Health and family planning systems

Health services are urgently needed yet the resources available are extremely limited. Funds for health services through the government of Bangladesh are about US$4 per capita per year, so the majority of health services are obtained from non-government and private sources. Services provided are often of low quality and are especially inaccessible for the poorest groups of society even though they are intended to reach the poor.

Past programmes were doorstep-deliverable, however, while these were considered to be effective they were also considered to be too expensive to continue. Instead, community clinics were initiated in an attempt to provide services in a more cost-effective manner. The experience with community clinics has been mixed and the withdrawal of doorstep services without effective alternatives has had some negative impact on programme performance, such as with family planning and immunization. NGOs and private sector contribution to health care is increasingly being debated and these discussions will benefit from evidence from operational and health systems research.

Most families wish to limit the number of children or to space their pregnancies using contraceptives, but many still experience difficulty in using them. The use of long-acting, low-cost clinical methods of contraception is declining, and temporary methods have high discontinuation rates. The effect of this is seen in a high proportion of families who discontinue their family planning method sometimes because of perceived side effects. Unintended pregnancies are still common. Family planning programmes now approach this issue as a way to assist families achieve their desired family size rather than as a method for ‘population control’. The issue of providing appropriate family planning services however is obviously of crucial importance to national strategies for achieving replacement fertility in the near future. Better systems are needed to increase longer acting family planning methods and to improve use of temporary methods.

Decisions regarding the allocation of limited resources should, whenever possible, be based upon scientifically supported evidence. Evidence applicable to such decision-making is very limited and what does exist is not effectively disseminated to the decision makers. These represent the major challenges of the programme: to produce relevant knowledge and to appropriately communicate it.

ICDDR,B works closely with the Ministry of Health and Family Welfare and is in a position to influence decisions that will shape the health sector programme. Within the NGO sector, the formerly separate rural and urban service delivery programmes have been united under a single National Service Delivery Programme (NSDP). There are tremendous opportunities to work with the NSDP, both in terms of evaluating current programmes as strategies (such as depot-holders) and identifying new direction and knowledge-based interventions.

ICDDR,B scientists understand the difficulties in providing health care services at a low cost. We are documenting the costs of various health packages, such as Integrated Management of Childhood Illness, Essential Services Package and nutrition services, as well as exploring alternative funding strategies. ICDDR,B is also working with communities to see if there can be a community-based health cooperative model that will be more responsive to community needs and will allow for more community control and input.

ICDDR,B has considerable experience in conducting operations research to strengthen health and family planning services and in evaluating these services. Building on what has been learned from intensive studies in its hospitals and field sites, programmes can be recommended for implementation to the Ministry of Health and Family welfare or NGOs. Additional studies assess acceptability, cost, impact, and sustainability, and evaluation and impact during scale up. This was the case with ORS, the family planning programme and may also be applicable for other interventions.