The Director General of WHO has given very high importance to improving impact of its work at country level. To achieve this, WHO announced Organisation wide Country Focus Initiative (CFI) at WHA 2002. The CFI is being implemented in the countries through the mechanism of Country Cooperation Strategies developed by WHO in consultation with Government and other relevant partners. The Country Cooperation Strategies define strategic agenda for working in and with individual countries and implication and adaptation of WHO's technical response repertoire to optimally implement it. Also, as a part of organisation wide changes, CFI envisages to ensure well led, well equipped and well staffed WHO country teams who work in partnership with relevant partners at country level to support member states along WHO technical and policy lines. In this context, the Country Cooperation Strategy (CCS) for Bangladesh has been developed.

This CCS document presents WHO's strategy for cooperation with Bangladesh. Its emphasis is on an initial period 2004-2007.

Its overall objective is to contribute to the achievement of the Millennium Development Goals (MDG) in Bangladesh through supporting both the National Strategy for Economic Growth, Poverty Reduction and Social Development (IPRSP) and the associated Health, Nutrition and Population Sector Programme (HNPSP), which also aims to achieve MDGs.

This CCS for Bangladesh is the outcome of wide consultation between WHO and a number of Politicians e.g. Hon'ble Minister of health, State Ministers, Senior policy level representatives of several ministries i.e. secretaries of health, education, finance, establishment along with national health and development institutions, representatives of NGOS and other development partners.
The rationale and main lines of action of the CCS were discussed and agreed with GoB during a first mission in September 2002. It took place at an opportune time when both the IPRSP and the HNSP conceptual framework were being conceptualised and thus enabled WHO both to contribute to the strategic dialogue as well as to identify the framework for this CCS which will contribute to the achievement of MDGs.

Since then, a number of consultations have taken place between Headquarter/ Regional Office/Country Office to finalise this document. I wish to acknowledge the contribution of CCS team from WHO Headquarter/Regional Office/Country Office staff/GoB counterparts and the Development Partners who contributed to the lines of action mentioned in the document.

BACKGROUND

Since Independence in 1971, Bangladesh has made significant achievements with regard to reducing poverty and improving health status.

Infant mortality has declined from 153 deaths per thousand live births in 1975 to 94 in 1990, and to 66 by 2000. Under five-mortality rate declined from around 240 deaths per 1000 live births to 94 over the same period. Life expectancy at birth rose from 48 years in the mid 1970s to 61years by 1998.

The current population of Bangladesh is 130 millions, with a population density of 876 per sq. km. Total Fertility Rate declined from 6.3 in 1975 to 3.3 in 1997-99 with a consequent fall in annual population growth from 2.9 per cent per annum in the mid-1970s to 1.5 per cent in the late 1990s. Average household size is currently 4.8 persons compared with 5.5 in 1991.

During the 1990s income poverty declined by some 1 .5 per cent per year. However, achieving the MDGs by 2015 will require considerable additional efforts. The overall goal of reducing income-poverty by half will require a 3.3 per cent decrease in income poverty per year over the period 2000-2015. This will have to be achieved for a population that is expected to reach 180 million by 2025.

With regard to health, the MMR (320 per 100000 live births) is one of the highest in South Asia and in the world outside Sub Saharan Africa. Level of malnutrition is also amongst the highest in the world. Women and female adolescents, as well as children, are seriously affected. The DHS 1999/2000 found that 45 per cent of under-fives are stunted, 10 per cent wasted and 48 per cent underweight, 78 per cent of infants are anaemic, as are 49 per cent of women.

At the same time patterns of mortality and morbidity are changing. Based on WHO burden of disease estimates, mortality due to communicable. perinatal and maternal causes will decline front around 50 per cent to 30 per cent of total mortality during the period 1990 to 2010. Non-communicable diseases (including cardiovascular diseases, diabetes, cancer and mental illness) will increase to around 60 per cent of total mortality. Injuries (intentional and accidental) are predicted to increase slightly from around 9 per cent to 11 per cent. Monitoring and analysis of major health risks, defining appropriate, affordable health systems responses, including engaging other sectors, will all require WHO advice and support. A particular challenge will be reorientation and strengthening the capacities of the national health system to address the transition and scale up the interventions needed to protect and improve the health status of the poor.

These projections neither take account of disturbing regional trends in HIV/AIDS and TB, nor the possible emergence and reemergence of other communicable diseases including SARS, dengue, kala azar and malaria. Strong WHO support for national surveillance and rapid response will be required in this respect. Environmental risk, including the evolving problem of arsenic contamination of drinking water will also continue to occupy WHO's attention.

Against this background, Bangladesh has initiated a new more intensive strategy for economic growth, poverty reduction and social development with the aim of achieving the MDGs. The country's longstanding group of development partners, including WHO, are expected to plan important roles.

Health is an important integral component. In this regard a new Health, Nutrition and Population Programme (HNPSP) has been elaborated. The first phase of HNPSP will extend from July 2003 to June 2006. Its scope is broad, incorporating most of the current and emerging public health issues outlined above.

In the light of the substantial changes outlined above, this WHO Country Cooperation Strategy (CCS) has been elaborated with the aim of optimising WHO's impact and influence as principal development partner in the field of health.

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ACCELERATING PROGRESS TO ACHIEVE THE MDGS

In strategic terms, the most significant challenge for WHO is to adjust to the shift in the way that health is perceived in the development process in Bangladesh. Until recently health was perceived primarily as one of a series of development goals and as a consumption sector. Now health is seen as a core element of the new National Strategy for Economic Growth, Poverty Reduction and Social Development. This strategy comprises five component policies, as follows:

• pro-poor economic growth
• human development
• women's advancement and closing gender gaps
• social protection
• participatory governance

Improving health outcomes for the poor, through protecting, promoting and improving health status, is central to the human development component, which aims to radically improve the capabilities of the poor. Health outcomes are also intimately linked to the women's advancement and social protection components as well. There is also an important linkage with the fifth component since improving the performance of the health sector itself will require action with regard to governance including increased accountability to the public, especially the poor.

WHO will need to monitor and maintain linkages with all of these components in order to ensure the strategic overview necessary to inform WHO policy and technical advice to each of the components, especially human development.

HNPSP- STRATEGIC CHALLENGES

In the period since the first CCS mission the MoH has, elaborated both the conceptual framework and first implementation plan for the new health sector strategy (HNPSP) duly emphasising its place within the overall strategy for economic growth, poverty reduction strategy and social development. It will build on the preceding health sector programme (HPSP 1998-2003), but with a greatly increased focus on protecting and improving the health of the very poor.

The HPSP was one of the world's first examples of a Sector Wide Approach (SWAP) in which the international community agreed to pool resources and coordinate technical contributions within one overall sectoral programme and implementation plan. WHO was closely involved in HPSP planning and implementation.

HPSP's achievements include:

• developing the Essential Services Package (ESP) Much focused resources on cost-effective interventions for the country's most common health problems
• rural focus with the intent of providing access to the rural poor through primary level services and the introduction of new community level clinics
• improvements of overall national health policy and systems development

As a result, 65 per cent of public expenditure on health is now said to be directed to the ESP whilst 55 per cent of people using primary health facilities at Upazila and community levels are from the two poorest income quintiles. That being said, utilisation of public health facilities in Bangladesh remains very low. There are several factors contributing to it of which staff absenteeism, low morale of staff and lack of drugs have been identified as prominent ones.

However, HPSP suffered several constraints as well. The proposed structural reform of unifying traditionally separate Health and Family Planning directorates was one of the biggest constraints, which could not be carried out as planned because of cultural, social, political and administrative difficulties. Difficulties regarding reconciling IDA guideline and existing government regulations and practices led to procurement problems leading to nonutilisation of allocated funds on one hand, and lack of drugs and equipment to health facilities on the other. These factors contributed to the diminishing consumer confidence in public curative care facilities and hence the nonutilisation.

In the new HNPSP, these constraints have been recognised and simplified and decentralised procurement process has been proposed. Similarly, instead of structural integration of the two directorates, functional integration at service delivery points has been proposed.

The new HNPSP is also challenged to be "more pro-poor" and to ensure close linkage to the overall planning, implementation and monitoring of the national strategy for economic growth, poverty reduction and social development. According to its conceptual framework and implementation (PIP) documents, it will incorporate the following principles and objectives for which WHO technical advice and provision of good practice examples will be required:

1. Making explicit the definition and quantification of poverty objectives, including setting targets and introduction of monitoring for reduction of health inequalities.
2. Identifying specific target groups, both urban and rural, and including geographic and ethnic vulnerable groups.
3. Increasing overall expenditure on health with the aim of increasing impact of effective interventions on pro-poor health outcomes.
4. Improving resource allocation methods and practices.
5. Improving governance of public health facilities in order to remove barriers to access by the poor, such as unofficial fees, behaviour of health staff particularly to poor women.
6. Strengthening health sector response to the multiple determinants of ill health affecting the poor, including capacity to work across sectoral boundaries to tackle malnutrition, water arid sanitation issues.
7. Reassessing ESP services to improve their relevance to the needs of the poor.
8. Strengthening overall health services planning, management, monitoring and thereby quality at points of contact with poor people.
9. Identifying ways to prevent arid offset the impact on families of catastrophic health events such as road accidents and injuries affecting household breadwinners - a common cause of household poverty in Bangladesh.

At a purely technical level WHO will continue to be called upon to provide analysis, information and advice with regard to a wide range of public health problems - communicable and non-communicable diseases, reproductive health, environmental health, including difficult problems such as arsenic contamination of ground water.

But the fresh awareness, at the level of senior policy makers, that the Future development of the country is dependent on improving and sustaining health outcomes amongst the extreme poor, creates an imperative for WHO to articulate advice and support within a framework with which the organisation is not sufficiently familiar as yet i.e. health in poverty reduction.

In many respects the new health agenda in Bangladesh contains main Health For All principles-reducing health inequities, action at local level selected "essential elements", people's participation, collaboration across sectors. Thus it provides an opportunity to rethink and develop the new WHO approach to Primary Health Care called for by WHO's new Director General Dr. J. W. Lee

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PARTNERS FOR HEALTH IN BANGLADESH

According to the World Bank (Review of Public Expenditure, 2002) budgetary expenditures in Bangladesh are among the lowest in the world at 15 per cent of GDP. Around 30 per cent of this total is allocated to "reasonably well targeted social services" including health. Despite the low real amounts (health receives around I per cent of GDP) this is widely acknowledged to be the source of the country's relatively rapid progress in human development and poverty reduction over the past decade. Success is attributed to interalia, good policy frameworks, sustained attention In public officials, engagement of a range of national stakeholders, including NGOs and communities, and wide donor support.

For example, the recently completed health sector SWAP (HPSP, 1998-2003) was supported by the following: World Bank, Canada, European Commission, Germany (KFW and GTZ), Netherlands, Sweden and UK (this group known as the "donor consortium") plus USAID, Japan (JICA), Asian Development Bank, Islamic Development Bank, UNDP, UNICEF, UNFPA and WHO.

Nevertheless, Bangladesh needs to increase both the quantity and quality of social expenditure in order to achieve the MDGs (Ref. WB Public Expenditure Review 2002). Current per capita expenditure on health and education (US $12) falls well short of India's (US $21) and Sri Lanka's (US $37). However, there are a number of serious obstacles including drainage on public funds by inefficient public industries, lack of fiscal sustainability, weak overall development planning and poor absorptive capacity.

With regard to external concessional assistance, "annual sectoral development plans (ADPs) receive large volumes of aid, varying from 20 to 70 per cent of development expenditures. Lack of reforms and reduced absorptive capacity-mainly stemming from weak procurement capacities are at the root of a decline in aid from nearly 5 per cent of GDP in 1900 to about 2 per cent in 2001.

One solution could be the development of a public expenditure programme that donors could collectively support. In this regard, the health sector SWAP (HPSP) is seen by the World Bank and some donors as a step in the right direction.

With regard to this relatively positive health sector experience, WHO along with DFID has supported the Health Economics Unit (MoH) that was created as part of the HPSP through modest funding and technical support for conducting a number of economic analyses, some of which involved both SEARO and WHO HQ. In this way WHO Bangladesh has accumulated valuable experience in the field of economics and health.

In view of (a) WHO's successful advocacy for more attention to health in the macroeconomic context (CMH report and current follow up), and (b) the high importance of good economic and financial analysis, management and decision making (see above) this theme merit, high priority in the CCS.

WHO's PRESENCE IN BANGLADESH

WHO has been a very significant partner of the Government of Bangladesh (GOB) since 1972. Since then, WHO has regarded its prime functions as:

• providing sustained technical support in health development and in shaping health policy,
• providing state of the art technical guidelines for service delivery,
• promoting health research
• developing national and institutional capacity

WHO's collaboration with GOB is formalised through the Programme Budget process and biennial Plan of Action jointly developed and agreed by GOB and WHO.

The current programme comprises 24 areas of work. A number of these are WHO global priorities, approved by the Executive Board and World Health Assembly. These are surveillance, prevention and management of communicable diseases; prevention, treatment and management of HIV/AIDS, Malaria, and 'tuberculosis; non-communicable diseases (cancer, cardiovascular diseases and diabetes); tobacco; maternal health: mental health and substance abuse; health and environment; food safety; essential medicines (access, quality and rational use); blood safety and clinical technology; evidence for health policy; and development of effective and sustainable health systems.

Many, but not all, WHO-supported activities have been included in the Annual Operational Plan of HPSP, in keeping with the SWAp principle of coordination of all sources of support, even though WHO funds were not part of the "basket" of external and domestic resources. This is a good example of WHO involvement in a prototype development cooperation process which will be refined and increasingly utilised in coming years. It could be useful to share an analysis of WHO's contributions and experiences in this SWAp process for the benefit of CCS in other countries.

There are a number of areas where WHO is the only external partner and where both WHO funds as well as technical expertise have been instrumental in ensuring implementation of programmes of both national and global significance achieving the leprosy elimination target of less than 1 case per 10,000 population, in dengue control and, most recently, developing national capacity to prevent and control SARS. In these extremely important areas, no other donors are providing support to GoB. In the case of Polio Eradication. WHO is providing the technical support and establishing a very high standard Polio surveillance system as well as meticulous planning of highly successful NID. Apart from WHO, UNICEF, Japan Government, USAID, Rotary International, and DFID are the significant partners of GoB. The government has shown a very high level of political commitment and national ownership of the programme compared to some other countries in the region.

The HPSP sector programme did not include any significant component on environment and health. However, WHO has been providing technical and policy support, especially in capacity building and generating evidence in this area. For example, WHO supports (a) the Ministry of Local Government, Rural Development and Cooperatives in capacity building for water quality surveillance, sanitation and hygiene, and (b) the Healthy Cities programme, comprising 8 City Corporations, and Pourashavas in community oriented "health conscious" development planning.

Since 1993 substantial WHO support has also been given to finding solutions to the serious problem of arsenic contamination of ground water, first alerting GoB and then supporting the first water quality tests. Since then capacity building at regional and national level has been a regular feature of WHO support to Bangladesh. Currently, in collaboration with UNICEF and FAO, plans are under preparation to study arsenic in the food chain in more details.

Since 2000, the link between Children anal Environmental Health has received special attention.

In the area of food safety, WHO has supported the Institute of Public Health in conducting assessments, training and capacity building, and raising public awareness.

WHO also supports GoB in emergency preparedness and response, and has assisted in the development of both policy and practice. Recently, capacity building in investigations of communicable disease outbreaks and surveillance, and nutrition in emergencies have been supported, while mass casualty management training will take place in the near future.

WHO'S INVOLVEMENT IN I-PRSP

WHO's global and local advocacy and dissemination of the CMH report has been particularly effective in sensitising policy makers to give health high priority within the context of the strategy for reduction of poverty beginning with preparation of the Interim PRSP. The Ministers for Health and Finance and Secretaries for Health, Finance, Economic Relations, Planning and Education were all personally engaged in discussion on the relevance and implications of the CMH report for Bangladesh. This has resulted in the CMH findings and recommendations being well reflected in the IPRSP document.
In addition WHO provided support in developing the health component of the IPRSP document.

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WHO'S COUNTRY BUDGET

WHO's budget for the 2000-2001 biennium comprised US$10.6 million, regular budget and US$ 11.5 millions extra-budgetary resources. The totals for the 2002-2003 biennium were US$ I l.5 million regular budget and US$ 8.7 million extra-budgetary.

WHO COLLABORATION WITH OTHER DEVELOPMENT PARTNERS

Examples of collaboration with other UN partners include the following:

• with UNICEF in child health particularly polio eradication, routine immunisation and IMCI.
• with UNFPA in reproductive health and sale motherhood
• with FAO in the area of food safety, arsenic in food chain and implementation of Codex Alimentarius in Bangladesh.
• with UNDP in promoting health and controlling malaria and other diseases in Chittagong Hill Tracts.
• As a cosponsor of UNAIDs, WHO participates in various theme groups and taskforces.

WHO has been only recently included as a member of the Local Consultative Group (LCG) of the major development partners, although it has been a member of a number of sub/groups (see below). Since health is now so central to the new poverty reduction strategy, WHO will bring health dimensions in the mainstream dialogue between GOB and development partners. WHO technical advisors are also acting as members of several subgroups e.g. (a) HNPSP subgroup (b) the LCG subgroup on water supply and sanitation (c) LCG task force on development in Chittagong Hill Tracts (d) LCG subgroup on environment and transport. In addition to the LCG mechanism, WHO also has bilateral collaboration with DFID and Netherlands, USAID (polio eradication) and CIDA (TB control).

WHO collaboration with other partners includes (a) Bangladesh Medical Association and the Private Practitioners' Association. (b) Chittagong, Dhaka and Rajshahi Medical Colleges, (c) major NGOs, including BRAC, ICDDR'B, Damien Foundation and (d) development research institutions, including Bangladesh Institute of Development Studies (BIDS)

TOWARDS A WHO STRATEGIC AGENDA

The 2002 CCS mission discussed WHO's future role and functions in Bangladesh with senior GOB decision makers including Secretaries for Health, Finance and Planning, and representatives of external development partners, including World Bank, UNDP, UNICEF, DFID, EC.

These culminated in a formal high level meeting on 4th, September 2002 comprising Secretaries Health, Planning and Finance, representatives of national health and development institutions, NGOs including BRAC and WHO Country staff. The meeting was chaired by the Principal Secretary to the Prime Minister of Bangladesh.

The following points of consensus emerged:

KEY DEVELOPMENT CHALLENGES

The key development challenges for Bangladesh for the foreseeable future are accelerating poverty reduction and sustainable economic growth. As noted in the I-PRSP, "All routes matter ... health matters more than most."

CHALLENGES TO WHO

There are three fundamental challenges to be addressed by WHO in connection with its future strategic importance in Bangladesh:

1. How to increase the impact of health on productivity and poverty reduction?
2. How can WHO become a closer partner of GOB in pursuing this goal?
3. How can WHO increase its influence amongst the development partners in the context of poverty reduction?

STRATEGIC IMPORTANCE OF THE WHO CORPORATE STRATEGY

The WHO corporate strategy provides a very useful framework for designing a more coherent and focused programme of support to Bangladesh. It was noted that WHO support to date has concentrated only on two of the elements (disease control and health sector development) and that, even in the health sector component, a pro-poor focus has not been very prominent.

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WHO's PRINCIPAL FUNCTIONS IN BANGLADESH

The meeting concluded that WHO's principal functions should be as follows:

1. To provide the latest global health information, examples of good practice and WHO policy positions to countries i.e. not only to ministries of health, but also to finance and planning and the research and training institutions that support them.
2. To support development of national health, poverty reduction policies, strategies and plans, including public health norms and standards in collaboration with other Development Partners and UN Agencies.
3. To provide international technical expertise in areas of newly-agreed importance e.g. in macroeconomics and health; pro-poor health systems; as well as core public health areas where national expertise and capacity requires urgent strengthening e.g. communicable disease surveillance, control and management.
4. To support analysis of operational problems in health systems organisation, financing and access to service, especially by the poor.
5. To bring examples of country success and good practice to international attention e.g. Bangladesh Human Development Report 2000 and the Interim PRSP.
6. To influence thinking and policies of development partners by sharing global health information, good practice and WHO policy positions and advice from global, regional and counts levels.
7. To support GoB in mobilising resources such as GAVI and Global fund (GFATM)

IMPLICATIONS FOR WHO - SOME KEY PRINCIPLES

1. Strengthen WHO presence through more and better quality support from both SEARO and WHO HQ for high priority and new emerging issues. In addition to better flows of information and advice through WHO's evolving communications system, it is clear that more frequent and well timed visits by WHO experts would add substantially to WHO ability to influence policy development and implementation.
2. Reorient WHO support to a new generation of health issues within the framework of national poverty reduction strategies
3. Focus the WHO biennial work programme on fewer, less fragmented and more strategic high priority areas, in keeping with (i) and (ii) above. Inherent in this process would be the need for a better balance between WHO engagement in programme implementation and activities with a more strategic focus such as strengthening national policy, sharing good practice and capacity building in key areas. WHO's expertise in areas such as disease control and EPI and polio eradication is probably unique and "hands on" support is necessary for sometime. In other areas such as Health System Development, Reproductive Health, Human Resources Development, Environmental Health, Nursing, HIV/AIDS, presence of WHO experts at country level is being seen by GoB as well by Donors as an overall strategic technical support to the planning, implementation and monitoring of health sector programme as a whole and as such h is being reflected as WHO contribution in the annual operational plain of specific priority programme of the DGHS. This is an innovative way of being an active partner in SWAp while keeping WHO mandate, processes etc. intact and such practice will continue. This is also in line with strengthening WHO country presence and country focus initiative and this will be continued.

PRINCIPAL THEMES FOR WHO'S COUNTRY COOPERATION STRATEGY IN BANGLADESH

In the light of current health trends, and the central role of health in national poverty reduction and development strategies in Bangladesh, particularly the Interim PRSP and the HNP Sector Programme, the following themes provide an appropriate and coherent framework lot WHO cooperation for the foreseeable future of at least five years. They should be adopted as the core elements of a new WHO Country Cooperation Strategy.

• Macroeconomics and Health
• Developing a pro-poor health system
• National Surveillance System and rapid response to communicable diseases
• Protecting and improving women's health and reduction of Maternal mortality, especially among rural poor
• New WHO initiative on environmental crisis affecting children's health
• Initiating action on new, emerging health issues

Note: Annex 1 of this document contains a number of specific examples of activities to be taken up within the CCS.

CCS AND WHO/GoB COLLABORATIVE PROGRAMME 2004-2005

The CCS needs to be put into operation as soon as possible in order to enable WHO to take its place with GoB and other development partners in taking forward the HNPSP. The immediate need is to integrate CCS into the ongoing preparations of Country Work Plans for the 2004-2005 biennium, which has started already and should be further refined.

The overall WHO "Managerial Framework" and guidelines for elaborating the Programme Budget 2004-2005 foresee no significant changes in the principles, terminology, content or format being used for the preparation of 2004-2005 country work plans. The salient features are:

• application of logical framework
• application of results-based budgeting principles and
• use of limited number of areas of work which serve as common building blocks for programmes and budgets across the organisation.

These criteria fit well with the CCS objectives and principles. Thus attempt has been made in the core principle in the preparation of the Bangladesh Country Work Plan 2004-2005 to align WHO's activities to support achievement of HNPSP outcomes, through its agreed strategies, approaches, (selected) thematic technical areas and monitoring, based on the CCS framework and with due regard and adherence to WHO's Managerial Framework.

In further development of the work plans, a degree of flexibility will be retained in order to incorporate WHO priority areas which lie outside the HNPSP frame. WHO support to strategic planning and monitoring, of HNPSP needs to be intensified.

In order to improve impact and cost-effectiveness in implementing the Country Programme, further development of the WHO Programme Budget 2004-2005 will apply the following principles And directions.

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CONSOLIDATING AND PRIORITISING WORK PLANS TO SHARPEN FOCUS

The 2002-2003 programme contains 24 areas of work covering a total of 45 work plans. This is seen to spread limited resources too thinly Adoption of the CCS and linkage to the HNPSP frame will enable the 2004-2005 programme to focus on a smaller number of priority areas within WHO's Areas of Work.

INTRODUCING A STRATEGIC APPROACH TO STRENGTHEN AND CONSOLIDATE CAPACITY OF NATIONAL INSTITUTIONS

Training under the WHO collaborative programme in the past has been handled on regional basis. During the current (2002-2003) biennium a bold initiative has been introduced with a view to availing in-country resources and capabilities.

In line both with this initiative and the ongoing management and capacity building initiatives by MOHFW/DGHS, it is proposed to review national/in-country fellowships in terms of fields of study, training institutions, syllabi and content, logistics and other organisational aspects. The expected outcome will be considerable upgrading of the capacities of core national health and health-related institutions and creation of a critical mass of human resources necessary for carrying through health reforms in line with set objectives.

STRENGTHENING NATIONAL DISEASE SURVEILLANCE AND RESPONSE SYSTEM TO IMPROVE ANTICIPATION AND REACTION

Bangladesh is prone to natural disasters, emergencies and epidemics It is proposed to undertake an in-depth review of the capacities required by the key institutions such as Director Disease Control in DGHS office, Civil Surgeons' office at district level, IEDCR etc with a view to creating a competent national network of expertise with the capacities for surveillance, forecasting, preparedness and response. This process will take place in the wider context of WHO support for improved surveillance and response to outbreaks of communicable diseases worldwide.

NETWORKING OF PUBLIC HEALTH INSTITUTIONS TO STRENGTHEN CAPACITY AND CREDIBILITY OF NATIONAL EXPERTISE IN HEALTH WITHIN HNPSP

The prominent place accorded to health in the national strategy for economic growth, poverty reduction and social development creates a major challenge to the national health institutions. Against that background it is proposed to support the institutions of excellence in establishing a dynamic networking of institutions within the country, region and outside the region. This will include provision of exchange visits, continuing and group educational activities and pilot project initiatives in critical and innovative areas such as health financing, planning and management; exchange of global health information and examples of good practice; and support for analysis of operational problems in health systems organisation, success stories, good and innovative and employable practices.

CREATING PARTNERSHIPS AND MECHANISMS TO ENSURE SUSTAINED SUPPORT FOR HEALTH WITHIN NATIONAL STRATEGY FOR ECONOMIC GROWTH, POVERTY REDUCTION AND SOCIAL DEVELOPMENT

In line with the ongoing global follow up to the CMH Report, and to ensure appropriate dialogue on investing in health in Bangladesh, it is proposed to create a sustained relationship with the Ministry of Finance and other key stakeholders as partners through the setting up of a committee on Macroeconomics and Health. Its principal outcomes will include:

• estimation of the cost of a pro-poor health system development of national health investment plan, measures to assist in analysing and predicting impact of disease on productivity and economic growth
• identification of sustainable measures to increase health sector expenditure

CONCLUSION

The Government of Bangladesh is committed to achieving the Millennium Development Goals (MDGs) and is fully aware that greater efforts will be required. Against this background GoB has welcomed WHO's initiative to refocus and deliver its support in a more upstream and strategic manner. This first CCS for Bangladesh has been developed through consultation with a wide range of partners in the development process - government, NGOs and external partners.

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Annex 1: Examples of activities under each theme of CCS

The 2002 mission outlined a range of examples of possible focused activities under each of the main theme, of the CCS framework, us follows:

1. Macroeconomics and I Health
   • Estimating the cost of a pro-poor health system
   • Developing national health investment plan in context of macroeconomic instruments e.g. Medium-Term Expenditure Framework
   • Improving health sector expenditure to justify increased allocations
   • Human Resources Planning and capacity building implications for a pro-poor system
   • Analysing and predicting impact of disease on productivity and economic growth
   • Strengthening MOHFW capacity for stewardship role
     
     
2. Developing a pro-poor health system
   • Prioritisation of health sector interventions and analysis of trade-offs
   • Geographical targeting to benefit high poverty areas,
   • Social insurance mechanisms, including through micro finance
   • Access by the poor to affordable and good quality essential drugs
   • Behaviour of health personnel as obstacle to access by poor women
     
     
3. Rapid Response to Communicable Diseases
   • Strengthening national surveillance system
   • Improving response to outbreaks
   • Control, management and monitoring of diseases which are major causes of poverty e.g. TB
     
     
4. Protecting and Improving Women's Health, especially the rural poor
   • Better access to health services in general, in addition to reproductive health services
   • Community-based management of pregnancy and delivery through skilled birth attendants
   • Improving women's nutrition
   • Combating violence - a public health response
   • Promoting rights-based approach to health
     
     
5. Healthy Environments for Children
   • household drinking water - quantity and quality
   • hygiene and sanitation
   • indoor and outdoor air pollution
   • disease vectors e.g. mosquitoes
   • chemicals e.g. pesticides and lead
   • accidents and injures
     
     
6. Public Policy Response to New and Emerging Public I Health Issues
   Achieving health outcomes for the poor requires a policy response across many sectors
   • Tobacco control
   • Arsenic contamination
   • Trade-addressing national public health implications of international trade agreements, including access to medicines
   • Violence against women and children - a new public health response
   • Road traffic Acciden