CASE STUDY

Improving Women's Health Through Public-Private Partnerships in Bangladesh

In Bangladesh, maternal mortality is one of the key health issues facing women. Photo credit: ADB.
In Bangladesh, maternal mortality is one of the key health issues facing women. Photo credit: ADB.

The project aimed to improve the access and use of high-quality primary health care particularly for women and girls in Bangladesh.

Overview

The Urban Primary Health Care Project strengthened and expanded primary health care infrastructure and services with a focus on the urban poor. The project provided preventative and curative services, including access to immunization, reproductive health services, limited curative care, nutrition-related services, community outreach on health issues, and assistance for women survivors of violence.

In project areas, there were significant improvements in key indicators, including under-5 mortality, maternal mortality, total fertility, child malnutrition, and control of sexually transmitted infections.

During the project design phase, a gender action plan (GAP) was developed. This plan provided analytical background and set out a series of initiatives to strengthen attention toward gender equality issues and improve access of women and girls to health services.

In addition to the GAP, other approaches that contributed to the project’s gender equality performance were pro-poor targeting particularly women and children, public-private partnership health service delivery model, and creation of awareness among adolescent boys and girls.


Project information


Project snapshot

  • May 2005: Loan approval
  • September 2014: Closing date
  • $91 million: Overall project cost
  • $30 million: Asian Development Bank loan
  • $10 million : Asian Development Bank grant
  • $18 million: Government of Bangladesh
  • $25 million: Department for International Development of the United Kingdom
  • $5 million: Swedish International Development Cooperation Agency
  • $2 million: United Nations Population Fund
  • $1 million: ORBIS International
  • Executing agency
    • Local Government Division of the Ministry of Local Government
    • Rural Development and Cooperatives

Context

With rapid urbanization in Bangladesh, the urban poor faced many unmet primary health care (PHC) needs. In 1998-2005, the Government of Bangladesh implemented the Urban Primary Health Care Project with the support of the Asian Development Bank (ADB), United Nations Population Fund (UNFPA), and Nordic Development Fund.

For this project, nongovernment organizations (NGOs) were contracted as agents to deliver urban PHC, resulting in significant gains and a decision to continue with an expanded initiative.

The second phase of the project was approved for 2005-2012 (later extended to 2014), with support from ADB, the Department for International Development of the United Kingdom, the Swedish International Development Cooperation Agency, and the United Nations Population Fund. In this phase, contracted NGOs continued to provide PHC services.

The overall purpose of the Second Urban Primary Health Care Project was to improve access to and utilization of efficient, effective, and sustainable high-quality PHC services for the urban poor areas covered by the project, with particular focus on women and girls. The project covered six city corporations and five municipalities.

Challenge


Prenatal care is important in ensuring the health of both the mother and child. Photo credit: ADB.

One of the key health issues identified during project planning was maternal mortality. In 2005, Bangladesh had a maternal mortality ratio (MMR) of 300 per 100,000 live births. There were low rates of antenatal care and births in health facilities. Therefore, maternal and child health was seen as a crucial issue to address when delivering urban PHC.

Improving PHC in urban settings has obvious gender equality dimensions, given the prominent challenges relating to maternal and child health. Improving maternal health through improved prenatal and antenatal care, attended births, emergency obstetric facilities, and community outreach is a crucial gender equality issue in PHC.

Solutions


Strengthening women and baby-friendly facilities in health care infrastructures is one of the aims of the project. Photo credit: ADB.

Provision of primary health care through public–private partnership agreements and behavior change communication marketing

The following activities were undertaken:

  • Identify the poor people through poverty assessments and household listings and ensure availability of services to them.
  • Provide counseling to parents and adult members of households on safe delivery. Improve access to basic curative service.
  • Provide counseling and motivation to husbands and adult members of household to ensure safe deliveries for women.
  • Conduct awareness sessions and door-to-door counseling, and ensure condom supplies.
  • Conduct training for staff on gender-based violence.

Urban primary health care infrastructure and environmental health

Strengthen women and baby-friendly health care infrastructure facilities (breastfeeding corner, separate toilet, etc., for both service provider and recipient) in poor areas.

Building capacity and policy support for urban primary health care

The following activities were undertaken:

  • Strengthen the capacity of local governments to plan, finance, budget, monitor, and supervise urban PHC services.
  • Promote women's employment and leadership in the health sector in recruitment and management.
  • Promote women's participation in health care institutions and forums.
  • Promote gender-inclusive monitoring and evaluation and research.

Sheuly Begum, a 25-year-old homemaker, panicked when she went into labor with her second child. Her husband, a 35-year-old security guard, immediately took her to a clinic, which was a 15-minute drive by a rickshaw in Dhaka's congested Pallabi area. In the next 24 hours, Sheuly gave birth to a healthy boy without any complications, thanks to the doctors at the Al-Haj Jahurul Islam Matri Sadan (maternity center).

This clinic is run by Khulna Mukti Sheba Sangstha, a nongovernment organization working in partnership with the government under the Urban Primary Health Care Project.

Kamrun Nahar Dolly, a doctor at the maternity center, said another day of delay could have been disastrous either for the baby or for Sheuly, or both.

"The baby could have died inside the uterus. Or Begum could have suffered fistula," said Dolly.

"The doctors here have saved me and my baby. I'm grateful to them," said Sheuly seated on a bed covered with a clean white sheet, cuddling her 5-day-old boy.

Source: Project officials of the Second Urban Primary Health Care Project.

Numbers and facts

194 deaths per 100,000 live births Overall, MMR fell from 322 deaths per 100,000 live births in 1998-2001 to 194 deaths per 100,000 live births in 2007-2010
Over 40% Maternal mortality dropped
By 25.6% Under-5 mortality rate was reduced
By 41.3% MMR was reduced
By 16.7% Total fertility rate was reduced
By 10.1% Child malnutrition was reduced
By 87.9% Sexually transmitted infection prevalence was reduced
Approximately 300% Increase in the number of deliveries in hospitals or health care clinics
Sixfold Increase in the total number of antenatal care checkups and an eightfold increase in the prenatal care checkups during 2006-2011
65.1% Proportion of married women of reproductive age using modern contraception reached
30% and 70% Women’s employment in the health care sector in the project areas grew, with 30% of managerial positions and 70% of service provider positions held by women at the end of the project
60% and 20% Female staff also benefited from the training offered by the project, comprising 60% of participants in the in-country training but only 20% in training offered outside of Bangladesh

Results

Pro-poor targeting

The project plan targeted delivering 30% of all PHC services (including medicines) free of charge. Participatory poverty assessments, based on social and economic indicators, were used to identify poor households, who were provided with health cards that entitled them to free services. These assessments were updated annually by the partner NGOs. Project-monitoring systems recorded the percentage of services used by these poor households.

Public-private partnership delivery model

A key element of the project was partnering with private sector and NGOs for the delivery of health services. Project staff identified this element as one of the key features that contributed to gender equality results. This was affirmed in a study that found the NGO-run facilities and programs to have improved health service coverage, equity, quality, and efficiency. Nonetheless, further assessment needs to be done on this model.

Gender action plan

The project design included a GAP. This plan played an important role in setting out specific activities and indicators relating to gender equality dimensions and results.The GAP included background information on gender equality concepts and the various commitments of the Government of Bangladesh to gender equality.

One of the striking features of this project includes providing awareness among teen boys and girls on their reproductive health through a three-month learning session. Every Sunday, 15 girls, from nearby schools and slum areas gathered on the second floor of the center to listen to the lecture of health workers about the changes in the bodies of teens. Topics on sexually-transmitted infections and HIV and AIDS are also tackled in the sessions.  Meanwhile, 15 boys attended a separate session  every Tuesday.

It was through this initiative that girls like Sufia Akther, 13-years old, from the nearby Bhola shantytown that houses several thousand people, learned about personal hygiene.

"I've learned here about the benefits of using clean sanitary napkins when I'm on period," Sufia said.

"Before coming here I had no idea about HIV or AIDS," says Saifuddin Ahmed, a 16-year-old slum dweller who earns a living by operating a tricycle rickshaw in Dhaka's northern Mirpur area. Through the session, he was also able to ask questions on STIs, which he initially deemed as a taboo subject to be discussed.

"I thought these are the subjects not to be discussed publicly," Saifuddin said. "Now I feel free to share the knowledge with peers."

Source: Project officials of the Second Urban Primary Health Care Project.

Lessons


Addressing the health care needs of all women, not just that of pregnant women, is an important consideration in the program. Photo credit: ADB.

Improving women's access to PHC

Locating health care facilities in the vicinity of poor, urban households can make health care more accessible to women and their families. Pro-poor targeting can also increase access for the poorest families, including households headed by women.

Engagement of NGOs and the private sector through public–partnership agreements with local governments is effective in expanding health care coverage to poor communities and providing employment and leadership opportunities for women in the health sector.

Improving awareness and knowledge of good health care practices

Courtyard meetings and door-to-door counseling are effective ways to raise awareness and support the adoption of good health practices, including hygiene, child health, and reproductive health.

Improving women's participation, employment, and leadership in the health sector

Preparation of a gender action plan ensures that health projects are designed with an understanding of gender-based constraints to women's participation and with procedures to overcome these constraints.

Improving data management

For the implementation of gender-inclusive policies and programs, it is necessary to ensure that data management information systems track sex-disaggregated statistics.

Scope expansion

The basic steps the project took to view maternal and child health in a broader context (such as work with men and other family members on attitudes to safe delivery) could be expanded. It is important to address men's involvement and participation in reproductive health care.

Younger unmarried women have different needs compared with married women in the middle of their reproductive years. Also, there are a multitude of factors that determine whether women seek health care and whether the health care provided actually meets their needs.

Going beyond prenatal and postnatal care

It is important to address the health care needs of all women, not just pregnant women. Although maternal health is a crucial issue, women's health needs go beyond prenatal and postnatal care.

A gender analysis or approach in PHC involves understanding how and why women's and men's health care needs differ and how to ensure that women and girls receive appropriate and equitable care from health care institutions.

NGO partnership

Questions related to partnership with NGOs that can be further explored to deliver strong gender equality results are as follows: What are the comparative advantages offered by NGOs in terms of addressing a broad suite of services related to reproductive health care and how can these be maximized? How can NGOs be encouraged to promote women as health care managers at senior levels and support their participation in decision making at all levels (internally and within the community)?

Documentation

The project completion report includes a brief summary of activities, outcomes, and challenges, but it does not match the level of detail provided in the original GAP. There is no comprehensive documentation on the challenge areas, whether all the recommended activities were undertaken, or whether there were any unanticipated results.

Understanding gender equality

The various committees that deliver high-quality health care services to the poor still lack awareness and understanding of gender equality dimensions. For example, the members of the Ward Primary Health Care Coordination Committees are not well informed regarding their roles, responsibilities, and obligations to provide women and children with equitable access to urban PHC.

Infrastructure

There is still a lack of gender- and child-friendly infrastructure with sufficient space. An evaluation of the project notes that both newly constructed centers and some of the buildings rented by NGOs do not meet current good practice guidelines (in terms of confidentiality, infection prevention, patient flow, etc.).

Discrimination

A shortage of female management staff suggests that women health care workers experience discrimination in the profession despite the growing number of female doctors and health care workers in lower management levels. Further attention to this issue is advised.

Resources

ADB. Bangladesh: Second Urban Primary Health Care Project.

ADB. 2015. Bangladesh: Second Urban Primary Health Care Project. Gender Equality Results Case Study Series. Manila.

Related links

Video: Providing Primary Health Care Services in Urban Bangladesh

 

   Last updated: May 2016

 

Meet the expert

  • Imrana Jalal
    Senior Social Development Specialist (Gender and Development), Sustainable Development and Climate Change Department, ADB

    A lawyer by profession, Imrana was a Commissioner with the Fiji Human Rights Commission. She is the author of the Law for Pacific Women, architect of the Family Law Act 2005, and former Chair of the UN Committee on Harmful Practices Against Women, and continues to be a member of the Fiji Women’s Rights Movement, Women Living Under Muslim Law, and the Asia-Pacific Forum on Women, Law and Development. Ms. Jalal is also a Commissioner on the International Commission of Jurists, Geneva.

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Disclaimer

The views expressed in these articles are those of the authors and do not necessarily reflect the views of the Asian Development Bank, its management, its Board of Directors, or its members.




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