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Evaluation database

Evaluation report

2018 Bangladesh: Effects of the Intervention ‘District Evidence-Based Planning and Budgeting (DEPB)’ for Improvement of Maternal, Neonatal and Child Health Services in Bangladesh: Results of Endline Survey in Six Selected Areas



Author: Nahid Akhter Jahan, Sushil Ranjan Howlader, Shamsuddin Ahmad,Sharmeen Mobin Bhuiyan, Nasrin Sultana, Md. Azhar Uddin, K. M. Nafiz Ifteakhar Tulon, Rafia Rahman, Farah Ishaq and Israt Tahira Sheba

Executive summary

With the aim to continuously improve transparency and use of evaluation, UNICEF Evaluation Office manages the "Global Evaluation Reports Oversight System (GEROS)". Within this system, an external independent company reviews and rates all evaluation reports. The quality rating scale for evaluation reports is as follows: “Highly Satisfactory”, “Satisfactory”, “Fair” or “Unsatisfactory”. You will find the link to the quality rating below, labelled as ‘Part 4’ of the report, and the executive feedback summary labelled as ‘Part 5’.

Background

In order to boost up the use rate of MNCH services so as to achieve the targeted objectives within the stipulated timeframe, the MOHFW of Bangladesh has introduced using the support of UNICEF a modified version of the local level planning, titled DEPB, at the primary level health facilities of Bangladesh. DEPB has already been implemented in all upazilas of 25 districts, covering about 40% of the areas. The UNICEF commissioned to IHE of Dhaka University a study for evaluation of DEPB. The study had three components: baseline, midline and endline surveys.
The base-line survey was conducted during November-December 2014, the mid-line survey was done in April-May 2016 and finally, the end-line survey has been conducted in January 2018. The base-line assessment focused on the process and preparation of DEPB, MNCH service utilization before DEPB, and the capacity of managers to prepare a local plan. The mid-line evaluation of DEPB collected information on the process of implementation of DEPB, challenges faced in implementation of DEPB, short-term effect of DEPB on MNCH service utilization, and issue of sustainability. The reports of the baseline and midline surveys have been completed and submitted earlier, in 2015 and 2016 respectively. This report presents the findings of the endline survey conducted in early 2018. 

Purpose/Objective

- to assess the level of and challenges in implementation of the intervention in the selected areas and compare the level so as to identify the factors which are congenial for intervention and the factors which obstruct the process of implementation;
- to estimate the amount of inputs used under and outputs of the DEPB intervention;
- to assess the change in the level of quality of services under the intervention;
- to gauge the effectiveness of DEPB and ascertain its cost-effectiveness;
- to identify the factors for which women may still not be using the MNCH services from the qualified sources; and
- to recommend strategies and measures for more effective implementation of the DEPB and accelerate its effects on the use rate of MNCH services.
This report presents the findings of the endline survey and estimates the effects of the intervention.

Methodology

The study uses pre-post design and the mix-method approach. Both qualitative and quantitative surveys were adopted. A quantitative survey was conducted using a structured format and detailed statistics were collected on inputs and outputs to assess the inputs used and outputs produced in the facilities. Besides, qualitative surveys comprised discussion with the managers, FGDs with the users of services and in-depth interviews with the non-users.

Findings and conclusions

Implementation of DEPB has considerably increased use of MNCH services. The increase has been brought about in the services provided at the CCs and the UHCs. The effect of implementation of DEPB varies depending on the geographical area and punctuality of fund disbursement.
Increased use of MNCH services even in the most inaccessible areas of the country
The essential ingredients were supplied by UNICEF on the supply side and services of one NGO were hired under the intervention to increase demand for services.
The magnitude of effects of DEPB in some areas is, however, lower than expected, mainly due to delayed implementation, insufficient implementation in some areas, acute remoteness of some areas, and in some cases reduction of the inputs of the regular program after implementation of DEPB.
Additional inputs can effectively work only when the inputs of the regular program exist and work properly. The problems that are prevalent in almost all health care facilities visited under the study were: decrease in sanctioned posts, vacant posts, very high absenteeism and improper input mix. DEPB, after all, is an added input to the main health sector program.
Some of the study areas are the hinterlands of the country and they are highly inaccessible. The minimum necessary infrastructural and socioeconomic conditions do not exist there for the programme to work.
One main reason for the effects of the intervention not being as high as expected is that there is seemingly a relatively elongated gestation gap between full implementation of intervention and the use of services.
More importantly, comparison of overall average costs clearly shows that intervention is economically efficient because it has reduced average costs of service provision in most DEPB upazilas.
Interestingly, use of MNCH services at the UH&FWCs did not increase or increased marginally in most of the facilities at union level even after implementation of the DEPB intervention.

Recommendations

Training on DEPB should significantly increase. Imparting of training was not adequate either in terms of number of persons trained and the duration of training.
Presence of the doctors in the facilities to be increased.  In most cases the number of providers and staffs is less than the number employed in the study upazilas. And also in most cases they do not remain in the facilities for full office hours.
Transfers to be reduced. Trained mangers and providers had been transferred from the DEPB areas to the nonintervention areas and untrained providers and managers were sent from the nonintervention areas to the DEPB areas. So it is recommended that the providers and managers trained on DEPB should be transferred within the DEPB areas or they should be retained in the facility for some years.
24/7 services at UH&FWCs and some CCs to be provided. The UH&FWCs and CCs should be made more active, especially when it comes to MNCH service provision. At present the facilities remain open for the patients only for a few hours much less than the prescribed hours. Arrangement should be made for providing services 24 hours in all days of the week. In this regard, one nurse may be appointed in the facilities to ensure provision of quality health care, especially for delivery care.
Major inputs to be identified and supplied appropriately. In the planning process, need should be assessed more accurately and broadly. Moreover, need assessment should be done in consultation with all the stakeholders of the community.
Government should allocate fund for DEPB by using finance from the pooled fund and unutilized budget. This is necessary for ensuring sustainability.
Mobile van and boats to be provided in hard-to-reach areas. .
Cohesion between the two wings of MoHFW to be increased. There is lack of coordination between  DGHS and DGFP  offices.
Referral system in the primary level public facilities to be strengthened.

Lessons Learned

Under no circumstances, the amount of inputs provided by the government to the facilities should decline after implementation of DEPB.



Full report in PDF

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Report information

Year: 2018

Office/Country: Bangladesh

Region: ROSA

Type: Evaluation

Theme: Health, Safe motherhood, pre/post natal care, low birthweight

Language: English

Sequence #: 2018/002

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