SUSTAINING ADVOCACY FOR ICPD AGENDA IN HEALTH REFORMS UNDER REGIME CHANGE: LESSONS FROM BANGLADESH ROUNAQ JAHAN COLUMBIA UNIVERSITY

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SUSTAINING ADVOCACY FOR ICPD AGENDA IN HEALTH
REFORMS UNDER REGIME CHANGE LESSONS FROM
BANGLADESHROUNAQ JAHANCOLUMBIA UNIVERSITY
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A case study of how changes in government shift
policy commitment to health sector reforms (HSR)
and ICPD agenda.
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Study based on Columbia University-IWHC
collaborative project on HSR in Bangladesh

• Data sources included
• documents and interviews with key informants
• consultations with community based Health Watch
  Groups
• authors own personal notes as a member of the
  World Bank led team negotiating reforms during
  1996-1998.

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Bangladesh adopted its first Health and
Population Sector Strategy (HPSS) in 1996 and a
five year national Health and Population Sector
Programme (HPSP) in 1998.

• .

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HPSS/HPSP introduced major health sector reforms

• sector wide programming
• integrated service delivery through unification
  of health and family planning services
• community and stakeholder participation
• decentralization and autonomy
• public-private-NGO partnership.

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Key elements of ICPD agenda were adopted.

• Goal to improve health of vulnerable women,
  children and poor.
• Client-centered Essential Services Package (ESP)
  delivered through the primary health care system.
• ESP to include comprehensive Sexual and
  Reproductive Health (SRH) and 60 to 70 of
  budget.

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• SRH integrated through unification of health and
  family planning services.
• Poor women to participate in policy/program.
• Gender issues mainstreamed.

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HPSS/HPSP marked major departures in health
programming.

• Communities and stakeholders consulted.
• Civil society included in policy dialogues.
• Population control agenda of reproductive health
  dropped.
• Prioritization of maternal health.

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• Family Planning (FP) to shift attention to both
  men and women.
• Side effects of contraceptives recognized.
• Violence against women treated as a public health
  issue.
• RTI/STI, adolescent health, safe abortion
  services taken into account.

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HSR in Bangladesh a massive effort.

• Restructuring of a national program of
  approximately 3 billion.
• Changing the service rules and training of the
  Ministry of Health and Family Welfare (MOHFW).

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Government of Bangladesh (GOB) reached a
consensus with the donors on major reform
elements in 1995 when it was led by the
Bangladesh Nationalist Party (BNP).
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The reform design survived a regime change in
1996 when the Awami League (AL) came to power and
adopted HPSS and HPSP.
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Opponents of reforms however took advantage of
the next change of government in 2001 from AL to
BNP and reversed decision on one key
elementunification of Health and Family Planning.
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The current government is again prioritizing FP.

• Policy reversal on unification justified on
  grounds of deteriorating morale of FP causing
  stagnation in TFR and CPR.
• Maternal health strategy approved in 2001 not yet
  implemented.
• Allocation for maternal health reduced.

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Implementation of HPSP stalled and GOB-donor
dialogue deadlocked since 2001.
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Questions addressed in the paper

• Why and how did the reform design adopt the ICPD
  agenda?
• Why and how did the policy commitment to one key
  elementintegration of health and family planning
  serviceschange?

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Why and how did HPSS/HPSP adopt the ICPD agenda?
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• The participatory process of HPSS/HPSP
  formulation enabled alliance building of ICPD
  advocates from civil society, donors and
  government to work on the design issues.

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The four important mechanisms for developing
HPSS/HPSP were

• World Bank led preparatory missions
• 17 task forces set up by the government with
  tripartite membership from government, donors and
  civil society
• log frame workshops on program design
• nationwide consultations with communities and
  stakeholders.

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Preparatory missions set the agenda of
negotiations.--International consultants in
preparatory missions facilitated the
participation of Bangladeshi civil society
advocates.
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Task Forces and log frame workshops elaborated
technical design issues.

• SRH advocates from donor agencies in partnership
  with GOB and Bangladeshi civil society pushed the
  ICPD agenda.
• Costing of the ESP package critical for
  comprehensive SRH.

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Community and stakeholder consultations carried
over two years

• validated the ICPD agenda
• created transparency
• facilitated consensus-building.

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Consultations organized in a GOB-donor-NGO
partnership.

• Village level consultations with service users
  and providers using PRA in 5 regions.
• District level workshops with service users and
  other stakeholders in 10 regions.
• National level GOB-NGO public dialogue with media
  participation.

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Consultations revealed consensus on

• delivery of comprehensive SRH as part of ESP
• improving availability and quality of services
• improving management and coordination
• establishing transparency and accountability
• building partnership with communities and other
  stakeholders
• decentralization.

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• Consultations indicated lack of consensus on
  services unification.

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• The health officials favored unification on
  grounds of improving efficiency and avoiding
  duplication.
• The FP officials opposed unification on grounds
  of loss of status and morale leading to
  deterioration of services.
• Female services users preferred integrated SRH
  from one stop center. But the main concern was
  getting quality services.

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Unification decision supported by

• donors
• civil society
• powerful professional groups such as the
  Bangladesh Medical Association.

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The final decision on unification taken by the
Secretary, MOHFW and the Prime Minister.
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The design of reforms initially driven by donors
but GOB and civil society on board after two
years of consultation.--GOB took ownership of
reforms and drafted HPSP without foreign
consultants.
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Why and how did the policy commitment to
unification of health and family planning change?
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GOB unified Health and FP in stages

• Lower levels unified by early 2000.
• Higher levels remained bi-furcated till 2001.
• Government approval of higher level unification
  secured before 2001 election but never
  implemented.

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In 2001 after the change of AL government, an
opponent of unification became Secretary, MOHFW
and succeeded in securing support of top
political leadership.
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Civil society remained silent on this reversal
while donors protested against it.
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GOBs policy reversal on unification facilitated
by lack of information on gains and shortfalls of
HPSP.

• Gains
• Reducing maternal mortality
• Improving ANC
• Increasing skilled birth attendants
• Reducing severe malnutrition, infant and child
  mortality

• Shortfalls
• Stagnation in TFR and CPR
• Lack of improvement in access and service quality
• Erosion of national ownership
• Lack of transparency and accountability

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GOB and donors neglected to engage civil society
and promote public accountability

• The FP lobby used data on TFR and CPR to argue in
  favor of reverting back to vertical FP services.
• The supporters of unification failed to counter
  the FP lobby through public dialogue on
  achievements and limitations of HPSP.

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Civil society advocates ignored during
implementation uninformed and uninvolved about
the government-donor contestations over HPSP and
next health program.
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Lessons to sustain advocacy for ICPD under regime
change
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Advocacy for ICPD best sustained by autonomous
civil society organizations whose commitment will
not change with shifting election results.
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Civil society advocates need to

• be informed by evidence and analysis of
  implementation experiences
• build alliances with researchers, professionals,
  community based groups and the womens movement
• pro-actively involve media.

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The government needs to

• institutionalize partnership and dialogue with
  civil society
• ensure transparency and accountability.

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Donors need to

• Support civil society advocacy organizations and
  not simply service NGOs.
• Promote independent assessment of policies and
  programs.