Type of Review: Project Completion Review
Project Title: Maternal, Neonatal and Child Survival project (MNCS)
Date started:2007
Date review undertaken: June, 2012
Description
Outputs substantially exceeded expectation
Outputs moderately exceeded expectation
Outputs met expectation
Outputs moderately did not meet expectation
Outputs substantially did not meet expectation
Scale
A++
A+
A
B
C
Introduction and Context
What support is the UK providing?
The UK provided £7.5 million over 3.5 years (January 2009 – June 2012) to support BRAC in
implementing the Maternal, Neonatal and Child Survival (MNCS) project in Bangladesh.The
project was co-funded by Australia (AusAID) and the Netherlands (EKN). AusAID supported
both the implementing partners i.e. BRAC and UNICEF. The overall budget for the MNCS
project for 5 years was estimated as £24.7 million.
The project aimed to reduce maternal, neonatal and child mortality and morbidity, particularly
among the poor and socially excluded. Its outcomewas to ‘improve community maternal,
neonatal and child health (MNCH) practices, and increase utilisation of quality care and
services by the poor and socially excluded communities’,achieved through providing quality
maternal and neonatal health (MNH) services to communities and at health facilities level by
engaging with community leaders and Ministry of Health and Family Welfare (MOHFW)
managers and providers.
BRAC mobilised the communities and provided community based maternal, neonatal, child
health and family planning services while UNICEF supported the Ministry of Health and Family
Welfare (MoHFW) in strengthening and improving clinic and hospital based services,
especially the availability of emergency obstetric care.
During the first phase, the project was implemented in 4 remote districts of Bangladesh
(Gaibandha, Rangpur, Mymensing and Nilphamari) where health outcomes were poor and was
scaled up to an additional 6 districts in 2010, reaching a total population of about 20 million in the
10 districts.
What were the expected results?
The main results expected were measurable increases in access to and quality of MNH
services particularly among poor and marginalised communities in the project areas. It was
projected that by the end of the project, in the 10 target districts:
 An additional 35,000 women with obstetric complications will have received high
quality care;
1

700 maternal deaths will have been averted, with maternal deaths in the 10 districts
reduced by more than 10% from baseline level;
 Deaths of more than 34,500 children under five will have been averted, including
19,000 neonatal deaths.
and
 The proportion of women who received antenatal care at least four times during
pregnancy () would increase from 14% to 80%.
 The proportion of women whose babies were delivered by Skilled Health Personnel
would increase from 15% to 30%.
 The proportion of mothers who received postnatal care within 48 hours of child birth
would increase from 12% to80%.
 The proportion of complicated pregnancies identified in the community and
appropriately managed at a health centre with necessary doctors/ nurses and drugs
and logistics would increase from 12.5% to 30%.The proportion of new-bornskept
warm and protected against falling of body temperature would increase from 18.5% to
50%.
The results were expected to be achieved through several innovative approaches such as
developing local women to become community health workers and providing community based
MNCH services, simultaneously increasing demand for maternal-new born care by the
community while strengthening provision of these services in Government health centersand
engaging Local Government and civil society in financing the health needs of the very poor.
The project largely exceeded the set targets for the expected results particularly with regards to
MNH services provided at the community level.
What was the context in which UK support was provided?
At the time of project design, Bangladesh was significantly off-track to achieve Millennium
Development Goal (MDG) 5 - reduce maternal mortality. Though the Maternal Mortality Ratio
(MMR) had declined from 574 deaths per 100,000 live births in 1990 to 320 in 2001,this was
still unacceptably high. More than 12,000 women died every year from complications related
to pregnancy and childbirth. While Bangladesh was on track to meet the MDG target for
reducing under-five mortality (MDG 4), 57% of all child deaths under 5 years, and 70% of child
deaths below one year, occurred in the first month of life.More than 50% of women living in
rural areas didnot receive any care during pregnancy; childbirth assisted by skilled attendants
was the lowest in the world at 18%, with more than 80% of the women delivering their babies
at home.Only 21% of women received any postnatal care.
Reducing maternal and neonatal mortality was a priority commitment of the Government of
Bangladesh (GoB) in its Poverty Reduction Strategy. It was also a priority objective of the
Health, Nutrition and Population Sector Programme (HNPSP) which the UK supported with
other donors. HNPSPlargely focused on strengthening services like skilled attendance at child
birth, emergency obstetric care (EmOC), sick new-born care management and
referral.However it was becoming evident that because of the delayed start-up of HNPSP,it
would be challenging to achieve the expected results through that programme. The newly
elected GoB recognised these issues and requested DFID and other donors to fund the
BRAC/UNICEF MNCS project to expedite progress towards the MDG target for reducing
maternal deaths. (Project memorandum; Quest 1963409)
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Section A: Detailed Output Scoring
Output 1: Increased knowledge and improved MNCH practices in communities
Output 1 score and performance description: Scored at A+ (output
moderatelyexceeded expectation).
Source: BRAC MNCS performance
report, May 2012; Quest
3534009Indicators
Milestone
(2011)
1. Percentage of women aware of
maternal danger signs and know
what needs to be done (BRAC
referral mobile number and hospital)
2. Proportion of delivered women
having adequate knowledge of
neonatal danger signs (5) know what
needs to be done
3. Proportion of low-birth weight
(LBW) babies received special care
(frequent breastfeeding, proper
wrapping and hand washing)
4. Proportion of eligible couple using
modern contraceptive method
40%
Significantly exceeded target. 83% women of
reproductive age are aware of the maternal
danger signs and the steps to be taken.
40%
Significantly exceeded target. 70% women of
reproductive age know the new born danger
signs and the steps to be taken.
55%
Significantly exceeded target. 95% of low-birth
weight (LBW) babies in phase-l districts and
96% in phase-ll districts received special care.
63%
5. Proportion of married adolescent
girls giving birth
18%
Achieved target. 66% of eligible couples in
phase-l districts and 64% in phase-ll districts
use modern contraceptive method.
Partially achieved. Though proportion of
married adolescent girls giving birth in phase-1
districts reduced after 3 years of interventions
but in the new 6 districts it did not yet reduce.
As a whole the proportion increased to28%.
Progress
Progress against expected results:
BRAC trained local village women to become community health workerscalled Shasthyo
Shebikas (SS) while existing traditional birth attendants were trained to become ‘New-born
Health workers’ (NHW) and included in the team of frontline maternal-new-born health
workers. The SS and NHW visited house to house, registered all the pregnant women, and
counselled them and their family members on proper diet and care for the pregnant women
and young children. To prevent emergency, they particularly emphasised the need for the
pregnant women and their family members to recognise the danger signs during pregnancy
such as blurring of vision, bleeding etc. and those for new-borns (difficulty to breathe, indrawing of chest etc.) so that they seek proper care immediately. The project used mass
media like TV and radio to raise awareness on these as well. 69% of the pregnant women had
birth plans showing who would deliver and where the deliveries would take place. The NHW
provided essential care to the new-born at household level i.e. drying, wrapping and early
breast feeding. For low-birth-weight babies, BRAC developed special low cost jackets to keep
the new-born warm.
Apart from the above services the SSs registered all the couples of reproductive age with
special emphasis on newly-wed couples. BRAC’s programme for adolescents’ encouraged
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married adolescent girls to participate so that they could be informed about family planning
among other issues. The Adolescent Clubs also engaged with the elders of the villagesto try to
prevent f adolescent marriages. However various case studies by BRAC indicate that early
marriage is a social problem and cannot be addressed fully by Health interventions alone.
(BRAC Annual report, 2011; Quest 3534015)
Impact Weighting (%): 30%
Revised since last Annual Review? NO
Risk: MEDIUM
Revised since last Annual Review? NO
Output 2: Improved provision of quality MNCH services at household and community
levels.
Output 2 score and performance description: Scored at A+ (Output moderately exceeded
expectation).
Progress against expected results:
Indicators
1. % pregnancies identified by SS/SK in
first trimester
2. % of women delivered at home
received misoprostol in the community
3. % of PNC delivered by SKs within 48
hours for home deliveries
Milestone
(2011)
55%
40%
70%
4. % of neonates with sepsis received
care from trained providers
60%
5. % children with pneumonia managed
by trained providers increase from 0%
at baseline to 90% by EoP
70%
Progress
Exceeded set target. 66% in both phase-l
and phase-ll districts.
Significantly exceeded set target. 80%
Exceeded set target. 84% in phase-l and
82% in phase-ll districts.
Significantly exceeded set target. 94% in
phase-l and 88% in phase-ll districts.
Significantly exceeded set target. 96% in
phase-l and 91% in phase-ll districts.
Source: BRAC MNCS performance report, May 2012; Quest 3534009
Often young women especially in the villages would not be aware of their pregnancy or were
shy to report it, delaying their registration beyond the first three months of pregnancy. The
BRAC community health workers (SS and NHW) went house to house to enquire and register
them and informed the BRAC health service providers called the Shasthyo Kormi (SK) to
provide the services to the registered pregnant woman or a sick child. The SKs visited the
pregnant women once every month, checked them up and recorded the findings in the
antenatal card given to the women. SKs also referred them to the local health facility for
necessary routine investigations helping them prepare for child birth. SKs left their mobile
phone numberswith the pregnant women so that they could be contacted in case of any
emergency. Near to term the pregnant women were given drugs (Tablet Misoprostol 400mg)
that prevent bleeding after child birth, a very common cause of maternal deaths in Bangladesh
(echoed in the Bangladesh Maternal Mortality Survey, 2010). SKs with potential were trained
further to become Communitybased Skilled Birth Attendants (CSBA) who helped pregnant
women during childbirth ensuring a safe environment. The SKs routinely checked on women
within 48hrs of child birth and paid further visits depending on the condition of the mother and
the newly born baby. They identified any signs of infection in the newborn and among children
less than five year old and referred them to the appropriate health centres, if needed.
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A rigorous monitoring and supervision system, coupled with the use of mobile
phones,strengthened the overall network of community based services provided by BRAC.
The data for every identified pregnant woman and new-born is regularly reported and followed
up through the robust Health Management Information System (HMIS). (Independent review
report, 2010; Quest 2551008)
Impact Weighting (%): 30%
Revised since last Annual Review? No
Risk: Medium
Revised since last Annual Review? No
Output 3: Increased availability and access to quality continuum of MNCH care and
services at facilities
Output 3 score and performance description: Scored at A (output met expectation).
Progress against expected results:
Indicators
1. Project supported health facilities in project
districts providing quality services {24
hours/7days services and necessary drugs
available; (oxytocin, MgSO4, antibiotics)}
Milestone
(2011)
50%
2. Proportion of target population within 2 hours
travel from home to a CEmOC facility
60%
3. Proportion of total births taking place in
facilities in project supported districts
25%
4. C-Section rate at all CEmONC facilities in
project supported districts remains within
5-15%
5. Case fatality rate at all EmONC facilities for
maternal complications in project supported
districts reduces to <1% by EOP
1%
Progress
Exceeded set target. 60% of the
targeted facilities provide quality
MNCH services as defined by the
project. (Annual report 2011,
QUEST 3534015).
80% of the target population are
within 2 hours travel time from
health centres providing CEMoC
services. (Annual report 2011,
QUEST 3534015).
Almost achieved at 24.5%. This is
slightly higher than the national
average for hospital births in rural
areas i.e. 22.8%. (BDHS 2011)
Achieved. At 8.4% the rate of C
sections remained within the UN
recommended range of 5%-15%.
Achieved at 0.9%
This output was the responsibility of UNICEF who aimed to strengthen public health service
delivery in the target districts. Considering the wider shortage of trained human resources in
the public system, UNICEF targeted three health facilities per district and strengthened their
capacity for providing emergency obstetric and special new born care. UNICEF supported the
government, relevant NGOs and the civil society to develop local level plans for addressing
the need in maternal-new-born care. These plans upon approval by the Centre allowed the
local government authority to fillthe gaps in providing the MNH services by recruiting the
necessary staff locally, providing logistics, upgrading the women’s and new-born wards in the
hospitals, and supporting construction of new-born special care units. The doctors and nurses
wereprovided further training in emergency obstetric care and new-born care. A system for
providing incentives (Pay for Performance) for services provided outside working hours was
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introduced to ensure the availability of staff and buy drugs for carrying out a caesarean
section. The C-section rate increased from the baseline level of 7.5% but still remained within
the UN recommended range due to increased care seeking for complications. The case
fatality rate reduced slightly from 1% at baseline to 0.9% and remained within the
recommended level.(Annual Report 2011, Quest 3534015)
Impact Weighting (%): 30%
Revised since last Annual Review? No
Risk: High
Revised since last Annual Review? No
Output 4: Increased participation, accountability and responsiveness to communities’
voice in MNCH services
Output 4 score and performance description: Scored at A +(output moderately exceeded
expectation).
Progress against expected results:
Indicators
1. At least 30% members of the village/
ward MNCH committees are women
and 20% are poor
2. Percentage of maternal death
Milestone
(2011)
30% are
women,
20% are
poor
40%
reviews conducted by village/ward
level committees increased
3. Percentage of women referred by
60%
MNCH committee members received
services from health facilities.
4. % of women referred to facilities
showed overall satisfaction with
obstetric services
50%
Progress
Exceeded set target. 41% members of the
village/ ward MNCH committees are women
and 20% are poor
Significantly exceeded set target. Maternal
death reviews conducted by village/ward
level committees increased from 0% to
79%.
Almost achieved at 58%.
Achieved. 50% women referred to facilities
showed overall satisfaction with obstetric
services. It will be further elicited through
detail qualitative study end of the year.
Source: BRAC MNCS performance report, May 2012; Quest 3534009
The project formed local level committees in communities to gain support and participation
from community leaders. Such committees created opportunities for participation in health
planning and decision making by women and the poor. The engagement of the committee
members in analysing the reasons and factors behind the death of a pregnant woman or a
new born, greatly increased their understanding of the issues and helped resolve critical
barriers like mobility of women, treatment by male doctors, arranging transport round the
clock, and raising funds to support the very poor. A BRAC staff member called the ‘Referral
Programme Officer’ at the government hospital ensured prompt registration and management
of the patient by the doctors and nurses upon reaching the hospital. Such experience greatly
increased the confidence of the communities in terms of seeking care from the facilities.
(BRAC performance report, May 2012; Quest 3534009)
Impact Weighting (%): 10%
Revised since last Annual Review? No
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Risk: Low
Revised since last Annual Review? No
Section B: Results and Value for Money.
1. Achievement and Results
1.1. Has the logframe been updated since last review? NO
1.2. Overall Output Score and Description
(To be generated automatically by ARIES).
1.3 Direct feedback from beneficiaries
The project beneficiaries include target communities, Local Government bodies, and
Government Health facilities. Generally beneficiaries valued the services provided by BRAC
health workers and reported these to be effective. The women reported positive changes in
their children’s health after following the advice of the BRAC health workers. Pregnant women
and their families were particularly happy about the check-ups being delivered in or close to
their houses. Village leaders very much appreciated local women being developed to become
health workers and respected the skills of the CSBAs. In most cases the families of the
CSBAs were found to be very supportive of the profession and some made extra efforts and
gave up a room in the house for arranging safe child births.
Members of the Local Government bodies could see the difference smooth transportation was
making and eagerly supported and supervised the functioning of the system and resolved
issues. There were obvious benefits to people in their constituencies. As well as women
receiving improved health care drivers had steady income and the clinics were more
responsive. Local Government staff appeared very proud of these changes.
At the district and sub-district facilities the health managers and service providers were happy
to see the number of patients’ rise, along with improvements to their facilities and additional
incentives for performance exceeding agreed bench marks. They mentioned that the BRAC
staff in the facility help them greatly in responding to the needs of the patients as they take
care of all the formalities for admission, informs/ alerts all relevant staff, manages the relatives
of the patient etc. They particularly mentioned the blood collection initiative of BRAC which
tremendously helped them meet the need for extra blood. (Field Visit report, May 2012; Quest
3534021)
1.4 Overall Outcome score and description: ‘A+’ Outcome moderately exceeded
expectation
Progress achieved:
The project Outcome,Improve community MNCH practices and utilisation of quality MNCH
care and services in the project supported districts, is measured by the following:
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INDICATORS
1. Proportion of women who
received at least four antenatal
check-ups (ANC)
BASELINE MILESTONE
PROGRESS
2011
14%
80%
Exceeded set target. 89% in phasel and 84% in phase-ll districts.
2. Proportion of women delivered
by skilled birth attendants
3. Proportion of complicated
pregnancies appropriately
managed at functional facilities in
project supported districts* (Met
need for Emergency Obstetric
Care)
4. Proportion of new-born
protected with thermal care
(drying and wrapping within 10
minutes)
15%
30%
Exceeded set target.. 32% in both
phase-l and phase-ll districts.
Exceeded set target.. 63% (up to
December 2011)
23%
50%
19%
50%
Significantly exceeded set
target.96% in phase-l and 94% in
phase-ll districts.
5. Proportion of new-born
initiated breastfeeding within one
hour of birth
6. Proportion of under-five
children suffered from acute
respiratory infections (ARI),
managed by trained providers.
51%
85%
Exceeded set target. 96% in phasel and 93% in phase-ll districts.
21%
75%
Exceeded set target. 96% in phasel and 91% in phase-ll districts.
The project exceeded expectations against all outcome indictors during implementation.The
project was implemented for more than 3 years in the phase-I districts and almost 2 years in
the phase-II districts. The results reflect the excellent progress made in increasing awareness
and demand for quality services by the community through the intensive work of the
community health workers. A total of 5,087 SSs, 1,136 SKs, 6,064 Newborn Health workers
and 356 CSBAs were trained by end of December 2011. Pregnant women and their families
proactively sought care at home from these health workers and at the facilities. The
community leaders and the local government promoted accessibility to services by ensuring
an effective transport system and enhanced the accountabilityof the facilities by participating in
the user forums and community groups.
On the service provision side, UNICEF worked with the health facilities to meet the additional
need for drugs, logistics and human resources due to increased referral and care seeking.
UNICEF helped establish 11 new-born special care units in 8 district hospitals and 3 medical
college hospitals. Five doctors, 48 nurses and 243 support staff were recruited to help
maintain services round the clock.
The score is backed by BRAC’s robust HMIS that recordsdata for the entire target population
enabling estimation of progress made in each category. External reviews also confirmed the
robustness of the HMIS. (MNCS project Review report, 2010; Quest 2551008). Several
qualitative studies were undertaken by BRAC involving the University of Aberdeen to
understand the progress especially in output four. The summaries are included in the final
performance report of BRAC provided in May 2012. (Quest 3534009)
1.5Impact and Sustainability
The project made a significant impact on the behaviour and practices of the community
regarding maternal, new-born and child health. They were more than doubly aware of the
maternal danger signs; more women started breastfeeding their new-borns within one hour of
birth (87.7%) and continued exclusive breast feeding until 6 months (62.1%). Use of ORS in
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management of diarrhoea increased considerably. Considerable increases in utilisation of
services were also seen e.g. in terms of use of contraceptives,antenatal and postnatal care
and skilled assistance during child birth. This sort of change in health care was possible due
to the engagement of the local community health workers. All these changes resulted in a
drop in the maternal and neonatal mortality rate by 30% and 23% respectively between 2008
and 2011. (BRAC performance report, May 2012; Quest 3534009)
Sustainability:
The project considers sustainability in terms of behaviour change in the knowledge, attitude
and practices of the community which will drive them to continue appropriate practices and
seek proper care in the coming years. The strategy of developing local women to become
community health workers, is in itself is sustainable given that these women will remain as a
resource for the communities. Engaging local elected representatives in arranging the
transport system and generating emergency referral funds also is a step towards establishing
sustainable systems. The project will continue under the strategic partnership of DFID and
AusAID with BRAC and will be further expanded.
The engagement of development partners in the health sector programme will help strengthen
service provision and quality aspects through policy dialogue with the Government based on
lessons learned from the project.
2. Costs and timescale
2.1 Was the project on-track against financial forecasts: Yes
The project was on track against financial forecasts. Project implementation costs were
reimbursed every quarter upon receipt of expenditure statement against planned activities
from BRAC. By June 2012, DFID had provided a total of £7.5m to BRAC for implementing the
project.
2.2 Key cost drivers
The main cost drivers were the cost of provision of preventive and curative services to the
communities by the community health workers (30%) and training and development of CHWs
((23%).(BRAC performance report, May 2012; Quest 3534009)
2.3.Was the project on-track against original timescale:
The project was largely on-track against planned timescale. The scale up to additional 6
districts was planned after 12 months of implementation in the four phase 1 districts. In reality
the scale up took place in May 2010, after 15 monthsof implementation following further
consolidation in the phase-1 districts.
3. Evidence and Evaluation
3.1 Assess any changes in evidence and what this meant for the project.
Two sets of evidence based results –the Bangladesh Maternal Mortality Survey,2010 and the
Demographic and Health Survey,2011, have been disseminated recently and
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showconsiderable progress in the area of maternal, new-born and child health confirming that
the country is on track to achieving MDGs 4 and 5. Maternal mortality reduced by 40% from
the 2001 level while there is steady progress in the reduction of child and new-born mortality.
These results suggest that the strategies being supported by projects like the MNCS and the
UN Maternal New-born Health Initiative (MNHI) are contributing to accelerating the progress.
Provision of community based services through mobilising the communities, improved
emergency transport and communications and effective referral have greatly increased care
seeking. Supporting health facilities in proper planning, retaining and recruiting necessary
staff, and making available necessary logistics have made them more responsive, resulting in
a positive impact on progress towards MDGs.
However,better documentation and in-depth study of the various approaches could lead to
further evidence on what works and what does not work so as to trigger richer policy dialogue
and focus on key health systems constraints.
3.2 Set out what plans are in place for an evaluation.
The project will continue under the Strategic Partnership Arrangement (SPA) between DFID,
AusAID and BRAC. The SPA will be reviewed annually, and a long term evaluation strategy is
being developed.
4. Risk
4.1 Risk Rating (overall project risk): Medium
Did the Risk Rating change over the life of the project? No
This is mainly because though the demand for services and community based MNCH service
provision could be increased, the availability of critical services was constrained due to lack of
skilled human resources to meet those growing demands.
4.2 Risk funds not used for purposes intended
DFID reimbursed funds to BRAC on the basis of agreed work plan on a quarterly basis. At the
beginning of each year DFID and other donors discussed and agreed the action plan with the
implementing Partners. BRAC and UNICEF both carried out regular audit of the funds
disbursed further, according to their set procedures. BRAC received funds from DFID for
other projects as well. An Institutional and Financial Review of BRAC, completed in 2010 in
advance of the SPA, demonstrated that BRAC has sound financial management and
procurement systems in place.
4.3Climate and Environment Impact
There was limited scope for generating environmentally hazardous by-products in the MNCS
project. Training was given to project staff and community health workers (CSBA) to ensure
effective confinement and safe handling of health care waste thus providing significant health
protection. The health care waste such as sharp needles, infectious waste and some
pharmaceuticals generated during a safe delivery were disposed safely in accordance to
BRAC’s infection prevention protocol.Environmental safety in the community was also
promoted and ensured by health promoting messages and practices e.g. prevention of open
defecation, healthy toilet etiquette, safe disposal of household and other solid wastes. Internal
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coordination and linkage with BRACs WASH (Water, Sanitation and Hygiene)programme
contributed in ensuring environmental sanitation at community level.(BRAC performance
report, May 2012; Quest 3534009)
5. Value for Money
5.1 Performance on VfM measures
The project did not define any VfM measures at design. However, BRAC takes continual value
for money improvements seriously, as demonstrated by the following:
To get assistance during child birth from the CSBA, a family would need to spend (mainly to
purchase logistics) only Tk. 200 on an average in the project areas whereas cost of normal
delivery in the health centre would vary from Tk 1,200 (in a public facility) to Tk. 2,200 (in
private facility).
In Nilphamari, a total of 70 maternal deaths were estimated to have been averted till 2011
since the initiation of the project in 2008. Over the same time period US$ 2,021,030 had been
allocated to implement MNCS interventions to save the lives of those 70 women in the area.
(BRAC performance report, May 2012; Quest 3534009)
5.2 Commercial Improvement and Value for Money
Procurement of project goods was carried out following BRAC procurement rules and
regulations. A rigorous evaluation of suppliers to ensure quality of procured goods,
managerial and staff capacity, after-sales service, prior experience and reputation, and legal
standing was carried out by BRAC procurement department.
Procurement planning was done as per the work plan submitted to the donors in accordance
with the contractual agreement. The process started from a needs assessment at the
beginning of a year and ended after successful delivery of the goods.
Value for money is achieved through competitive tendering processes, maintaining quality,
delivering products at right time, in the right place, at the right price including the right
packaging and right sourcing. Accordingly, all procurement for the MNCS project was done to
maximise the value of funds. As an example, the per unit price of Misoprostol tablet has come
down from Tk 5.29 in 2009 to Tk 4.89 in 2011 because of competitive bidding
procedures.(BRAC performance report, May 2012; Quest 3534009)
5.3 Role of project partners
This project envisaged BRAC would work closely with communities to provide community
based MNCH services and UNICEF to work closely with the MoHFW to strengthen the
services in the facilities. The MOHFW endorsed the project and the project areas, extended
its cooperation and participation in developing the local level plans, delegated limited authority
to recruit necessary staff and procured additional logistics according to the approved plans
and released funds to the local level. These were audited by UNICEF following the UN
procedure.
DFID, AusAID and EKN supported BRAC while only AusAID provided support to UNICEF,
given resources for MNCH services largely exist and provided through the Health Sector
Programmes (HNPSP and the recently approved HPSDP). The donors provided input through
quarterly coordination meetings and semi-annual field visits. The use of CSBAs, establishing
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birthing places in the houses of CSBAs, referral system, establishing new-born care centres in
the hospitals were particularly emphasised by the donors. Independent external reviews were
jointly organised by DFID and AusAID that provided guidance to the project.
5.4 Did the project still represent Value for Money : YES
The project did represent value for money and continues to do so. Saving women and
children lives is morally justified while such interventions are proven to be amongst the most
cost effective1. Health shocks are one of the most important factors that cause households to
fall into poverty in Bangladesh2. Maternal mortalityaffects the poorest women most, with the
rate of maternal mortality in the poorest quintile60 percent higher than that of the wealthiest 3.
(Project memorandum; Quest 3534009).
In this project most of the indicators exceeded the set targets meaning that the return for the
money invested was much more than expected. BRAC provides effective health services at
very low cost mainly because of scale of its operations and adopting a number cost efficient
measures like developing local women to become service providers, bulk procurements
through bidding process, harnessing local support and resources like promoting community
funds for the very poor etc.
Within the scope of the strategic partnership (SPA) with BRAC, MNCS concept will be
expanded to five more districts based on the lessons learned. The investment of the last 4
years is more likely to continue to yield results in the near future.
5.5 If not, what action will you take?
Not applicable.
6. Conditionality
6.1 Update on specific conditions
Not applicable
7. Conclusions
The project has demonstrated excellent results despite the short implementation period of only
a little over 3 years in the phase-1 areas and about 2 years in the new districts. Key lessons
from this project review and from the experience of similar projects (Joint UN MNHI) include:

There is a need to address both demand for services and provision of services,
simultaneously, to maximise impact on health seeking behaviours and health outcomes.

NGOs with an in-depth understanding of the local context are well placed to adopt
1
World Development Report 1993
BIDS, Chronic poverty in Bangladesh
3 DFID Bangladesh factsheet, November 2006
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strategies that are low cost and culturally acceptable - for example training local women to
become community health workers.

These women have demonstrated their potential through driving the outputs above target
levels in most of the cases; CSBAs in particular have successfully filled the gap in
providing skilled attendance during child birth.

Partnership with local private vehicle owners was very effective in ensuring transportation
during emergencies. The sustainability of these local arrangements has been further
strengthened through involving the Local Government.

Use of IT - especially mobile phone networks - has contributed greatly in several ways
such as notifying the status and location of patients with complications to senior referral
staff, preparing the facility for admitting and providing necessary services, communicating
data, etc.

The performance of public health facilities (at sub-district and district levels) can be greatly
improved by working closely with the health managers and making effective changes in the
way things are run. E.g. local level planning, delegation of authority to local health
managers to use project funds for improving quality of care was very effective; recruiting
support staff to help the obstetrician carry out operations in the evening hours made it
possible to offer emergency care round the clock.

Leadership by District Health Managers and motivation of service providers are critical to
improving services. In this regard Pay for Performance generated enthusiasm and
motivation among the public providers/ managers to take measures for setting bench
marks, improving quality and increasing coverage of services.

UNICEF was able to leverage resources from the Health sector programme for EmOC
training, drugs, equipment and supplies.

More attention needs to be paid to documenting, analysing, and generating evidence to
learn further form the experiences.
8. Review Process
This project completion review was undertaken by DFID staff based on the BRAC MNCS
project annual report for 2011, an updated performance report (until March 2012), compiled by
BRAC, previous independent annual review reports and reports of field visits undertaken with
other Partners. The stakeholders of the project i.e. the communities, Local Government
representatives, Ministry of Health and Family Welfare officials were consulted on the value
added by the project.
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