control Programme is providing support to the Government by

strengthening national capacities for dealing with HIV/AIDS and by providing assistance for

pilot interventions activities through NGOs.

The United Nations Fund Population Activities: Improving Reproductive Health and

Stabilising Population Growth

UNFPA is providing comprehensive support to the Ministry of Health and Family Welfare's

Maternal and Child Health and Family Planning ( MCH/FP) programme through the supply of

contraceptives and equipment. Under the on-going Health and Population Sector

Programme (HPSP) of the Ministry of Health and Family Welfare, the UNFPA is providing

technical support in the following areas for Building institutional capacity for Reproductive

Health Care and for organization and management of reproductive health care under the

Essential Services Package (ESP) of the health sector.

United Nations High Commissioner for Refugees: Managing the displaced population.

From the health perspective, the UNHCR's programmes in Bangladesh for refugees

includes:

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•= assessment of the health needs of the Rohiyngya refugees providing technical and

financial support to the district level health authority for providing emergency and routine

health care services to the displaced population;

•= establishing epidemiological surveillance system in the refugees camps for monitoring

the mortality and morbidity trend amongst the refugee population and also to observe

health situations in the refugee camps.

NGOs

Bilateral donors execute many of their programmes in the health sector , through the work of

the NGO. While most of the NGOs are working in the socioeconomic sector and their major

work include income generation, education and social development, yet health development

is invariably a key element of their service. There is however a great deal that could be done

to improve the coordination and synchronization of the work of the NGOs and the work of the

government to reduce overlap and duplication. However, there is a general

acknowledgement that a the NGOs provide a better quality of services and are better

accepted by the consumers. Moreover the NGOs in general have a more flexible

management system, enabling them greater flexibility in decision making which makes

programme implementation easier.

The current involvement of NGOs in the health and population sector is very wide and

dispersed. Hence it is rather difficult to pin point specific areas of the roles. However, NGOs

have proved their excellence in respect of social mobilization community linkage and

targeting the poor. On the other hand, HPSP has indicated several priority areas for NGOs.

Major involvement of NGOs in future would be in area of fostering Behavioural Change

Communication (BCC) delivering the ESP and managing and providing hospital and hospital

services on competitive basis.

Banks The World Bank, under its new sector strategy for health, nutrition and population is also a

co-financier of the current Health and Population Sector Programme (HPSP) of the

MOH&FW, whose goal is to improve the health and family welfare status of the population,

particularly among the most vulnerable women, children and poor of Bangladesh. The World

Bank is also assisting the Government of Bangladesh in implementing an integrated nutrition

project which focuses on children under two years -of age and pregnant and lactating

mothers.

In collaboration with FAO, WHO, UNICEF and UNDP, the Bank also assisted the MOH&FW

in the preparation of the National Plan of Action for Nutrition.

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The HPSP is expected to be financed by a Consortium led by the World Bank. The other

Consortium members include , The German government (Kfw and GTZ), the British

government (DflD) , the Dutch government , Canadian (CIDA), Swedish (SIDA) and the

European Commission (EC). The initial estimates indicate that the consortium will donate

around 450 million for HPSP during the five year period.

Bilateral Donors Outside the consortium, it is also expected that other bilateral donors, such as the

government of Japan, Asian Development Bank (ADB), the government of United State of

America (USAID), Islamic Development Bank(IDB), OPEC, the Saudi government, Kuwait,

Qatar, France, Denmark, Norway, Korean etc will provide financial support to the health

and population sector.

Community Support The long term goal of community participation as enshrined in the Health and Population

sector strategy is to develop sustainable processes that lead to organized communities

working in partnership with Government for the achievement of common goal for the sector.

Local communities are already participating delivering several elements of the essential

package as, e.g., EPI and MCH. Local level planning, community involvement in

implementation, and monitoring for the ESP will be used as an entry point for such

partnerships between Government and communities and will thereby serve as a testing

ground towards strengthening local self-government and community empowerment.

Similarly, local communities will be involved in supervising the low performing areas and the

management of hospitals as they are being made more autonomous. To develop the

necessary competencies and foster needed attitudinal changes, will require training for the

adoption and utilization of existing tools and techniques for participatory appraisals, planning

, implementation and monitoring. Government functionaries and program managers would

likewise require training to prepare them for the attitudinal changes that are required for

working in a team and for going into partnership with civil society. External facilitator as well

as peer-group motivators would be needed for such processes; NGOs could act as trainers

for facilitators and motivators, as community organized processes take shape.

4. WHO’s Collaboration

Bangladesh joined the World Health Organization in 1972. Major objectives of WHO's

collaborative programmes in Bangladesh are to achieve the goals of Health for All.

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The work of WHO is carried out through its Programme Budget (PB) and implemented

through the detailed plans of action (DPOA). The DPOA of 2000-2001 for Bangladesh has

been formulated to harmonize and reconcile with the programme objectives and goals of the

Health and Population Sector Programme (HPSP). Moreover, the DPOA have been

formulated in a way that the activities would complement and supplement the activities of the

HPSP for ensuring technical backstopping of the WHO's technical resources for HPSP.

In the current biennium 45 plans of action have been accommodated under 8 clusters. Brief

programme activities are as under:

Prevention and control of Communicable Diseases - Malaria, Tuberculosis, elimination

and eradication of leprosy and polio respectively. Epidemiological surveillance of these

diseases will be further strengthened.

Non Communicable Diseases – programmes will cover mainly of public health awareness

of the risk factors, health education for life style and behavioural changes, case

management guidelines for cancer, diabetes and cardiovascular diseases.

Health systems and community health – programmes will be in the areas of IMCI, Women

Health and Development, making pregnancy safer, development of reproductive health

strategy, adolescent health care and prevention and control of STD/HIV/AIDS. Health

systems and human resource programme will further be strengthen.

Sustainable development and Health environment – programmes are mainly targeted at

strengthening of nutrition education, food safety, promotion of occupational health, water

supply and sanitation programme and emergency health preparedness.

Social change and mental health – promotion of mental health programme, care of the

elderly, health promotion and prevention of blindness and deafness as well as promotion of

community based rehabilitation. Tobacco free initiative programme will further be

strengthened.

Health Technology and pharmaceuticals – development of revised essential drugs and

their quality control, continued action for eradication of poliomyelitis and strengthening of

blood safety programme.

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Evidence and information for policy - introduction of ICD-10, strengthening of national

health library and documentation centre, promotion of health research as well as

development of health information system.

External relation and governing body – WHO collaborative programme planning and

management including implementation monitoring will further be strengthen. Support will

provided for implementation of HPSP.

5. Role of WHO in Health and Population Sector Programme (HPSP):

The basis of WHO collaboration within the HPSP, 1998-2003 has been clearly outlined in the

Letter of Agreement (LOA) signed between the Government and WHO in November, 1998.

The goal of HPSP is to contribute to the improvement of health and family welfare status of

the populace specially among the most vulnerable groups. As per the LOA, specific tasks for

WHO will be in the following areas:

(i) Technical assistance,

(ii) Fellowships and study tours

(iii) Local training of trainers and curriculum development

(iv) Workshops and training programmes in specialized areas,

(v) Monitoring and evaluation of training programmes and workshops; and

(vi) Selective procurement of medical and biological supplies requiring

specialized technical inputs.

WHO, through its technical assistance programme will mainly be involved in the

implementation of Essential Services Package (ESP) which is the core component of HPSP.

Major contents of ESP are:

Child Health Care - providing basic preventive and curative care for ARI, CDD and

vaccine preventable diseases.

Reproductive Health Care - aims at population control measures, safe pregnancies and

delivery including emergency obstetric care (EOC), managing maternal and adolescent

health and prevention of RTI/STD/HIV/AIDS.

Communicable Disease Control - prevention and effective management of major

communicable diseases like TB, Leprosy, Malaria and Kala-azar.

16

Behavioural Change Communication - to make information and education to individuals

and communities towards improving health status, in particular, general hygiene, sanitation

and prevention of major non-communicable diseases.

Limited Curative Care - to provide common conditions and injuries. This will cover basic

first aid, treatment of medical emergencies, pain relief and promotive aspects of personal

health.

WHO, under its constitutional responsibility, has been providing technical assistance to its

Member States, in the promotion of health status of the people. Its technical expertise is

mainly directed to poverty reduction through prevention and control of major communicable

and non-communicable diseases, extension of a sound technical information base and

health research. HPSP and its strategic approach through ESP bear much relevance to the

work of WHO. Therefore, WHO will play a proactive and key role to provide a broad based

support to the implementation of ESP as envisaged under the HPSP.

6. Strategic Intervention on the Priority Health Areas

WHO’s strategic interventions on the priority health areas will have to be designed within the

framework of the six core functions. It is through this approach that it will be possible to focus

on selected tasks and maximize the outcomes of WHO-country collaborative programmes. A

brief resume of such strategic interventions is presented below. Annex 4 shows that for a

specific programme area, emphasis shall be given to each core function.

Reproductive Health:

Safe delivery, family planning, maternal nutrition, :

There are sufficiently and appropriately supported in areas of family planning and

maternal nutrition by other agencies, particularly, UNFPA and UNICEF. WHO thus

may give less strategic interventions to these areas. The focus of support should be

given to development of guidelines for management and reducing risk of abortion

and for infertility management. Partnerships with other agencies is required to build

national capacity.

Adolescent health:

Advocacy for addressing extent of problems of risk factors that may adolescent health

should be addressed. Management of information and research development is required in

17

this area to support national activity. Development of guidelines and training on life skills

among school children is considered as one of the effective approach.

STD/HIV/AIDS Management: This only area that WHO can provide best interventions among all concerned agencies.

Advocacy for strengthening surveillance, national commitment and syndromic management

will be strongly supported. Promoting partnerships, developing of guidelines and capacity

building for syndromic management as well as surveillance are priority interventions.

Information management of both will need some support. Catalytic action may be needed for

enhancing broad-based, well-informed national commitment. A long-term is required to

provide technical support to national HIV/AIDS control programme and reproductive health

as well as UNAIDS.

Child health Integrated Management of Childhood Illness (IMCI):

IMCI has been introduced into Bangladesh for quite sometime. The country still requires

strong technical support to make this integrated approach widely implemented. A long-term

staff is required to build national capacity. To make the services more effective and

sustainable, strong partnerships with other agencies like UNICEF and interested donors is

necessary.

EPI:

Although EPI is one of the most successful programme in the country, technical support is

continued to be required, particularly when new vaccine will be introduced. While incidence

of immunizable diseases has been gradually reduced, more attention has to be given to

issues of safe injections. Technical support, particularly in areas of disease surveillance,

programme monitoring and logistics distribution of vaccines has to be continued. The

country may have to prepare for measles eradication after polio is eradicated from

Bangladesh.

School health:

School is a very important hub to introduce health knowledge and skills for their well being

from school age to the elderly age. Standard guidelines for different programmes are very

important to be developed in such a way that it can be integrated into school curriculum. The

approach can be done to BCC component of ESP. Life skills training manual and capacity

building for national staff is also essential.

18

Control of communicable diseases Tuberculosis:

The country is in the expansion phase to expand DOTS strategy to cover the whole country.

WHO technical support has to be continued to help building national capacity in the new

implemented areas, monitoring programme and support clinical trial of drug combination and

operational research, particularly, in area of programme sustainability. Partnerships with

NGOs is very important to support the government in expansion coverage of services.

Standards, tools and guidelines have to be developed in the context of HPSP.

Malaria, Kala azar and DHF:

These 3 diseases should be implemented as an integrated vector-born disease control

programme. It requires WHO technical support in areas of disease surveillance, vector

control and laboratory diagnosis and case management. The support can be effectively done

through the National Committee on Integrated Control of Vector-born Diseases (INCOVED).

Emerging and re-emerging diseases:

Most of emerging and re-emerging diseases are communicable diseases and highly

infectious with short incubation period. They therefore tend spread rapidly. The most

effective strategic intervention is strengthening surveillance system to be able to early detect

of new cases and to establish early warning system. WHO technical support in areas of

strengthening surveillance, setting standard for case definitions and laboratory diagnosis,

outbreak investigation and response, as well as antimicrobial resistance test is mostly

needed.

Cross border issues: The cross border related diseases are poliomyelitis, HIV/AIDS, TB, malaria, DHF and

cholera. WHO has to play a strong catalytic role as well as technical role in supporting

common-border countries, in areas of disease surveillance, technical cooperation (laboratory

diagnosis, training, fellowship) and information management and research.

Elimination and eradication of diseases

Leprosy:

Although the country has achieve, at national level, the target of leprosy elimination, WHO

has to maintain momentum of support to country to make sure that this target (<1/10,000

population) is achieved at all sub-national levels. Existence of LTS is therefor essential to

support national control programme, particularly in areas of disease surveillance, case

finding, supervision and programme monitoring

19

Poliomyelitis:

With strong technical support from WHO, Bangladesh has made a considerable progress

toward poliomyelitis eradication. However, eradication target has to be extended to 2005.

Continued LTS support is very crucial at this stage, particularly in areas of setting and

monitoring standard of disease surveillance, strengthening laboratory capacities,

partnerships with other supporting agencies. Research to address some operational

problems may be required.

Limited curative care:

Basic simple emergency services such as minor burn, bites, fall and injuries, choking shock,

pain, high fever etc., eye, ear, skin diseases and helminthiasis are the cases that have been

identified for management by peripheral health workers. WHO should provide technical

support in developing simple diagnostic and clinical management guidelines for health

workers. In addition to children and women, special attention should be given to elderly, and

bread earners (factory workers, farmers).

WHO should also provide technical support in area of developing guidelines and training in

diagnosis and management of major Non-communicable Diseases, (CVD, cancer and

diabetis) in the secondary and tertiary health facilities.

Environmental health

Arsenic contamination in water:

The county needs epidemiologically trained health and engineering staff in area of arsenic

contamination. Support from WHO should be therefore aims at building national capacity,

either in forms of training by experts within the country or inform of fellowships outside the

country. In a long-term, the country will have local experts that can work effectively under the

government, NGOs or WHO recruitment. For a short-term support, STC (preferably national,

if available) should be recruited to support implementation of the project – Building

Community Based Arsenic Mitigation Response Capacity in 3 Upazillas of Bangladesh

(WHO-UNF/UNFIP-UNICEF). Major WHO strategic interventions are a) development of

training and information modules, b) water quality measurement, c) arsenic safe water

supply solution, d) mitigation of health effects of exposure to arsenic, e) retrospective of

health effects of arsenic and f) based line health survey and linked health research.

20

Food safety:

Food safety is critical in Bangladesh to create consumer awareness and to reduce incidence

of adulteration of oils and other food stuffs. It is further increasingly necessary to promote

export. WHO should provide more support in areas of advocacy, promoting application of

standards of food/drink quality, and strengthening laboratory capacity both in terms of

equipment/supplies and staff.

Other environmental health priorities include Health and Environment, Water Supply and

Sanitation, Acute Respiratory Infections (due to air pollution) and Harzardous waste.

Nutrition

The National Nutrition Programme (NNP) was established separately from HPSP.

Intervention strategies of NNP are based on community feeding, identification and on the

spot management of mild to moderate undernourished children and referral of severely

malnourished children. WHO should consider providing an expert (STC or LTS) to review

sustainable issues of these strategic interventions, to coordinate flow of information between

NNP and HPSP and to suggest plan how to integrate NNP with HPSP.

Health system development

Essential drugs:

Although Bangladesh has long been supported by WHO in areas of essential drugs with

considerable success in introducing national essential drug list and producing of all essential

drugs within the country, further technical support is still required. Major areas of support are

quality assurance and drug supply management.

Health Information System (HIS):

WHO has in the last 2 biennia support country to establish national health information

system (HIS). Most of systems are in places, including trained staff. There are however,

problem of quality, timeliness, completeness and analysis of data thus data have rarely been

use by policy makers for planning. This is mainly due to lack of proper supervision and

monitoring. To make this important system functional, continued support from WHO is

required particularly, in areas of monitoring, supervision and analysis of data.

Health service delivery:

WHO had support the Intensified PHC Project in 12 district of Bangladesh. Experiences

gained from this project shall be well contributed to the newly established Health System

Development Programme, under HPSP. Long term technical staff is required as a

21

backstopping to operationalize the ESP at upazila level and below, especially in areas of

planning, training, strengthening decentralized management, monitoring and supervision.

Quality assurance:

Several studies highlight the low utilization rate of public health facilities due to poor quality

of services. The main Health Care Quality Assurance Programme is reflected in the HPSP.

WHO can have a wider role in implementation of major technical activities within the QA

Work plan. WHO should also supplement support to the widening scope of selected major

activities like developing standards, monitoring programme and client satisfaction survey.

Health technology Country needs technical support for capacity building in areas of hospitals laboratories,

blood screening, monitoring of antimicrobial resistance and rational use of antimicrobial

drugs. WHO may support the country by providing guidelines and experts to conduct training

in each specific areas.

In area of blood safety, WHO should provide technical support to country to finalize national

policy on blood safety. Guidelines on blood safety practice should be widely distributed to all

blood banks and blood transfusion centers. This should be supported training of concerning

staff on blood collection, storing, and screening for potential haematological infections. Disaster management With regularly facing with emergency situation, particularly, flood, Bangladesh gains a lot of

experience in the management of this emergency situation. The latest incident in 1998,

WHO very effective supported country in relieving health problems among affected

population. This support has to be remained with country to ensure more effective response

to the emergency situation. Areas of support include building national capacity (disease

surveillance, case management, outbreak investigation), supplies of essential drugs and

vaccines. Partnerships with the UN Disaster Management Team (DMT) is very important for

a concerted effort and avoid duplication.

All the above priority health programmes require support of 2 important component namely,

human resource development and health education/communication.

WHO has continuously provided support on human resource for health, particularly in the

area of medical education. More focus support should be given to Policy Research Unit

(PRU) and Human Research Development Unit and collaboration with DFiD and CIDA.

22

Assist in developing database of institutes and trained human researces as part of HIS is

also required to facilitate evidence-based dicission making. WHO should also continue

providing import into upgrading of curricula specially for auxilliary health personnel and

implementation of revised curricula for other categories.

Some WHO priority areas like TFI, NCD, Mental Health & Substance abuse are not included

in the national priorities. WHO may support country in providing technical input through BCC,

by developing IEC materials/approach on how to reduce risk factors of above health areas.

7. Operational Strategy:

The operational strategy will take into account country needs and health challenges, the core

functions and the strategic direction in the WHO ‘s Corporate Strategy and the role and

contributions of other development partners. It includes identifying areas for change and

emphasis on function where there is a comparative advantage for WHO based on the

tenants of PHC. WHO’s limited resources need to be carefully utilized for optimal effect and

benefit. This practically implies the careful identification of priority areas where WHO is best

able to contribute. This will enable the country team to carry out the collaborative activities

more efficiently, responsibility and accountability.

There is a need to critically study the capacity of the WHO country office. The right mix of the

staff as well as the strength of human resources should appropriately reflect the type and the

load of work to be addressed. It should also take into account the resources available at the

Regional and the HQ level in the concept of One WHO. It may also draw from the

recommendations of the in-house meeting on strengthening WHO Co-operation in

Bangladesh, which took place in Bangkok in 1998.

National expertise over the years has been developed in many areas of public health. The

use of appropriately trained and deployed national expertise in project planning, programme

execution and implementation can efficiently benefit the collaboration both in terms of

national capacity building and sustainability. Where ever feasible national capacity building

activity should be strengthened. Recruitment of National Programme Managers will facilitate

better management of WHO’s work.

Health and Population Sector Programme (HPSP) is a unique programme of Bangladesh for

health development. Based on the principles of primary health care it has been formulated

within the framework of national policies outlined in the Fifth Five-Year Plan. It embraces the

issues and problems of almost all the programme areas and is also ready to accommodate

23

the new emerging issues. It is therefore necessary to ensure that the WHO collaborative

efforts are in harmony with those of the HPSP. WHO’s technical resources should provide

technical backstopping and act as a main catalyst to other donor partners in supporting the

vital health needs of the country.

Inter-country Programme approach will be another important strategy in addressing the

common issues among the countries of the member states in the region. In the spirit of the

regional solidarity, the inter-country programme activities will be formulated in consultation

with countries. It will also include the sharing of information and the use of institutions of

technical excellence available in the region.

8. CONCLUSION

The visit helped in identifying major disease areas in Bangladesh to which priority for WHO

assistance should be directed in years to come. These priority health areas include:

diarrhoeal diseases; vector-borne diseases like malaria, dengue haemorrhagic fever (DHF)

and Kala azar; acute respiratory infections (ARIs), and water-borne diseases. Among non-

communicable diseases, diabetes mellitus has emerged as a leading health problem; these

disease areas need to be looked into, together with other emerging NCDs like

cardiovascular diseases and cancer. In the area of reproductive health, malnutrition,

maternal mortality, nutritional deficiency anaemia and HIV/AIDS would call for WHO support.

Blood safety and surveillance, as also food safety are other areas of concern to WHO.

Considering that there are other partners, both international and NGOs, active in the field of

nutrition, WHO will be able to play a crucial role in the area of maintenance and

standardization of nutritional norms.

In the area of environmental health, arsenic contamination of water is another priority area

for WHO concern, besides health problems resulting from tropical storms which afflict the

country with unfailing frequency.

Moreover, WHO’s future role in Bangladesh’s health programmes would have to be aimed

more at macro issues like health sector reform, health care financing, and overall health

system development, including decentralization.

9. ACKNOWLEDGEMENT

The CCS team wishes to put on record its gratitude to WR, Bangladesh and his staff for their

tireless work during the preparatory period as well as during the team’s visit to make this

24

mission successful. The team thanks all UN partner agencies and World Bank

representatives who provided valuable inputs of their experience and working with HPSP. A

special word of thanks is also due to the senior staff of the Ministry of Health and Family

Welfare of Bangladesh who shared their experiences and views on HPSP and national

health programme.

25

Annex-1

Tentative Programme for CCS Mission to Bangladesh (04 - 11 October, 2000)

Date & Time Event Remarks

04.10.2000 (Wednesday)

15:40 hrs

(HTP & DPR) arrived by BA 145 Dr Khalilullah will join CCS team, who arrived on 30th Sept. 2000.

17:00 hrs WR to meet the team at WR Office 05.10.2000 (Thusday)

13:30 hrs to 14:00 hrs

Meeting with Prof. A B M Ahsanullah, Director General, Directorate General of Health Services, Mohakhali, Dhaka Dr. ASM Mushior Rahman, Additional Director General, Dr. Ranjit Kumar Dey, Director (Planning) and officials at DGHS, Mohakhali, Dhaka

Confirmed

15:00 hrs Courtesy meeting with Mr. Sayed Alamgir Farrouk Chowdhury, Secretary, Ministry of Health and Family Welfare through Mr. Mir Shahabuddin Mohammad, Joint Secretary (Public Health & WHO), Ministry of Health & Family Welfare, Bangladesh Secretariat, Dhaka

Confirmed

16:00 hrs Meeting with Mr. Shuyun Xu, Representative of UNFPA, UN Houses, IDB Bhaban (15th floor), Begum Rokeya Sharani, Sher-e-Bangla Nagar, Dhaka

Confirmed

19:30 hrs Dinner at WR’s Residence (Apartment Nos. 302 and 304, “Prime View” Building, Block-F, Plot No.7, Gulshan-1, Dhaka-1212)

06.10.2000 (Friday)

09:00 hrs to 16:00 hrs

SEARO team and WRO core group meeting (venue-WR Office)

07.10.2000 (Saturday)

10:00 hrs Meeting and discussions with selective Government official invitees at WR Office : Mr. Mir Shahabuddin Mohammad, Joint Secretary (Public Health & WHO), Ministry of Health & Family Welfare, Dhaka, Mr. M A Muktadir Mazumder, Joint Chief (Planning), Ministry of Health & Family Welfare, Dhaka, Prof. A B M Ahsanullah, Director General of Health Services and all Line Directors Dr. ASM Mushior Rahman, Additional Director General of Health Services, Directorate General of Health Services, Mohakhali, Dhaka. Dr. Asib Nasim, Deputy Team Leader, Programme Coordination Cell (PCC), Priya Prangon, Paribagh, Dhaka

13:00 hrs Working lunch at WR Office 14:00 hrs Work to be continued.

26

08.10.2000 (Sunday)

09:00 hrs Retreat with WRO country staff (full-day) (modalities for programme area-wise time-slotting or common meeting to be worked out with Dr Palitha Abeykoon)

09.10.2000 (Monday)

10:00 hrs Continue discussion with CCS Team with WHO core group.

15:00 hrs Meeting with Mr. Mir Shahabuddin Mohammad, Joint Secretary (Public Health & WHO) at Ministry of Health & Family Welfare, Bangladesh Secretariat, Dhaka

Confirmed

10.10.2000 (Tuesday)

09:30 hrs Meeting with Mr. Jorgen Lissner, Resident Representative UNDP, UN Offices, IDB Bhaban, Begum Rokeya Sharani, Sher-e-Bangla Nagar, Dhaka

Confirmed

11:00 hrs Meeting with Dr. B. Sorensen, Team Leader (Acting), Health, Population and Nutrition Team, World Bank, 3A Paribagh Road, Dhaka-1000.

Confirmed

12:00 hrs Meeting with Ms. Shahida Azfar, Country Representative of UNICEF, BSL Office Complex (3rd Floor), Dhaka Sheraton Annex, 1 Minto Road, Dhaka-1000

Confirmed

Hrs Report preparation 14:00 hrs HTP leave Dhaka for Bangkok 11.10.2000 (Wednesday)

- DPR & LCO (Finalization of the report)

Evening DPR & LCO leave Dhaka for Delhi (BA 144)

27

Annex 2

CCS TEAM MEMBERS

Team Members from SEARO (1) Dr. Palitha Abeykoon, Director, Department of Health Technology and

Pharmaceutical (HTP) (2) Dr. Sawat Ramaboot, Regional Adviser, Disability/Injury Prevention and

Rehabilitation (DPR) (3) Dr. M. Khalilullah, Regional Fellowships Officer (4) Dr. Kan Tun, Liaison Officer for Country Offices (LCO)

Core group members from WHO Office, Bangladesh

1. Dr. Witjaksono Hardjotanojo, WHO Representative in Bangladesh

2. Dr. Ohn Kyaw, Management Officer

3. Brig. (Retd.) Q M S Hafiz, National Programme Officer

4. Dr. A B Siddique, National Consultant

5. Dr. George John Komba-Kono, Medical Officer (PHC),

6. Dr. Derek A C Lobo, Medical Officer (Leprosy),

7. Dr. Pierpaolo de Colombani, Medical Officer (TB),

8. Dr. Don R Bandaranayake, Medical Officer (Medical Education)

9. Ms Melinda Mailhot, Operation Officer, Polio Eradication

10. Mr. Han A. Heijnen, Scientist (Water Supply and Sanitation),

11. Mr. K L Gera, Administrative and Programme Officer

Team Support Personnel

1. Mr. Sukumar C. Saha, Administrative and Programme Assistant

2. Mr. Kh. A. Ismail, Secretary

3. Ms. Shahida Akhter, Computer Assistant

28

Annex 3

WHO CORPORATE STRATEGY AND COUNTRY COOPERATION STRATEGY

The objective of WHO, as set out in its constitution, is the attainment, for all people, of the highest possible level of health.

The corporate frame policy framework of WHO is more specific and intended to enable WHO to make the greatest possible contribution to world health through increasing its technical, intellectual, and political leadership.

The corporate strategy for the WHO Secretariat reflects the values and principles articulated in the Global Strategy for Health for All, as reaffirmed by the Fifty-first World Health Assembly, in 1998.

The work of WHO, to respond effectively to a changing international environment, takes the following new ways:

•= Adopting a broader approach to health within the context of human development, humanitarian action and human rights, focusing particularly on the link between health and poverty reduction;

•= Playing a greater role in establishing wider national and international consensus on health policy, strategies and standards by managing the generation and application of research and expertise;

•= Triggering more effective action to improve health, and to decrease inequities in health outcomes by carefully negotiating partnerships and catalyzing action on the part of others; and

•= Creating an organizational culture that encourages strategic thinking, global influence, prompt action, creative networking and innovation.

To realize the goals of building healthy populations and communities and to

combat ill health, WHO has identified four strategic directions:

1. Reducing excess mortality, morbidity and disability especially in poor and marginalized populations.

2. Promoting healthy lifestyles and reducing factors of risks to human health that arise from environmental, economic, social and behavioral courses.

3. Developing health system that equitably improves health outcomes, respond to peoples’ legitimate needs, and are financially fair.

4. Developing and enabling policy and institutional environment in the health sector, and promoting an effective health dimension to social, economic, environmental and development policy.

The WHO Secretariat works towards these strategic directions through a set

of core functions that are based in the Constitution and are focused on:

•= Articulating consistent, ethical and evidence-based policy and advocacy positions;

•= Managing information, assessing trends and comparing performance of health system; setting agenda for, and stimulating, research development;

29

•= Catalyzing change through technical and policy support, in ways that stimulate action and help to build sustainable national capacity in the health sector;

•= Negotiating and sustaining national and global partnerships; •= Setting, validating, monitoring, and pursuing the proper implementation of,

norms and standards; •= Stimulating the development and testing of new technologies, tools and

guidelines for disease control, risk reduction, health care management and service delivery.

30

Annex 4

National Health Programme Areas and WHO Core Functions

Weight of WHO Core functions (median value of scale 1-4)*

PROGRAMME AREAS

Advocacy research technical Partner ship

Standard New technology

Guide lines

Safe motherhood

2.5 1 2.5 2 2 2

Family Planning Adolescent Infertility Neonatal Care

2

IMCI 3 2 2 2.5 2.5 2.5 School Health

3 3 3 4

HIV/AIDS 3 2 Stop TB 3 2 2 2.5 1.5 2 Malaria 3.5 2 2.5 2 2 3 Kala-azar 2.5 1 2 1 3 DHF 3 2 2.5 2 2 3 Cross Border Issues

Polio 2 3 2 2 1 1 Leprosy 3 2 2 2 2 2 Curative Care

2 1 1.5 1 1.5 1.5

Arsenic 2 2 2 3 3 3 Blood Safety 3 2 1 2 2 1 Nutrition 3 1.5 2 2.5 1 1 Essential drugs

3 2 1 1 1 1

HMIS 2 2 3 1 2 2 Health Service Delivery

3.5 2.5 3 2 3 2.5

Health System Evaluation

3 2 2 1 2 1

Health Technology

2 1 1

Disaster Management

3.5 1.5 2 3 2 1.5

Filaria 3 3 3 3 3 3 Medical Education

1 2 2 2 2

31

Core functions Advocacy research technical Partner

ship Standard New

technology Guide lines

ARI/Air pollution

4 3 4 4 3

Water Supply and Sanitation

4 3

Food Safety 4 3 4 3 Hazardous Waste

4 3 3 4

IPCS/Poison control

4 3 3

Health & Environment

4 4 2 4/

Noise pollution

Surface water quality and pollution control

Slum development and housing

Occupational Health

EPI 2 3 3 3 4 3 Safe Injection 2 1.5 1.5 1.5 2 1.5

* The weights of core functions are given by several technical staff working in Bangladesh,

for different WHO programme areas and then only median values of those weights are

entered in this table.