Business Case
URBAN HEALTH
Bangladesh: Strengthening Care for Poor Mothers and New-borns
Business Case
1. Strategic Case
A. Context and need for a DFID intervention
1. Bangladesh is the most densely populated country in the world1 and rapid urbanisation (5%
annually2) is one of its major challenges. With a national population totalling close to 150
million, over 46 million currently live in urban areas (28%). Most urban dwellers live withinten
City Corporations of which Dhaka is by far the largest (pop estimate: 15mill3). Dhaka is the
fastest growing megacity in the world, with a four-fold increase in residents just in the last
decade. This pace of growth is expected to catapult it from its current position as the 11th
largest megacity, to 4th place by 2025 when its population is expected to swell to nearly 22
million.4
2. Despite Bangladesh’s overall prospects from a decade of GDP growth averaging 5-6%
annually, as urbanisation has grown so has poverty. Nearly half5 (20.7 million) of urban
residents live in slums that are congested and poorly serviced, and there are 2.1 million
more urban slum dwellers in 2010 than in 1999. While national statistics show health
improvements overall, the health of slum dwellers is far worse than the national averages or
of the rural population. Non-communicable diseases are escalating reflecting the
increasingly difficult living environment and poor diets.
3. Only 27% of slum dwellers consult qualified doctor, compared with 71% of other urban
dwellers; and health programmes reach slightly more than half of all slum dwellers. There
are huge environmental health challenges that aggravate health status: 79% of household
have no solid waste collection service, 25% have no toilet facility; and 22% lack sufficient
access to drinking water6.
4. Maternal and new-born care for the 20.7 million people living in urban slums is particularly
concerning, and disguisedin national level statistics7. The most vulnerable are poor young
women, most of who marry before the age of 18 (78%), give birth in the first year after
marriage8, and are malnourished. Most women in slums deliver their babies at home not in
facilities (84%) and without check-ups or advice from trained personnel (anti-natal coverage
1
Excluding city-states of Hong Kong and Singapore. Bangladesh has 964-people/sq. km (source: Pop Census, 2011
preliminary results).
2
Compared with 1.34% national population growth.
3
South Asia Population Growth, World Bank, 2009
4
Urban Inequalities, 2010
5
45%, Urban Inequalities, 2010
6
Urban Partnership Programme (UPPR), 2011
7
National maternal mortality is on a positive trajectory with a 40% decline over the last decade with the MMR dropping from 322
to 194 deaths per 100,000 live births by 2010.7
8
BRACManoshi, Community Health Solutions in Bangladesh: baseline survey (2007)
is just 25%). Traditional untrained birth attendants and unqualified providers assist a large
proportion of these women (36.3%)9. Recent research reveals the continuation of harmful
birth practices such as unhygienic vaginal examinations, applying pressure and/or tying the
abdomen, delays in recognizing and referring emergency cases, a strong correlation
between malnourished mothers and underweight babies, and poor care of new-born infants
immediately after delivery10.
5. These circumstances result in thousands of urban women and their new-born babies dying
each year, and among the poorest wealth quintile the chances of dying after childbirth is
increasing. In 2001, 67 in every 100,000 urban women died each year, and this has risen to
73 per 100,000 (2010).11 Women die primarily from bleeding (haemorrhage) and eclampsia.
While there has been a decline in deaths from these causes nationally, haemorrhaging and
eclampsia continue to be responsible for more than half of maternal deaths; and deaths after
childbirth. The main reason poor women die from these causes is because they (and their
relatives) are often ill prepared to seek medical advice if an obstetric emergency occurs
during delivery. Decisions are taken too late, and families are often poorly prepared with no
pre-arranged transport or money. Clinics are often inaccessible due to traffic and
unpredictable opening hours. Many are understaffed or distant from where they are needed
most12.
6. New-born babies die too, and the mortality rate is much worse among the urban poor, than
even among the rural poor in Bangladesh13. Neonatal mortality14 was 43.7 per 1,000 live
births in slums in 2006 compared with the national average of 37 per 1,00015. Of the
survivors, 63 in every 1,000 children born in the slums of Bangladesh die before their first
birthday16, higher than the national average of 52 per 1,000.
7. Malnourished mothers often give birth to low birth weight babies that struggle to survive and
thrive. The problem roots in the low status of women and intra-household food distribution
resulting in lack of total required calorie in-take and micronutrient deficiency among poor
urban women. 27% of women in slums are significantly underweight (BMI <18.5). The
physical condition of many slum women is worsenedalso by the violence they face; 73% of
women in the lowest income quintile reported having faced physical or sexual violence.17
Political economy of urban health:
8. Government’s response to the urban maternal and neonatal health challenges has been
fragmented in large part because urban primary health care (PHC) is not the responsibility of
the Ministry of Health and Family Welfare18. Urban primary health is the responsibility of the
Local Government Division (Ministry of Local Government, Rural Development and
Cooperatives), which allocates less than 2% of its budget to health. This small allocation
9
BDHS 2011
Midwifery in Bangladesh: in depth country analysis, The State of the Worlds Midwifery, 2011
BMMS surveys: 2001, and 2010
12
BMMS 2010 Preliminary Results
13
NIPORT 2005
14
The probability of dying in the first month of life
15
BDHS, 2010
16
Infant mortality
17
BDHS, 2010
18
The role of the Ministry of Health and Family Welfare’s in urban services is as a regulator and provider of hospital services
(secondary, tertiary and specialist).
10
11
isalmost exclusively allocated to environmental infrastructure.
9. For more than a decade Local Government has opted to provide primary health services
through partnerships with local and international NGOs. Notwithstanding issues of
sustainability, service delivery through NGOs offers both opportunities and challenges;
Bangladesh has some of the largest and most innovative NGOs, and new strategies for the
way forward in urban health should be considered in this context.
10. In recently commissioned research19 by DFID, the institutional arrangements of urban health
provision were usefully summarised:
“Beyond the operation of a few small and medium hospitals and outdoor
facilities…constraints have required Local Government Division to coordinate primary health
care on a project basis through contracting NGOs,….There are no permanent institutional
structures in place….nor government budget mechanisms to support urban primary health
care on a sustained basis”.
11. Skilled human resources in health are scarce throughout the public service, in both urban
and rural areas, and most especially for maternal health care. To respond, in 2001 the
Government created a cadre of public Community-based Skilled Birth Attendants (CSBAs).
Yet coverage has remained very low (3.6%) and mostly in rural areas.
12. Although private health care is increasing the quality of services is largely unregulated and of
grave concern. Many private clinics have opened which offer varied standards of care.
Evidence reveals that the poor do not routinely access quality private services primarily
because of cost; the result is that a high proportion of deliveries take place at home20.
Private clinics must be registeredwith the Ministry of Health and Family Welfare, while
private traders dispense drugs and supplies through licenses provided by Local
Government. There are growing numbers of caesarean sections performed by private
practices, in some cases unnecessarily and at great risk. This situation of scarce and low
quality care for the poor is increasingly untenable in City Corporations where the growth of
new slumsettlements has been greatest over the past decade; Chittagong and Dhaka have
the highest number of poor settlements established in the past 5 years21.Mapping of health
facilities in these, and the other City Corporations by DFID in partnership with ICDDR,B 22
reveals that proximity to primary health and emergency obstetric services is extremely
uneven for those living in slum.
Working in Partnership:
13. Addressing thisgrowing health crisis of the urban poor, within an institutional contextin which
Local Government leads but does not prioritise health resourcing, calls for new and more
strategic approaches. Bangladesh is a prime location for potential innovation given its history
as the home of the largest NGOs in the developing world (e.g. BRAC and Grameen), and as
the birthplace of participatory methods.
14. In urban health, new partnership approaches between public and non- State actors are
gaining traction as Governmentincreasingly recognises the value of non-State service
providers in assisting them to keep pace with the sheer magnitude of health challenges. This
19
Lesson Learning around MNCH and Nutrition Service Delivery in urban Bangladesh, ICDDR,B, July 2012
MSB proposal (see Annex 5)
Poor Settlements in Bangladesh, UPPR 2011.
22
International Centre for Diarrhoeal Disease, Bangladesh
20
21
is evidenced in e-health and telemedicine initiatives, for example, where coordinated efforts
have grown rapidly in the past 5 years. The foundation exists for building similar
transformative and strategic partnerships to address urban health through long-standing
experienced NGO providers who have worked in partnership with Government for more than
a decade. This would require, as a first step, agreed standards of care and capacity for
large-scale service provision.
15. In 2012, to inform how this might be shaped, DFID commissioned studies which included:
i.
O’Connell, et al, , End of Project Review Urban Primary Health Care (Phase II), March 2012
ii.
ICDDRB23, Lesson Learning around MNCH and Nutrition Service Delivery in urban Bangladesh,
July 2012, and
iii.
HLSP24, Strengthening Care for Poor Mothers and New-borns in Urban Areas of Bangladesh,
(Programme Document, Annex 15 and inputs into the Business Case), Oct 2012
16. The first study reviewed DFID’s investment in the second phase of the Urban Primary Health
Care Project (UPHCP II), which concluded in June 2012. The second study looked more
broadly at health service provision for the urban poor, identified the main actors,and
gathered users’ views of service provision. The third study (HLSP) deepened evidence on
the main actors by considering the4 largest maternal new-born and child health (MNCH)
providers in terms of quality of services, value for money, and willingness to coordinate
towards a harmonised system (Annex 4, details). The four service providers were:
1. Marie Stopes Bangladesh (MSB):who have served1.6 million patients annually through
400 service delivery outlets (including 132 static clinics; referral clinics, and mini clinics)
in 64 districts of Bangladesh. They also provide medical services to 80 urban garment
factories, two major urban adolescent centres, services for the homeless through mobile
clinic vans, and partner with 25 local NGOs to run drop-in-centres with a focus on
HIV/AIDS prevention, STI management for vulnerable and high risk groups. ‘Quality of
Care’ is a top priority. MSB is a preferred partner of Government in delivering Menstrual
Regulation and permanentand long-acting family planning services.
2. USAIDSmiling Sun Health/ Service Development Project (USAID-SS/HSDP): who
have served approximately 2.7m urban poor annuall. The programme is both urban and
rural, and in its totality isUSAID’s largest health initiative in Bangladesh. A new phase
began in 2013, and is now The Health Service Delivery Project (implementing partner:
Pathfinder). The urban component will workthrough 22 NGOs serving City Corporations
and Municipalities. Emphasis is on quality of care, management and financial
sustainability.
3. BRAC-Manoshi (urban):who have reached 2.9 million urban poor women through the
largest house-to-house health outreach service in Bangladesh.BRACManoshiworks in
six City Corporations, and isaiming to expand. They run slum-based birthing centres, and
when emergencies happen, they face challenges in ensuring patients receive
care.Manoshi is part of the overall BRAC programme and is multi-donor supported,
including funds from a Strategic Partnership Agreement with DFID.
4. Urban Primary Health Care Project (UPHCP2- ADB). Is a long-standing project (1998)
entering its third phase with Local Government and managed by ADB. Until 2012 DFID
provided 28% of the budget, for primary health care services delivered through 11
23
International Centre for Diarrhoeal Disease Research, Bangladesh
HLSP Team Oct 2012 : R.Ward, Dr.P.Thompson, Dr.Shawkat Ali, J.Venghaus, N. Faiz, Dr.Morsheda Chowdhury
24
NGOin 6 city corporations and 5 municipalities. On average, 23,970 women gave birth in
facilities25annually during the time of DFID support,and overall 22% of patients were
considered poor and received free services.
17. The key overall finding from the studies mentioned above was that there is “insufficient
supply of urban primary health care,and 24/7 emergency obstetric services in close proximity
to areas where large numbers of urban poor reside26.” Both the second study (ICDDR,B) and
the third (HLSP) found that each of the four programmes outlined above have strengths yet
coordination was limited. This has led to large geographic gaps in some areas, and overserved locations in others. Variations were wide in terms of working hours, staffing, and
voucher scheme use and eligibility. There were some similarities in standards of care, but
management capacity, potential to go to scale, and willingness to coordinate efforts varied.
18. The HLSPstudysuggested the need, and opportunity, for transformation through NGO
service delivery over the medium term, and provided the vision for a building a ‘system of
care’. The first step was identifiedas the need forimproved coordination, expansion and
provision of services to agreed standards of care. Both studies suggested linking together
the largest outreach service (BRAC), with high quality clinic providers in order to create a
continuum of care on a scale which could result in significant impact.
19. In late 2012, preliminary brokering began with potential partners to determine whether a
unified and harmonised system could be shaped. GIS mapping of existing health facilities
across the 4 organisations was completed, anddiscussion held on issues such as willingness
to open clinics to all poor clients from BRAC (Manoshi).
20. This preliminary work, ahead of this potential Business Case, was timely because each of
the 4 organisations mentioned above were shaping their interventions for the future. This
information has informed the appraisedoptions in this Business Case.
How does this support DFID priorities – globally, regionally and bilaterally?
21. The programme will contribute to DFID’s Operation Plan target (1.2 million assisted births)
by putting in place the means of supporting nearly 100,000 urban women in giving birth. It is
a stretch to come close to meeting this target in Bangladesh, but without this programme
DFID Bangladesh won’t make its way closer to it. .
22. The programme would support global strategic vision for women and girls outlined in DFID’s
Business Plan (2011-15). This prioritises care before birth (including delaying first
pregnancy), during and after childbirth; access to modern contraceptive methods; improving
immunization coverage, and delivering nutrition services. This is especially relevant in
Bangladesh where adolescent marriage is common, and many face domestic violence.
23. In terms of DFID’s global health priorities, the proposed programme is in line with the UK’s
Framework for Results for Improving Maternal and New-born Health in the Developing World
(2010), and represents operationalization of this in one of DFID’s priority countries. In 2010,
the UK government also committed to doubling its efforts for women and children by 2015.
This programme helps to meet this commitment by ensuring assisted births for nearly
25To
Dec 2011
Lesson Learning around MNCH and Nutrition Service Delivery in urban Bangladesh, ICDDR,B, July 2012
26
100,000 women, and is aligned with UN Human Right’s Council’s 2010 resolution on
Maternal Health and Scaling up Nutrition (SUN) framework.
24. The programme will operate alongside, and significantly complements our support to the
public Health Sector Programme in Bangladesh (HPNSDP, 2011-2016) which provides
primary health care mainly in rural areas but does not address urban primary health care
needs. It will coordinate with the Urban Partnership Programme (UPPR) efforts by
deepening impact on maternal health in the poorest areas.
25. Finally, this programme augments DFID’s regional investment in the Prevention of Maternal
Deaths through Unwanted Pregnancy (PMDUP) to address unsafe abortion, and unmet
needs for family planning services and nutrition needs respectively.
What are the consequences of non-interventions:
26. Given that achieving MDG4 and 5 requires addressing the maternal and child health needs
of the most marginalised, 20.7 million of whom live in urban slums, non-intervention could
stall progress.
27. For DFID non-intervention would mean an almost exclusively rural health focus in
Bangladesh, through support to the Government’s Health Sector Development Programme
(HPNSDP).
28. Non-intervention has several consequences which include (a) continued disjointed and
varied maternal and neonatal care for the urban poor urban in Bangladesh (b) 65fewer wellequipped clinics serving the urban poor (c) nearly 100,000 poor urban women would need to
seek skilled birth attendance from elsewhere and likely face user fees, as would over 1.1
potential additional family planning users, and (c) ad hoc access to clinical care for BRAC’s
poor urban clients facing emergencies during birthing and aftercare would continue.
B. Impact and outcome that we expect to achieve
29. The proposed programme couldcontribute to Bangladesh achievingMDG 4 (Child Mortality)
&MDG 5 (Maternal Mortality), and help to stem the tide of increasing mortality among the
urban poor. Mortality among new-borns in urban slums is far worse than even among the
rural poor (2200 die each year); and for their mothers mortality has increased since 200127.
IMPACT INDICATORS:
30. In general, the ‘low hanging fruit’ for achieving MDG 4 and 5 have been picked; maternal
and child mortality nationally has steadily reduced for the middle and upper wealth quintiles
and in most rural areas served by the Health Sector Development Programme. However, the
urban poor have yet to see significant improvements.Therefore, this programme’s impact
will be primarily on achieving MDG 4 and 5 in urban areas (maternal and infant
mortality), and most especially for the urban poor. In doing this, 4 indicators and targets will
be monitored: :
Maternal mortality reduction from 194to 143/10000 live birth
Infant mortality reduction from 43 to 31%
27
BMMS 2001, 2010
Neonatal mortality reduction from 37 to 21%
Total fertility rate decreased from 2.2 to 2%
OUTCOMES:
31. The proposed programme will provide support to achieving the impact highlighted above
bystrengthening maternal and new-born health services forpoor urban mothers and
new-borns. The following are the specific minimum targets expected:
98,052poor urban women assisted by skilled providers while giving birth
562,500poor urban women with 4 check-ups before birth (anti-natal)
175,375 poor urban women with a check-up within 48 hours of giving birth
1,166,305 additional users of modern family planning methods
32. These outcomes will be achieved by expanding new and existingclinics, in order to build a
referral system able to address emergency obstetric care, blood transfusions and caesarean
sections for poor urban women28. The programme aims to increase capacity utilisation of
existing clinics by providing services which include:









maternal nutrition: control of anaemia and distribution of Vitamin A
Training of 2500 health workers in nutrition messages and intervention,
ANC services including tetanus toxoid,
neo-natal and post-natal care within 48 hours of giving birth,
modern and long acting family planning methods,
hygiene promotion for all, including focused efforts on birth attendants and new mothers,
adolescent reproductive health services,
emergency support to victims of gender based violence,
menstrual regulation services (through Marie Stopes)
Details of expected service delivery and standards are providedin Annex 2.
28Clinics will provide 24/7 emergency services to the poor free of charge, and to non-poor women for agreed fees.
2. Appraisal Case
33. What are the feasible options that address the need set out in the Strategic
Case?
OPTION 1: Support to Urban Primary Health Care Project (Phase 3)
34. Under this option DFID would support the third phase of the Asian Development Bank (ADB)
project with Local Government Division (2013-18). Evidence used in considering this option
is based on DFID’ssupport toPhases 1 and 2 (2005-12) which was assessed inthree studies:
a. Urban Primary Health Care Project II, Report of the end of project review (Quest no:
3516067). March 2012which independently assessed the project’s: results, quality of
care, value for money; potential for delivering on critical success criteria; and political
economy of health within local government,(Quest 3516067)
b. Lesson Learning around MNCH and Nutrition Service Delivery in Urban Bangladesh,
independent research on key lessons for scaling up maternal and new-born health
services (ICDDR,B 2012), (Quest 3674312)
c. DFID Project Completion Report, (UPHCP II), 2012.(Quest 3619259):
OPTION 2: A ‘system of care’ through unifying and scaling up services with proven partners
35. Under this option DFID considers support to the development of a potential ‘system of
care’through unifying and harmonising approaches of those organisations’ experienced in
delivering quality maternal and primary health care in urban Bangladesh. Such a programme
could enable an expanded number of clinic and services near, and in, slums for maternalnew-born-child health, family planning and nutrition services; drive up standards of lowquality providers through ‘branding’ and increased client demand; and provide in the medium
term a more platform for a more coherent approach to urban primary health care by others
including Government. It would increase access, harmonise services across the key
providers and build a rigorous health referral system (i.e. continuum of care) for the urban
poor in Bangladesh.
36. The evidence used to inform this option included commissioned work by HLSP Strengthening
Care for Poor Mothers and New-borns in Urban Areas of Bangladesh, (Programme Document, and
Inputs to the Business Case, Annex 15); Lesson Learning around MNCH and Nutrition Service Delivery
in urban Bangladesh; internal reports from BRAC; andUSAID’s Smiling Sun mid-term
evaluation (2010).
OPTION 3: No additional financial resources
37. Under this option, DFID considers the implications of not funding urban primary health care,
beyond its already agreed support to BRAC (Manoshi) which forms part of the BRAC
Strategic Partnership Agreement in 2012.This is the counterfactual against which Option 1
and 2 should be compared. This considers services which will be on-going, and what they
will deliver even if there is no DFID assistance to urban health.
THEORY OF CHANGE:
38. The theory of change is based on the goal of reducing maternal and neo-natal deaths,
particularly among women living in urban slums in Bangladesh through proven health care
interventions, which address the main causes of death. To affect this change, it is necessary
to scale-up 24/7 emergency obstetric provision in close proximity to the slums, and to
harmonise services which prepare women for delivery (ante-natal care), including by
addressing nutritional needs and hygiene practices. To ensure mothers and babies survive
the birthing process, and immediate recovery period, post-partum and neo natal care (PNC)
by skilled providers is also required. It is equally important to support women to space
pregnancies and prevent unwanted pregnancies through quality family planning services.
Staff in clinics will also need to be able to identify signs of abuse, provide appropriate clinical
care, and know where and how to refer clients in relation to ‘safe houses’ and legal support.
The diagram below illustrates the overall Theory of Change.
Theory of Change:
Process
Inputs
Output
Provision of ANC,
PNC, skill attendants
at birth, neonatal
care, child health
care, Family Planning
services, voucher for
poor
Technical and
Financial
resources
Equip and upgrade
25 clinics close to
slums for providing
services at 24/7
Assumptions
Disbursement is on
time, HD team
manages
effectively and
efficiently
1)
Safe deliveries,
new born survival
Family planning,
nutrition and hygiene
promoted
High quality
behavioural change
campaigns
Health system
strengthening urban
mapping, M&E,
quality assurance,
and applied research
Impact
Delivery by skilled
attendants
Health facilities
equipped/ upgraded
to agreed standard;
Community demand
creation through
house-to-house
outreach and
information
Outcome
Additional Family
Planning Users
Efficient referral
system
established
(including for
victims of
violence)
Strengthened health
system to provide
better health service
in urban areas
Assumptions
1)Partners adhere
to agreed core
principles,
including for
harmonising
voucher scheme
2) Trained staff
retained and willing
to provide services
to the poor
Reduced
maternal and
new born deaths
in urban areas of
Bangladesh
Assumptions
1) Community is
willing to uptake
the services
2) Coordination of
programme
effectively
managed
3) No Stock out of
commodities
4) Referral system
well functioning
between partners
5) Communication
strategy and
application is
sufficient to change
hygiene, fp, and
nutrition behaviour;
Assumptions
1) Government
continues
supportive attitude
towards MSB and
USAID as key
service provider in
urban health
2) UK govt support
continues
3) No major
environmental
catastrophe
Assumptions and risks:
39. Applied research will be the key method for exploring the realities in relation to the
assumptions in the above chart. Applied research will be useful in informing the extent to
which a system which transforms health delivery in urban areas is emerging. This will require
assessment of performance, relations with Government and views of users. Applied
research will be used to provide strategic guidance going forward. In addition applied
research on demand for uptake of services;out-of pocket expenses; health seeking
behaviour towards including towards private sector urban maternal care;effectiveness of
behaviour change communications; the impact of climate change on urban slum health; and
the impact of harmonised voucher schemes may be undertaken.
40. The main risk underpinning these assumptions relate to retaining Government’s continued
support towards NGO service provision in urban health. Although long-term positive working
relationships have been established by some non-State actorswith both MOHFWand Local
Government, risks exist which result from frequent high-level staff changes within
Government. Mitigation will require maintaining close and active working relations between
programme partners and the two key Government Ministries.
B. Assessing the strength of the evidence base for each feasible option
41. The quality and strength of evidence on which to determine the best option is good.
Independent evaluations, research and commissioned programming, mostly in 2012, include
the following:

An independent assessment of potential partners, commissioned by DFID and led by
HLSP (August-October 2012) resulting in two documents:

Inputs to the Business Case and

Programme Document for Urban Health Care(Annex 15)

Independently commissioned research on health seeking behaviour in the slums, and
facility mapping by ICDDRB, (see Lesson Learning around MNCH and Nutrition Service
Delivery in Urban Bangladesh,ICDDRB, July 2012). (Quest 3674312)

Report of the end of project Review, Urban Primary Health Care Project II. A. O’Connell
et al, DFID, March 2012; and DFID’s Project Completion Report (Quest ref: 3516067)

USAID’sSSFP Mid-term evaluation, 2010,

Marie Stopes Bangladesh: Preventing Unwanted Maternal Deaths from Unsafe
Pregnancies (PUMDUP, 2011-2016) annual reviews 2011 and 2012, DFID (Quest:
3719113).
42. These studies have been used to inform the strategic choice and guide the management of
the potential programme. Substantial inputs have been included in the annexes to this
Business Case. Overall, the studies confirmed two fundamentalissues which influenced the
choice of option, that “there is insufficient supply of urban health care, and 24/7 emergency
obstetric services in close proximity to areas where large numbers of urban poor reside”
(study 2 above); and that “to have significant impact on the growing urban poor population in
Bangladesh requires a coordinated expansion of quality services by non-state actors”.
Assessing the strength of each feasible option:
43.
The following are considered the weighted critical success criteria of the programme.
Each option has been assessed29 and Option 2 scored consistently highest because of its
ability to provide potential scale, quality, integrated services, innovation and effect on the
institutional arrangements for urban maternal and new-born health.
Critical Success Criteria
1
2
3
4
5
6
Scale and harmonization of maternal
and new born health services through
coordination with other agencies
Delivering quality emergency obstetric
and new born survival care as a
comprehensive package (MNCHFP&
Hygiene) and as part of a continuum of
care for the poorest in urban areas
Integration of family planning, nutrition
and hygiene messages into maternal
care for the poorest
Expansion of ANC and PHC, in
coordination with other agencies to
benefit the poorest.
Introduction of innovations in maternal
delivery and new born care by outreach
workers in urban slums
Improving Public policy and
institutional arrangements for urban
health: improved institutional structure,
urban health information, and regulatory
functioning
Weighting
Option 2
(Partnership
Approach)
Score
Option 3
(Counterfactual)
(1-5)
Option 1
(UPHCP
III)
Score
5
2
4
0
5
1
5
1
4
2
4
1
4
2
3
0
3
3
3
1
3
2
2
1
Score
Option 1:Support to Urban Primary Health Care Project (Phase 3)
43. Under this option DFID would support Phase 3of Asian Development Bank’s project (ADB)
with the Local Government Division (2013-18).This would include support to subcontractednational NGOs to provide primary health care services to the urban poor. This
would be continued support to a project which began in 1998, and towards which DFID
provided resources equivalent to $25m during Phase 2 (2005-12; 27% of total
resources).The evidence for appraising this option comes primarily from independent
assessments30of past performance.
44. The 2012 independent evaluationfound achievements during past performance of
UPHCPwhich included the commissioning of the 2011 draft Urban Health Strategy
(remaining to be approved in Cabinet as of March 2013); the servicing of over 35 million
client visits over 7 years; and the provision of 22% of services free to the poorest (2012).
29R. Ward, et al, “Strengthening Care for Poor Mothers and New-borns in Urban areas of Bangladesh. Notes to the Business
Case”,HLSP, October 2012
30Report of the end of Project Review, Urban Primary Health Care Project II. A. O’Connell et al, DFID, March 2012 (Quest
3516067)
45. Challenges were also found which included managerial weaknesses and weak absorption
capacity. Overall there was slow implementation and delays in sub-contracting NGOs; only
60% of funds were disbursed. Ultimately $28m (of the total $91m) was not utilised within the
planned project timeframe.
46. The evaluation also found the programme’s clinical training did not follow national standards,
and there was limited overall adherence to national guidelines, as well as limited overall
improvements since the 2010 mid-term review. Significant sub-standard quality of care was
found and described as,“overall cleanliness of clinics was not good…infection prevention
was weak…disposal of clinical waste was handled improperly…partographs were not filled
to track progress in labour…clients records were not filled”31.. Concerns about low quality in
some emergency services, an under-developed referral system,and an unacceptably high
level of C-Sections (40%)32 were also reported. Low performance in the completion of
required infrastructure (comprehensive clinics, primary centres, and toilets); in retaining
trained staff; and in house-to-house outreach were also found.
47. Although the programme piloted public-private partnerships involving Local Government in
selecting NGO sub-contractors, the impact of political interference on the effectiveness and
efficiency of project implementation was noted. The final evaluation concluded that, “The
(programme) is yet to strengthen the role and responsibilities of the Local Government
Division towards delivering its mandate for the provision of urban PHC due to no permanent
structure for urban health in the Local Government Division”.33
48. Phase 3 of ADB’s programme was assessed for its potential (HLSP34). Therisk analysis
highlighted concerns about further driving down of quality of care. HLSP reported that
“Selection criteria (of NGO implementers) focused on ‘lowest cost’ as the main criteria for
NGO selection….as a result some high performing and high quality implementing
organisations from Phase 2 were not selected, leaving some good performing clinics in
precarious and imminent fear of closure”.
49. Staff turnover (including doctors), was also a continuing risk because of lack of opportunities
for professional development and job security. Family planning commodity supply which
hampered services during Phase 2 was also not addressed in Phase 3 planning. Overall,
HLSP’s assessment deemed UPHCP Phase 3 to be “relatively high risk” for DFID
investment in urban health provision on the basis of the Critical Success Criteria. This
summarises the issues from the evidence of independent assessments as to why UPHCP
Phase 3 is not the preferred option for supporting urban primary health care needs going
forward.
50. Despite the shortcomings and risks a potential opportunity does however remain. UPHCP 3
(or its NGO implementers) could align and join with other potential partners in urban health
at any time going forward, including those described in Option 2 below. Improved quality of
care,of management, and willingness to harmonise and scale up with other providers would,
31O’Connell et al, ibid (Quest ref: 3516067)
3240%of institutional deliveries were C-sections; because of incomplete client records the necessity for C-sections was not
possible to determine.
33
ibid
34R. Ward, et al, “Strengthening Care for Poor Mothers and New-borns in Urban areas of Bangladesh. Notes to the Business
Case”,HLSP, October 2012
however, be prerequisites.
Option 2 (Preferred Option): A ‘system of care’ through unifying and
scaling up services with proven partners
51. Under this option DFID would support the development of a ‘system of care’ for delivering
quality maternal and primary health, by harmonising, expanding and branding the services of
potential partner organisations. In doing this, the largest urban health referral system in
Bangladesh could be created to serve the urban poor. It could provide care from household
to comprehensive facilities.
52. In appraising this option, the four largest service providers were independently assessed
byHLSP35 for their quality of services, potential for expansion, management and financial
capacities (i.e. using the critical success criteria above). The first of these large providers is
assessed under Option 1 above. The three remaining are considered under this option36:
a. USAID’s urban Health Service Delivery Programme (HSDP, 2013 to 2017), plus
b. Marie Stopes Bangladesh (MSB) clinic services and
c. BRAC Manoshi community health services in the urban slums.
53. The three potential partners would together build a ‘system of care’. Implementation requires
this approach across organisations and their local sub-partners because no single
organisation has the capacity, technical expertise or reach to deliver all services in its
entirety. This ‘system of care’ would involve:
d. Expanding quality maternal and new-born health care services (including
emergency obstetrics) in close proximity to the urban poor;
e. Increasing access by building a network of harmonised services, and expanding
clinic hours, voucher schemes, family planning, nutrition, and gender violence
referrals and care.
f. Improving urban planning through partnering with Local Government at City
Corporations and Municipalities levels through Health Managers. Building capacity in
health GIS and MIS, location selection, service range, and monitoring. Coordinate
with other development partners supporting Local Government and Ministry of Health
and Family Welfare in their regulatory functions (e.g. European Union).
g. Rolling-out behaviour change that works, through scaling up out-reach and
innovative information dissemination to poor women
h. Innovations in training and tools for safe delivery (haemorrhage mats) and newborn care (birthing kits to reduce neo-natal deaths from pneumonia and asphyxiation;
35R. Ward, et al, “Strengthening Care for Poor Mothers and New-borns in Urban areas of Bangladesh. Notes to the Business
Case and Programme Document”,HLSP, October 2012 (Annex 15)
36
ADB was not selected based on evidence summarized above under Option 1.
and application of IT to provide quality services and increase efficiencies).
54. The full assessment report of findings from HLSP gives detailed evidence of the strength of
the three preferred partners: USAID, MSB and BRAC. To summarise, they were confirmed
as providers of quality reproductive health services, through wide networks of clinics/nodes
(746) in urban areas throughout Bangladesh for over a decade. The following provides a
summary analysis from the assessment:
i.
Government recognises these three partners as key service providers in urban health
for the poor. All have worked closely with both local and central government,
including as contracted service deliverers in urban and rural health care. USAID is a
preferred partner of Ministry of Health and Family Welfare, and MSB has
collaborated closely with the Directorate of Family Planning over years of service
provision in hard to reach areas.
j.
Strategies for ensuring uninterrupted supply of clinic commodities for drugs and
family planning are in place in both USAID’s project and in MSB. Equally both USAID
and Marie Stopes deliver quality emergency obstetric care, and were independently
judged to have the capacity for expansion (ibid). In terms of retention of staff, MSB
and USAID have historically faced fewer challenges than UPHCP, but are not free of
difficulties; they offer contracts and some career progression although retention when
public sector vacancies open-up is a challenge to all non-state providers.
k. Track records of innovations in maternal and neonatal health are well established
among the 3 potential partners, including the introduction of: urban birthing huts,
birthing kits, mobile clinics, and the use of mobile technologies for monitoring and
GIS mapping.
l.
The managerial and absorptive capacities were judged as ‘strong’. The chart below
gives a glimpse of comparative absorption capacity of each. Further details are
provided in the Finance and Commercial sections of this Business Case and in
Annex 4 (Due Diligence Assessment).
55. Further comparative data on potential partners’ performance in urban health is summarised
in the chart below. The figures give a baseline of operations in 2012, and illustrate that by
combining three of the potential partners (USAID, Marie Stopes Bangladesh and BRAC
(urban), this option would build on a client base of 7.2 million poor urban women and
children through 746 clinics and nodes. With DFID’s additional assistance this could expand
with 65 new and upgraded clinics. The data also illustrates their absorptive capacities and
the combined strength of their outreach.
56. Initial agreement on potential service harmonisation was reached in 2012 (see Annex 2
details). If technical and financial resources from DFID are made available, the partners will
begin by expanding and up-grade their clinics by 63, provide free emergency obstetric care
to BRAC (Manoshi)’s poor urban clients, harmonise their standards of care and voucher
schemes, and work towards agreeing a system of “branding” their quality services.
57. Additional resources would not be required byBRAC (Manoshi)because finance has been
previously agreed under the DFID-BRAC Strategic Partnership Agreement (2012).
Nonetheless they wish to be in this new partnership, in recognition of the services it could
provide to the poor women and new-borns reached by their network of community health
workers (7300), the largest in urban Bangladesh.
58. A Health Systems Strengthening (HSS) provider has been designed into the programme to
facilitate coordination across partner organisations, and towards building a ‘system of care’.
This provider would, together with partners, deepen the institutional linkages of the
programme with Local Government (including with City Corporations, municipalities where
implementation takes place), and Ministry of Health and Family Welfare, through existing
structures. This will include close cooperation with the new EU programme focused on
institutional strengthening of the Local Government Division in terms of urban health. Initial
discussions on this have been positive.
59. The HSS provider would also monitor the harmonisation of systems and standards; lead on
branding quality standards (described below); ensure quarterly reports and annual
independently assessments; commission practical applied research; and update the GIS
mapping of health facilities.
60. Quality assurance “branding” could give the programme identity, membership and quality
compliance. This will require establishing partnership standards and protocols, as well as
assessment systems and accreditation. Branding may also be a means of incentivising the
private sector and new NGOs to join as they strive to be ‘branded’ as high quality under this
large new partnership. Branding is a means also of informing clients/patients on where
quality services are guaranteed, thus driving performance and standards up through the
demand-side of service provision.
61. A Programme Document37 will guide implementation and includes benchmarks to determine
progress on the transformational/systemic aspects of this programme. The mid-term review
is one such benchmark which should be informed by applied research on the first steps
towards building a ‘system of care’. This should consider achievements and challenges in
harmonisation and links across partner organisation, and issues of sustainability. An
incremental approach towards sustainability will be important given the diverse and shifting
nature of service providers, financiers, and government officials. The challenge is that
without the first steps towards a ‘system of care’ for urban health services, what is there to
sustain? Sustainability is currently the concern of individual service providers (NGOs) as
they scrabble and compete for donor funds. Ad hoc and disjointed service provision has
resulted. Transforming this situation into a ‘system of care’ is the foundation for sustainability
because it could enable more rationale use of resources and clear standards of quality of
care for the poor in urban areas. Building this will require strong and experienced partners
willing to harmonise and scale up collaboratively in Bangladesh. This is the rationale for the
preference of Option 2 in this Business Case.
Partner Comparative Grid (2012 BASELINE)
Ward (et al), “Strengthening Care for Poor Mothers and New-borns in Urban areas of Bangladesh. Programme
Document”,HLSP, October 2012 (Annex 15)
37
OPTION 2: Proven Partners
#
Indicator
1
# of urban
clinics/service nodes
# of specialised
clinics
OPTION 1:
Sub
USAID/
HSD39
Marie Stopes
Bangladesh40
BRAC
(Manoshi)41
185
19342
132
421
26
47 ultrasi
6
comprehensive
5
UPHCP III
38
-totals
OPTION 2
746
58
2
# of staff in clinics
260243
6000
1090
852
7943
3
# of outreach staff
1422
Very few urban
163
7300
7463
4
Expansion of sites
over 5 years
42%
75%
45%
8%
5
Value of current
programmes44
£4.9m
£4.3m 45
£6.0m
£13.7m
6
Burn rate/absorption
capacity
60%
100%+
95%
98%
7
Admin or
management costs
N/A
5%46
15%
10%
8
Client base in urban
areas (mainly
women and children)
4.9m47
2.7m48
1.6m49
2.9m
9
Service range50
ESP+ & MR
ESP + EOC
ESP+RMNHC +
MR
BMNHC51
10
Contact unit cost
£0.22
£0.22
£0.82
N/A
11
% of clients treated
for free
38%
30%
30%
100%
12
Type of free
treatment
ESP+
MNCH
ESP+RMNHC +
MR
MNHC
13
Cost recovery %
21%
40%
48%
0%
14
‘Green’ audit
Yes52
Green-amber
Yes
Yes
15
M&E cost % total
costs
3%
>5%53
10%
10%
16
Staff costs (% of
total)
71%
70%
60%
21%
17
Staff turnover %
N/A
15%
15%
10%
38
£24m
7.2m
Quarterly reports January-March 2012
SSFP financial report 2011
40
MSB Interviews and DFID Urban Health Proposal 2012
41
Dr Morsheda and the BRAC 2011 Annual Report
42
47 are ‘Ultra Clinics’
43
Calculated from UPHCP II Project Design
44
This total expenditure for the most recent financial year has been netted of administration or management costs
45
2011 financial year
46
The admin changes were subsequently reduced from 30% to 5% after negotiations with USAID.
47
At 2.8 services per client
48
33% of total clients which were 8.3m in 2011
49
89% are total MSB clientsin 2011are urban poor or subsidized in some way
50Refers to the range of services provided by the partner organisations eg.EOC means Essential Obstetric Services, MR
means Menstrual regulation and BMNHC means basic maternal and new-born Health care etc.
51
Basic Maternal, Neonatal and Child Health Care,
52
UPHCP annual audit government auditors (FAPAD)
53
Doesn’t include evaluation money
39
Option 3:No additional financial resources
43. This option considers the situation of urban health if DFID does not provide additional
resources. Institutionally, choosing this option would be choosing the status quo in which
provision of services for the urban poor are disjointed, and of varied quality. It is likely that
without DFID involvement, the proposed multi-partner efforts to develop a ‘system of care’
would not be implemented at all.
44. It is against this Option, that Option 1 and 2 should be compared. Overall, comparatively
small urban health programmes of non-State (NGO) actors would continue. The main
players would likely be the same, albeit with UPHCP Phase 3 resourced mainly through ADB
loan financing and providing low-cost (and likely low-quality) care; Marie Stopes Bangladesh
would be scaled-down and mainly provide family planning services and not skilled birth
assistance; USAID’s programme would focus mainlyon rural rather than urban; and BRAC
(Manoshi) would continue their slum outreach work with no guaranteed referral clinics for
emergency obstetric care.
45. There would be lost utilisation of partners’ combined potential for scaling up and harmonising
services. With DFID potential funding, for example, 65 new and up-graded clinics, including
27 fully comprehensive clinics to serve 1200 poor urban women and girls each month with
care and counselling would not be realised. This potential will be lost without additional DFID
funds.
46. Overall, nearly 100,000 poor women would not be assisted at birth, three-quarters of who
will require emergency care, but may not receive services within close proximity of their
homes and may die. Over 550,000 poor women may go without adequate pre-birth checkups, and over a million fewer people will have readily available access to family planning.
Finally, new born care for over 12,000 babies requiring skilled assistance may miss out and
die (see Economic Appraisal below), and women victims of domestic violence would
continue to face challenges knowing where to access help.
47. The impact would be felt on the poor, because their out of pocket expenses on health care
are likely to rise if emergency maternal and new-born care needs arise. They could also face
additional expenses for basic ANC and PNC services, as well as family planning services.
Counselling and referral at clinics for women victims of domestic violence may not take
place. Finally, this option could result in more households being driven further into poverty
because of maternal deaths caused by lack of accessible 24/7 clinics.
48. Specifically, if no resources are provided the current number of clients served by Marie
Stopes as of 2012 will reduce from 2013 onwards by approximately 300,000 per year, or
1.5m over the proposed programme life (5 years). 25 clinics/nodes will close, including
comprehensive maternal services previously available and providing skilled birth assistance.
The range of services available to mothers and new-borns will also reduce, and this will
affect 6.4m clients who currently use the remaining 107 clinics/nodes of Marie Stopes.
Remaining services will focus primarily on family planning, ANC and PNC.
49. The numbers of clients serviced by USAIDwould remain at 2012 levels. Significant
expansion would be unlikely however, although some incremental expansion is being
planned as they strive for improved utilisation with their new 2013 implementing partner,
Pathfinder. BRAC (Manoshi) would likely continue to serve similar numbers of clients at
community level (utilising SPA funds), but face on-going challenges in accessing referral
services for comprehensive care and emergency obstetric cases.
Likely impact
environment?
(positive
and
negative)
on
climate
change
and
50. For Option 2, the preferred option, the potential climate change and environmental impact is
considered low and opportunities medium. The programme itself will not contribute to the
negative effects of climate change.Climate change is expected to increase weather
extremes in Bangladesh. As a result the rate
Climate change
Climate change and
of migration towards urban areas might Option
and environment environment
risks and
opportunities, Category
increase, which will increase the number of
impacts,
people seeking health services. The clinics
Category (A, B,
(A, B, C, D)
C, D)
will be equipped with the logistics and
resources to mitigate such challenges e.g.
24/7 services within and near slums, trained
staffs, medical equipmentand drug supplies.
51. Rapid urbanization and density of population
is high in slum areas, and the risk of
contaminating water sources with medical
waste and latrines is a challenge, although
this is mitigated because most clinic locations are on the edge of slum settlements and
therefore have vehicle access. This will be tracked through the third strand of the
programme (Health Systems Strengthening) and partner innovations to provide portable/low
technology incinerators with low carbon. Clinics will be maintaining quality as per the
standard protocol for medical waste and will be managed according to the Ministry of Health
and Family Welfare medical waste management protocol. The clinic staff and outreach
worker will be informed and oriented on medical waste management.
52. Water and sanitation will be provided at all clinics, and hygiene training especially for staff
and new mothers will be emphasized. City/Municipal health officers will be engaged to
provide monitoring and to inform urban users on pollution and health risks.
53. The programme will be addressing the reproductive need of the women including family
planning services and we expect continued use of contraceptives and child health. Effective
behavioural change communication on family planning will help reduce natural population
growth and therefore positively impact on the environment, while behaviour change
messages on child health such as management of diarrhoeal diseases will reduce the
incidence of potential cholera outbreaks in slum communities.
54. The urban slums are often located in low- 1
C
C
lying areas most exposed to the effects of
C
B
climate change. Little or no infrastructure 2
exists to provide protection from storm
3
C
B
events or to ensure mobility. The inherent
vulnerability of these settlements is amplified Categorise A, high potential risk / opportunity; B, medium /
potential risk / opportunity; C, low / no risk /
as the effects of global climate change manageable
opportunity.
become more pronounced. Slums within
Dhaka City Corporation for example are not flood prone most years, but they do have the
problem of water logging when heavy rains occur. Often drains are blocked with garbage
and there are open sewers which cause wide health risks (particularly diarrhoeal diseases).
Slum communities have minimum disaster management processes and precautions at
family level, like, fire wood preservation, placement of furniture up on bricks, repairing
houses before the rainy season but at community level, people do not generally make
collective efforts. Similarly the clinics based in and around the slums need to consider the
implications of water logging and other challenges. These issues will be discussed and
actions planned for in collaboration with the DFID supported Urban Poverty Programme
(UPPR) which has considerable expertise in urban slum mobilisation and up grading of
infrastructure.
C. What are the costs and benefits of each feasible option?
74. This section presents an economic appraisal of the proposed intervention. It does so by
covering the following;
i)
ii)
iii)
iv)
v)
Approach
Expected resource costs of the intervention
Expected benefit of intervention (by service delivery partner)
Balances of costs and benefits
Sensitivity analysis
Approach
75. This appraisal considers the partnerships being proposed in Option 2 with funding to Marie
Stopes Bangladesh (MSB), and with the USAID’s Health Development Programme. In the case of
MSB, we use a detailed proposal provided by the partner54, both to establish log-frame targets, and
to estimate their economic value. In the case of USAID, the appraisal is based on historic data for
the period 2008-2011 relating to the Smiling Sun Franchise Programme (SSFP).
76. The case for investing in the Bangladesh health sector is well established. The overall economic
outcome of it is an increase in labour productivity through investments in human capital, resulting in
a reduction in poverty. This comes from the following economic benefits;

A greater and more effective provision of healthcare (including for mother and new born) will
result in a reduction in citizens out of pocket expenditure by citizens, as they access more
public healthcare. The prevention of disease also offers an economic benefit to individuals,
who incur reduced out of pocket expenditure on drugs.
54Accessible
Safe Maternal and Neonatal Health Services in Urban Areas, proposal submitted to DFID (UK Aid)
by Marie Stopes Bangladesh (Annex 5 A+B)

Fewer instances of disease and illness, and more early treatment will result in additional
lives saved. We take the economic impact of this as the additional income that would be
earned, as well as the overall contribution to the economy made by individuals.

Saving a mother’s life has further benefits for her children and her family. ii Cost of
complicated deliveries can be catastrophic, accounting for more than 10% of annual
household income. Hence the monetised benefits of lives saved (mother, child, and family)
are extremely high.iii

The longer term vision around reforming the overall system of care has it’s own economic
benefits (although they are difficult to quantify). The bringing together of the currently
effective service delivery organisations is expected to improve the quality of care being
provided to patients in the short term, while in the longer run, this will result in a more
sustainable intervention. Further, the social marketing and branding likely to arise from this
intervention has the scope to increase the overall demand and uptake of health services.
77. In addition, to economic arguments, there is also a range of strong equity arguments in support
of this programme. In particular, there remains a very significant gap in the provision and access to
healthcare between the richest and the poorest segments of the population. To highlight one
example, 83.6% of rich citizens access antenatal care from a medically trained provider, compared
to only 30% of the poor. This programme, by providing maternal healthcare, will go a long way
towards reducing some of these disparities.
Expected resource costs of the intervention:
78. The funds for this urban health programme are estimated to be £38 million, of which £15.5
million will be allocated to MSB and £19.6 million to USAID for providing reproductive, maternal,
neonatal and child health (RMNCH) services through NGO clinics. The remaining £2.9 million will
be allocated to health systems strengthening (HSS), monitoring and evaluation (M&E), operations
research and other activities. It has been a conscious programme choice to allocate greater funds to
USAID on the basis of value for money. For example, as the unit cost analysis in section D
demonstrates, USAID is both cheaper on a range of unit costs (eg £23 per DALY compared to £56
for Marie Stopes), and offers a better return in terms of results. This is not to undermine the case for
working with Marie Stopes, who will offer Menstrual Regulation services not available through HSDP
(USAID) clinics, as well as on-demand long term family planning methods. These are important but
costly services, and the main reason why MSB unit costs are higher than USAID’s HSDP. These
services are not available through programmes supported with US government funds because of
decisions relating to rights to life taken at the Mexico City International Conference on Population
(1984) which continue to affect decisions under subsequent administrations.
79.In addition to money, there is also the opportunity cost of DFID staff time which will be required
to manage this project. We use the following profile of staff time to estimate a cost of this. Using
average costs for national and UK based staff, this equates to an annual management cost of
approximately £133,000.
Grade
National Staff
A1
A2
UK staff
0.3
1.0
B1
0.3
Total
1.3
0.3
1.0
0.5
B2
Total
0.5
0.3
0.8
2.1
The final cost we must consider is any potential fee that end users might be required to pay. While
the details are yet to be determined, it is envisaged that the poorest users will not be required to pay
a fee, while the remaining users will be. For the purpose of this appraisal, we assume that 80% of
beneficiaries would be required to pay a fee, with the poorest 20% of users obtaining services for
free. In terms of the cost, we take a conservative estimate of $20 per user, which is higher than the
highest international estimate taken across a sample of ten countries55.
Expected benefit of intervention (by service delivery partner):
80. Benefits of the programme are calculated by first estimating the number and types of
contraceptive methods that the programme will deliver to its clients over five years. Contraceptive
use is then converted into couple years of protection (CYP) by using conversion rates developed by
USAID. CYP is an estimate of the number of years of protection provided by each unit of
contraception. It is a commonly used measure of family planning performance. The conversion
rates are factors that indicate the number of contraception needed for providing a woman of
reproductive age with one year’s protection against pregnancy (1 CYP). The conversion rates vary
by contraceptive methods; for example, 15 cycles of oral pills are needed for 1 CYP as opposed to
120 units of condoms for the same. CYP is calculated by multiplying the quantity of each method
provided to clients by its conversion rate to yield an estimate of the duration of protection provided
per unit of that method. The CYP for each method is then added for all methods to obtain a total
CYP figure.
81. After calculating the CYPs that will be generated by MSB and USAID, we estimate the number
of disability-adjusted life-years (DALYs) that the CYPs will avert. DALYs are a measure of overall
disease burden, expressed as the number of years lost due to morbidity and mortality. DALYs are
calculated by multiplying the CYPs by a conversion factor developed through the PSI Translational
model, which was developed by Population Services International56. This model estimates that, in
Asia, 1 CYP is able to save a sum of 0.143 years of life lost due to premature mortality and
disability. We then monetise the estimated DALYs by using the per capita gross domestic product
(GDP) of Bangladesh for 1 year for each of the DALYs prevented. While other CBAs sometimes use
derived values or lifetime earnings to estimate the value of a DALY, we make the assumption that
as this is a one-off intervention, we can attribute for only 1 year of potential earnings. In addition, all
of the benefits are delayed by 1 year on the basis of the pregnancy cycle.
82. A stream of benefits from maternal, neonatal and infant deaths averted by programme
interventions is also calculated by considering the number of deaths that will be averted by first
estimating the size of population that the programme will cater for. The urban health programme
will provide 27 fully comprehensive clinics that can manage complicated deliveries (12MSB; 15
USAID). In this analysis a conservative estimate is made using only these, although the programme
will also give additional benefits through basic clinics and BRACManoshi care. The catchment
population in each clinic location is estimated at 500,000.
83.The number of expected births in each location is calculated by using the crude birth rate of 22
per thousand (0.022). We use this coefficient to estimate the number of births in the catchment
areas of the clinics. Next, we estimate the number of expected maternal, neonatal and infant
deaths by using the respective mortality rates indicated in the programme log frame. We calculate
two sets of numbers:
(a) Of deaths that will occur if the baseline mortality rates do not change over the five-year
period and
55
Family planning programmes in ten developing countries: cost effectiveness by mode of service delivery, Huber SC, Harvey
PD.
56
For further details, see annex 1: Notes on economic appraisal of DFID Urban Health Programme
(b) Of deaths that will take place as the mortality rates reduces envisaged by the log frame
due to programme interventions.
84.The difference between these two streams is the number of deaths averted. We monetise the
benefits by multiplying the number of deaths averted by the per capita GDP. Using this method, we
derive a stream of costs and benefits of the programme components (MSB and USAID). We then
do a cost-benefit analysis of each component by discounting the costs and benefits and calculating
the net present value (NPV) and internal rate of return (IRR) on the investments. Finally a costbenefit analysis of the programme as a whole and calculate NPV and IRR for the entire programme
are provided.
Benefits from Marie Stopes Component of the Programme:
85.. We calculate the benefits of the MSB programme from family planning, which involved
converting the contraceptives (Table 3) into CYPs by using the conversion rates developed by
USAID. The numbers of CYPs that will be generated by MSB are shown below.
CYPs in MSB Programme
1
2
3
4
5
Services
Pills
Condoms
Injectables
Implants
IUD
Total
2013
1,385
178
7,137
6,639
79,408
94,749
2014
2,771
356
14,275
13,279
85,517
116,198
2015
3,048
392
15,702
14,607
94,068
127,818
2016
3,325
428
17,130
15,935
95,290
132,107
2017
3,325
428
17,130
15,935
95,290
132,107
Total
13,854
1,782
71,375
66,395
449,573
602,979
86...We then convert the CYPs into DALYs by using the PSI Translational model. The DALYs are
then monetised by using the per capita GDP for the five-year period of project implementation. Per
capita GDP has been estimated on the basis of the World Bank’s estimate of $735 (£ 459) for 2011
and assuming an annual growth rate of 5.5% for each year going forward. Finally, we calculate the
monetary benefits from DALYs by multiplying the number of DALYs by the per capita GDP of
respective years. The results of this exercise are shown below.
Benefits from DALYs Averted – update this table. Indicate that benefits are deferred by 1
year.
Indicators
2013
2014
2015
2016
2017
Total
13,549
16,616
18,278
18,891
67,335
5.5%
5.5%
5.5%
5.5%
511
539
569
600
633
-
7,304,385
0.93
9,450,608
0.865
10,967,431
0.805
11,958,970
0.749
39,681,395
0.697
6,318,293
7,607,740
8,214,606
8,335,402
30,476,041
DALYs averted
Annual GDP growth
rate
Per capita GDP (£)
Value of economic
benefit - Family
planning (£s)
Discount factor
Discounted
economic benefit Family planning
(£s)
Thus, the discounted economic benefits of the Marie Stopes Bangladesh programme from family
planning are more than £30million.
87 We also estimate the benefits gained from maternal, neonatal and child deaths averted because
of programme interventions. MSB will provide services in 12 locations through 12 maternity clinics
and a number of primary health care centres. The combined catchment population of the clinics will
be 6 million (500,000 per clinic). We estimate the number of births in the catchment areas each
year by multiplying the population by the crude birth rate of 22 per thousand. In order to estimate
the number of maternal, neonatal and infant deaths averted, we first calculate the number of
expected deaths for each of the five years by using the respective baseline mortality rates (year
2012). We then estimate the number of deaths using mortality rates from the programme’s log
frame, which envisages yearly reductions in the mortality rates. The difference between the two
sets of numbers gives us the number of lives saved. The table below presents the results of this
exercise.
Number of Maternal, Neonatal and Infant Deaths Averted
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Indicators
Number of clinics
Population per
clinic
Total population
Crude birth rate
(per 1000)
Number of births
MMR
(baseline=194 per
100,000)
Maternal deaths if
baseline MMR
persists
Maternal deaths if
MMR is reduced
Maternal deaths
averted
IMR (baseline=43
per thousand)
Infant deaths if
baseline IMR
persists
Infant deaths if
IMR is reduced
Infant deaths
averted
NMR
(baseline=32 per
1000)
Neonatal deaths if
baseline NMR
persists
Neonatal deaths if
NMR is reduced
Neonatal deaths
averted
2013
12
500,000
2014
12
500,000
2015
12
500,000
2016
12
500,000
2017
12
500,000
6m
22
6m
22
6m
22
6m
22
6m
22
30m
132,000
175
132,000
165
132,000
158
132,000
150
132,000
145
660,000
256
256
256
256
256
231
218
209
198
Total
1,280
189
1,044
25
38
38
36
48
35
58
33
67
31
236
5,676
5,676
5,676
5,676
5,676
28,380
5,016
4,752
4,620
4,356
4,092
22,836
660
924
1,056
1,320
1,584
5,544
0.027
0.024
0.023
0.022
0.021
4,224
4,224
4,224
4,224
4,224
21,120
3,564
3,168
3,036
2,904
2,772
15,444
660
1,056
1,188
1,320
1,452
5,676
88. We can see in the above table that the programme will avert 236 maternal, 5,544 infant and
5,676 neonatal deaths. We monetise these benefits by multiplying the number of lives saved by the
per capita GDP. This is done in the table below.
Value of Lives Saved
1
2
3
4
5
6
7
8
9
Indicators
Maternal lives saved
Infant lives saved
Neonatal lives saved
Total lives saved
Annual GDP growth rate
Per capita GDP (£)
Value of economic
benefit from deaths
averted (£)
Discount factor
Discounted economic
benefits from deaths
averted (£s)
2013
25
660
660
1,345
511
2014
2015
2016
2017
38
924
1,056
2,018
5.5%
539
48
1,056
1,188
2,292
5.5%
569
58
1,320
1,320
2,698
5.5%
600
67
1,584
1,452
3,103
5.5%
633
Total
236
5,544
5,676
11,456
687,336 1,088,065 1,303,315 1,618,949 1,964,524 6,662,189
0.93
0.865
0.805
0.749
0.697
639,222
941,176 1,049,169 1,212,593 1,369,273 5,211,433
89. Thus, the MSB component of the programme will provide £5.2 million of discounted
benefits by saving maternal, neonatal and infant deaths. The MSB programme’s total
discounted economic benefits are summarised below by combining this with the value of
DALYS averted, and equalling £35.7 million.
Total Economic Benefits from MSB Programme
Indicators
1 Value of benefits
from DALYs averted
2 Value of benefits
from lives saved
3 Total economic
benefits
4 Discount factor
5
Discounted benefits
2013
2014
2015
2016
2017
Total
39,681,395
-
7,304,385
9,450,608
10,967,431
11,958,970
687,336
1,088,065
1,303,315
1,618,949
1,964,524
6,662,189
687,336
8,392,449
10,753,924
12,586,380
13,923,494
46,343,583
0.93
0.865
0.805
0.749
0.697
639,222
7,259,469
8,656,909
9,427,199
9,704,675
35,687,474
Benefits USAID’s component of the Programme:
90. Calculating the benefits of the USAID programme from family planning began with converting
contraceptives (Table 12) into CYPs by using the conversion rates developed by USAID. The
numbers of CYPs that will be generated by USAID are shown below. .
CYPs in USAID Programme
1
Services
Pills
2
Condoms
2013
171,475
2014
188,622
2015
2016
Total
207,484
228,233 795,814
3
Injectables
4
Implants
5
IUD
6
Vasectomy
7
Tubectomy
6,000
6,600
7,260
7,986
27,846
305,562
336,118
369,730
406,703
1,418,114
12,081
13,289
14,618
16,080
56,068
32,280
35,508
39,058
42,964
149,810
12,244
13,468
14,815
16,297
56,824
9,774
10,751
11,826
13,009
45,359
549,415
604,356
664,792
731,271
2,549,834
Total
91. The CYPs were converted into DALYs by using the PSI Translational model. The DALYs are
then monetised by using the per capita GDP for the five-year period of project implementation. Per
capita GDP has been estimated on the basis of the World Bank’s estimate of $735 (£ 459) for 2011
and assuming an annual growth rate of 5.5% going forward. Finally, we calculate the monetary
benefits from DALYs by multiplying the number of DALYs by the per capita GDP of respective
years. The results of this exercise are shown below. .
Benefits from DALYs Averted
1 DALYs averted
2 Annual GDP
growth rate
2013
2014
2015
2016
2017
Total
0
78,566
86,423
95,065
104,572
364,626
5.5%
5.5%
5.5%
5.5%
3 Per capita GDP (£)
4 Value of economic
benefit - Births
averted (£s)
511
539
569
600
633
£
-
£
42,355,493
£
49,153,550
£
57,042,694
£
66,198,047
5 Discount factor
0.93
0.865
0.805
0.749
0.697
£
36,651,589
£
39,566,669
£
42,713,600
£
46,110,821
6 Discounted
economic benefit Births averted (£s)
£
214,749,783
£
165,042,679
92. Thus, the discounted economic benefits of the programme from family planning are more than
£165 million. We also estimate the benefits gained from maternal, neonatal and child deaths
averted because of programme interventions. USAID will provide services in 15 locations (districts)
through 15 maternity clinics and a number of primary health care centres. The combined catchment
population of the clinics will be 7.5 million (500,000 per clinic). We estimate the number of births in
the catchment areas each year by multiplying the population by the crude birth rate of 22 per
thousand. In order to estimate the number of maternal, neonatal and infant deaths averted, we first
calculate the number of expected deaths for each of the five years by using the respective baseline
mortality rates (year 2012). We then estimate the number of deaths using mortality rates from the
programme’s log frame, which envisages yearly reductions in the mortality rates. The difference
between the two sets of numbers gives us the number of lives saved. The table below presents the
results of this exercise.
Number of Maternal, Neonatal and Infant Deaths Averted
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Indicators
Number of clinics
Population per clinic
Total population
Crude birth rate (per 1000)
Number of births
MMR (baseline=194 per 100,000)
Maternal deaths if baseline MMR
persists
Maternal deaths if MMR is
reduced
Maternal deaths averted
IMR (baseline=43 per thousand)
Infant deaths if baseline IMR
persists
Infant deaths if IMR is reduced
Infant deaths averted
NMR (baseline=32 per 1000)
Neonatal deaths if baseline NMR
persists
Neonatal deaths if NMR is
reduced
Neonatal deaths averted
2013
15
500,000
7.5m
22
165,000
175
320
2014
15
500,000
7.5m
22
165,000
165
320
2015
15
500,000
7.5m
22
165,000
158
320
2016
15
500,000
7.5m
22
165,000
150
320
2017
15
500,000
7.5m
22
165,000
145
320
Total
289
272
261
248
236
1,305
31
38
7,095
48
36
7,095
59
35
7,095
73
33
7,095
84
31
7,095
295
6,270
825
27
5,280
3,960
3,135
24
5,280
5,775
1,320
23
5,280
5,445
1,650
22
5,280
5,115
1,980
21
5,280
26,565
8,910
4,455
3,960
3,795
3,630
3,465
19,305
825
1,320
1,485
1,650
1,815
7,095
37.5m
825,000
1,601
35,475
26,400
93. We can see in the above table that the programme will avert 292 maternal, 8,910 infant and
7,095 neonatal deaths. We monetise these benefits by multiplying the number of lives saved by the
per capita GDP. This is done below
Value of Lives Saved
1
2
3
4
5
6
7
8
9
Indicators
Maternal lives saved
Infant lives saved
Neonatal lives saved
Total lives saved
Annual GDP growth rate
Per capita GDP (£)
Value of economic
benefits from deaths
averted (£)
Discount factor
Discounted economic
benefits from deaths
averted (£)
2013
31
825
825
1,681
2014
2015
2016
2017
551
859,170
48
3,135
1,320
4,503
5.5%
539
2,427,509
59
1,320
1,485
2,864
5.5%
569
1,629,144
73
1,650
1,650
3,373
5.5%
600
2,023,686
81
1,980
1,815
3,879
5.5%
633
2,453,655
0.93
0.865
0.805
0.749
0.697
799,228
2,100,603
1,311,397
1,515,337
1,710,508
Total
292
8,910
7,095
16,300
`
9,395,164
7,437,072
94. Thus, the programme will provide £7.4 million of benefits by saving maternal, neonatal
and infant deaths. TheUSAID programme’s total economic benefits are shown below, and
equal UK £172 million.
Total Economic Benefits from USAID Programme
Indicators
2013
2014
2015
2016
2017
Total
1 Value of benefits
from DALYs averted
2 Value of benefits
from lives saved
3 Total economic
benefits
4 Discount factor
5
Discounted benefits
£
-
£
42,355,493
£
49,153,550
£
57,042,694
£
66,198,047
£
214,749,783
859,170
2,427,509
1,629,144
2,023,686
2,453,655
9,395,164
859,170
44,783,002
50,782,694
59,066,380
68,653,701
224,144,947
0.93
0.865
0.805
0.749
0.697
799,028
38,737,297
40,880,068
44,240,719
47,851,630
172,508,741
Cost and Benefit of Entire Programme
95. The cost-benefit analysis of the total DFID Urban Health Programme, combines the costs and
benefits of the MSB and USAID components of the programme, discounts them, and calculates the
net present value and benefit-cost ratio.
96. We assume that the benefits of the programme will materialise in the second year of the
programme. We use a rate of 7.5% to discount the costs and benefits. The results of this exercise
are shown below.
Cost Benefit Analysis of DFID’s Urban Health Programme (£)
1. Costs - USAID
2. Costs - MSB
3. Cost - Other
4. Costs - DFID staff
5. Total costs
6. Benefits - USAID
7. Benefits - MSB
8. Total benefits
9. Net benefits
Discount factor
Discounted costs
Discounted Benefits
Discounted Net benefits
2013
4,226,040
3,273,634
9,079,854
133,615
16,713,143
(16,713,143)
2014
4,648,644
2,724,730
1,973,484
133,615
9,480,473
859,170
687,336
1,546,506
(7,933,967)
0.930
0.865
2015
5,113,508
2,927,889
2,558,739
133,615
10,733,752
44,783,002
8,392,449
53,175,451
42,441,699
0.805
2016
5,624,859
3,139,870
3,596,307
133,615
12,494,652
50,782,694
10,753,924
61,536,617
49,041,965
0.749
2017
3,426,032
1,237,099
133,615
4,796,747
59,066,380
12,586,380
71,652,760
66,856,013
Total
19,613,051
15,492,155
18,445,483
668,077
54,218,766
155,491,245
32,420,089
187,911,334
133,692,568
0.697
15,547,110
-
8,203,762
1,338,242
8,640,247
42,804,142
9,356,002
46,078,652
3,341,215
49,910,349
45,088,336
140,131,384
(15,547,110)
(6,865,521)
34,163,895
36,722,650
46,569,133
95,043,047
97. In summary: The cost-benefit analysis gives a net present value of £95 million and a
benefit-cost ratio of 3.11.
Sensitivity Analysis:
98.A sensitivity analysis was undertaken to explore the impact on the programme of the following
scenarios occurring;
1.
2.
3.
4.
Higher and lower costs per user (£10 and £20).
All benefits under the programme are delayed by 2 years.
The overall costs of the intervention were to exceed the initial budget by 20%.
The actual benefits were only 50% of what was intended.
Cost per
user (£)
Benefits
delayed by
2 years
Costs
increase
by 20%
Benefits
are only
half of
what we
expected
(PSI
regional
estimate)
13
10
20
7.50%
Scenario 5
Scenario 4
Scenario 3
Scenario 2
Sensitivity
analysis ……
Scenario 1
Baseline case
99.As the sensitivity analysis below indicates, the economic case underpinning this programme
remains robust under each of these scenarios. As such, we can have a high degree of confidence
that the intended economic benefits under this programme are likely to be realised. We do however
take note that the greatest risk of not realising intended economic benefits under this programme
comes from the risk of not delivering the intended benefits. As such, the monitoring of results will be
imperative.
7.50%
7.50%
2 year
delay
£ 38
million
£45.6
million
0.143
0.0715
Outcome…
…..
Net
Present
Value
Benefit:Co
st ratio
Internal
rate of
return
95,043,047
98,399,887
88,329,368
80,703,222
86,025,380
29,427,993
3.11
3.36
2.71
2.51
2.59
1.65
87%
97%
71%
65%
70%
35%
D. What measures can be used to assess Value for Money for the intervention?
Rates of return:
100.. The cost-benefit appraisal indicates the following:

The benefit-cost ratio shows that overall discounted benefits exceed the overall discounted
costs by a factor of 3.11. That this figure is greater than 1 indicates that the overall benefits
exceed the overall costs.

The net present value indicates that this programme will generate an economic welfare gain
of £95 million. This is the value, in discounted monetary terms, of the benefits in excess of
the costs of the programme.
Unit cost and Comparators (MSB):
101.We examined the cost-effectiveness of MSB Programme using key impact indicators and taking
into consideration the costs and benefits of the programme. According to the proposal submitted by
MSB, 31% of their clients are expected to be family planning clients. We therefore assume that
31% of the total costs will be spent on family planning and the remaining 69% on maternal, neonatal
and child health (£4.3 million and £9.7 million respectively). We calculate the unit costs of key
indicators by using the respective costs of the two broad components and the volume of benefits
generated. The results of this exercise are shown below.
Unit Costs of Key Indicators (£)
Costs
Effectiveness
(outcome costs)
Indicators
Cost per CYP
Unit
Costs
Efficiency (output costs)
£6.00 - DFID regional*
£9.70 - DFID Pakistan*
£8
Cost per DALY
Cost per maternal life
saved
Comparators
21.00 - DFID regional*
£67.7 - DFID Pakistan*
£ 56
£ 49,538
Cost per infant life saved
Cost per neonatal life
saved
£ 2,091
£
751
Cost per birth averted[1]
£
26
£21.43 - Developing country
average*
Pills
£
8
£5.19 - Developing country
average*
Condoms
£
2
£2.98 - Developing country
average*
Injectables
£
17
£6.15 - Developing country
average*
Cost of contraceptive
provision
Economy (input costs)
* DFID regional refers to Prevention of Maternal Death from Unwanted Pregnancy (PMDUP).
* DFID Pakistan refers to Delivering reproductive health results through non-state providers (2011).
* Developing country average comes from Adding it up: Costs and benefits of contraceptive services (UNFPA).
.
102.. It should be noted that CYPs generated and DALYs averted by MSB in the proposed
programme are relatively low because the family planning component relies mostly on short-term
methods that have lower CYP generating capacity. Sterilisation, which generates the highest CYPs
per unit, has been left out of the calculations. For the same reason, DALYs are also relatively low.
As a result, the unit costs of these indicators are higher than those in the PMDUP programme. The
costs per CYP, DALY and contraceptives can be tracked. However, it will not be possible to track
the cost of deaths averted annually because these indicators are monitored through nation-wide
surveys like the Demographic and Health Survey (DHS) and Maternal Mortality Survey (MMS) that
are undertaken at intervals of 4-5 years.
Unit Cost and Comparators (USAID):
103.We examine the cost-effectiveness of USAID Programme using key impact indicators and
taking into consideration the costs and benefits of the programme. We assume that 43% of the
funds will be spent on family planning and the remaining 57% on maternal, neonatal and child
health (£8.4 million and £11.1 million respectively). We make this assumption on the basis of
historical data of their previous programme budget (SSFP). We calculate the unit costs of key
indicators by using the respective costs of the two broad components and the volume of benefits
generated. The results of this exercise are shown in the table below.
Unit Costs of Key Indicators (£)
Costs
Indicators
Unit Costs
Comparators
Effectiveness
Cost per CYP
£
3
£6.00 - DFID regional*
£9.70 - DFID Pakistan*
(outcome costs)
Cost per DALY
£
23
£21 - DFID regional*
£67.70 - DFID Pakistan*
Cost per maternal life
saved
£
39,041
Cost per infant life saved
£
1,279
Cost per neonatal life
saved
£
590
Efficiency (output
costs)
£21.43 - Developing country
average*
Cost per birth averted[1]
Cost of contraceptive
provision
Economy (input
costs)
Pills
£
1
£5.19 - Developing country
average*
Condoms
£
3
£2.98 - Developing country
average*
Injectables
£
2
£6.15 - Developing country
average*
* DFID regional refers to Prevention of Maternal Death from Unwanted Pregnancy (PMDUP).
* DFID Pakistan refers to Delivering reproductive health results through non-state providers (2011).
* Developing country average comes from Adding it up: Costs and benefits of contraceptive services (UNFPA).
104.. The costs per CYP generated and DALY averted by the USAID programme compares very
well with those of the PMDUP Programme. The costs per CYP, DALY and contraceptives can be
tracked.
105. Cost Drivers:
 Construction/renovation of clinics is an important element of the programme. Delays in
construction work and cost escalations of construction materials can drive up costs.

International technical assistance to the programme can be a cost driver when fully loaded
costs (i.e. travel, accommodation, per diems and international fee rates) are taken into
consideration.

Staff costs will be sensitive to increments driven by national trends. If Bangladesh has a
surge in salaries in the next five years this could have a very material effect on programme
costs.

A range of unit costs are higher for the Marie Stopes clinics. This is because of the additional
cost of ensuring safe quality access to long term family planning methods.

Rentals for clinics may rise dramatically as the crisis for accommodation continues and
landlords could exploit the programme, particularly when the fittings and fixtures make it a
fairly permanent structure.

Finally, a key value for money metric will be the average number of contraceptive users
accessed per user. In the appraisal stage, we identify that the USAID proposal intends to
provide 11 services per user, while Marie Stopes intends to provide 4 services. There are
trade-offs in either increasing or decreasing this ratio (an increase becomes cheaper for
clinics to operate, reaches fewer beneficiaries with the same number of services). However,
this metric should be monitored over the course of the programme.
E. Summary Value for Money Statement for the preferred option
106.Both the cost benefit appraisal and evidence ratings indicate that this programme will
demonstrate good value for public funds. We approach this question by assessing the findings of
the cost benefit appraisal (CBA), the evidence base on impact, as well as the proposed unit costs
under the programme.
Cost Benefit Appraisal:
107.The summary of the CBA is provided below. This demonstrates clearly that in terms of
economic impact, this programme is creating sufficient welfare gains to cover the investment cost.
These gains come in the form of a combination of births prevented, maternal and neo-natal lives
saved, and reductions in out-of-pocket medical expenditures. The CBA also indicates that the
intervention is likely to result in benefits in a timely manner. As direct intervention, the impacts are
likely to occur right away, and will be measurable in the short to medium term. Finally, the CBA also
finds that under a number of fairly extreme scenarios (i.e. only half the intended benefits are
realised), the programme continues to demonstrate good value for money.
Summary of cost benefit appraisal
Total costs (£)
54,218,766
Total discounted costs (£)
45,088,336
Total Benefits(£)
187,911,334
Total discounted benefits (£)
140,131,384
Net Present Value
Benefit:Cost ratio
Internal rate of return
95,043,047
3.11
87%
Unit costs:
108. We have assessed unit costs in line with DFIDs 3E’s framework, at the economy, efficiency
and effectiveness levels. We have also benchmarked these to what other costs exist, although the
existence of comparators is somewhat limited at this stage. The unit cost at all 3 levels will need to
be managed and tracked closely during the implementation of this programme. The aim should be
to ensure that best practice is used across the 2 components of the programme (resulting in
consistency between the costs in the 2 components). However, the programme will also need to
demonstrate that these unit costs are no higher than international comparators and benchmarks.
3. Commercial Case
Direct procurement
A. Clearly state the procurement/commercial requirements for intervention
109.The programme will be implemented through a partnership with 3 organisations on service
delivery (Marie Stopes Bangladesh, USAID and BRAC) in up to a maximum of 10 urban areas in
Bangladesh, and a third contracted organisation for Health System Strengthening and Coordination.
110.Implementation requires a networked approach across these organisations and their local subpartners because no single organisation has the capacity, technical expertise or reach to deliver all
services in its entirety. In order to achieve coherence, maximise synergies (including with BRAC
house-to-house outreach) and potential economies of scale, and to minimise transaction costs, the
programme will provide finance to two established service delivery partners known for quality
provision in urban health in Bangladesh (see appraisal section of USAID and MSB), and one partner
organisation (BRAC) funded through a previous Business Case. These three service delivery
partners have the following proven strengths:
1. Capacity for significant scale up in cities in Bangladesh,
2. Requisite proven technical and operational skill to deliver in maternal and new born health
and family planning and report against programme objectives,
3. Demonstrated innovation and cost effective means of delivery.
111.. A Health Systems Strengthening and Coordination partner is planned for, and will be
contracted to manage results verification from the service delivery partners, independent monitoring
evaluation and applied research, and to link service providers and their findings with Local
Government and Ministry of Health and Family Welfare. The organisation/s will also house and
manage oversight of the GIS mapping of health facilities and services in all urban areas, and its
official use. The organisation/s will have expertise in operational research, health monitoring and
evaluation, and access to expertise on reproductive health systems in urban areas.
112.Funding for this programme will come from DFID. Additional co-funding comesfrom USAID and
could potentially come from other donor partner country programmes. The lead for overall
programme management will remain in the DFID Bangladesh office.
B. How does the intervention design use competition to drive commercial advantage
for DFID?
The Health Systems Strengthening and Monitoring and Evaluation Provider
113.. To obtain best Value for Money DFIDB plans to use a formal OJEU tender to invite an
appropriate organisation(s) to bid for the activities in the Health Systems Strengthening Component
(see Annex 12, draft TORs).
114.Competition to drive commercial advantage may include mini, open or limited –competition(s).
DFID’s Global Framework Agreements may be used.The overall value of this support will be £2.9
million over five years. Final decisions on the most appropriate routes to market that supports to the
Programme whilst delivering optimum VFM will be agreed after formal consultation with PrG.
Although it is expected that the majority of the TA will be delivered using contracts which have been
let competitively using formal OJEU procurement procedures.
.
C. How do we expect the market place will respond to this opportunity?
115.. Although the planned evidence of impact activities are specialist areas, with relatively few
“standalone” organisations that combine both the expertise and capacity to undertake this complex
and specialist work, we believe that there are a sufficient number of organisations in the market to
ensure that there will be effective competition. In addition based on previous experience we believe
that individual companies may wish to form a consortia to undertake this type of work, this should
significantly increase the pool of interested bidders. This is likely to favour the use of either one of
DFID’s Global Framework Agreements as the route to market for specific requirements such as
monitoring and evaluation. We will discuss most suitable options that deliver best value for money
with PrG for each required component.
116.Overall based on similar tendering exercises we are confident that there are sufficient
international companies with necessary technical capacity/capability to ensure that there will be
competition to deliver VFM. In addition the selected provider’s will be routinely monitored by DFID to
ensure effective delivery, and evidence of delivering VFM. In addition the company’s performance
will be closely monitored by DFID to ensure that conflicts of interests are managed transparently and
perverse incentives are controlled.
D. What are the key cost elements that affect overall price? How is value added and
how will we measure and improve this?
117.. Given that this component will primarily provide technical assistance, the successful bidders’
charges are likely to be largely driven by the cost of their operations in Bangladesh and the salaries
and fees that they pay to their staff and consultants. The Supplier will have to demonstrate how they
will achieve value for money by ensuring that their management and running costs reflect best
market prices, that their overheads are reasonable and they have strong staff capacity to implement
the programme effectively whilst delivering VfM.
118.The optimal balance of international versus national staff will be sought to ensure the right mix of
skills/ knowledge for the lowest price. In addition, the supplier will need to clearly demonstrate that
they can access adequate staff capacity to minimise the use of high priced consultancies. Draft
Terms of Reference included in Annex 12.
E. What is the intended Procurement Process to support contract award?
Health Systems Strengthening:
119.As set out earlier there is one component that will involve direct contracting. We will use the
Restricted OJEU competitive process for the component. In addition we may consider to use one of
DFID’s Global Framework
120.. We plan to use results-focussed and output based Terms of Reference that include SMART
deliverables and outputs, and clear delineation of responsibilities as the basis for a contract with the
implementing partner/s (draft at Annex 12).
121.. The contract for thesupplier will include a comprehensive monitoring framework, and a year on
year efficiency savings plan to be delivered by the successful bidder and that will need to be actively
overseen by DFIDB programme team. This will ensure the supplier takes ownership of key
performance indicators, targets and baselines from the outset of the programme. It will form the basis
not only for management of the programme by the supplier but also for performance-based
management of the supplier by DFID. Clear performance/payment milestones for the implementation
phase will also be agreed and monitored every quarter, linking physical and financial progress along
with an overall VFM assessment.
F. How will contract & supplier performance be managed through the life of the
intervention?
122.The contract will specify deliverables that are readily measurable and linked to payments
(particularly for administrative and reporting tasks) for performance against key SMART indicators.
Details of these will be finalised in discussion with DFID Procurement Group. Potential contractual
break points will also be agreed as required. Final TOR will be drawn up in consultation with
Evaluation Department and Procurement group.
Indirect procurement
A. Why is the proposed funding mechanism/form of arrangement the right one for
this intervention, with this development partner?
123.We propose to use an Accountable Grant mechanism and a Third Party Organisation
Memorandum of Understanding (indirect bilateral government-to-government) with the service
delivery partners. Comparative costs of delivery have been assessed (see Partner Comparative
Grid, in the Appraisal section and in Annex 4), and will be monitored throughout by DFID.
Procurement of the Health Systems Strengthening component will be competitively tendered
through OJEU.
124.. Specifically, the programme will engage through contracting as follows:

USAID: bilateral to bilateral Memorandum of Understanding (Annex 8, draft)

Marie Stopes Bangladesh: An accountable grant, based on a submitted proposal
with emphasis on value for money, costs and management for scaling up) (Annex
5a).

BRAC: no additional financial support from this programme. However, through
activities under the Strategic Partnership Agreement (ref: EDRM 3275103) they have
agreed to be an active implementing partner in this programme.
125.In partnership with the partners above we will develop and implement strategies to minimise
costs and increase efficiencies. In all cities the programme will work with BRAC community health
workers, who offer maternal health services in an accessible and low cost manner. The programme
will seek to make the drugs for maternal health more available – this is a lower technology
approach, which minimises costs and risks associated with surgical intervention. The partnership
will also share tools and resources.
126.Where politically and practically feasible the implementing partners may combine support
functions e.g. office space, to improve value for money (VFM). Open reporting of activities and
financial support from DFID and other sources will ensure that the risks of double counting and
double funding are minimised. Cost recovery systems of the 2 service providing partners
(MSB;USAID) will create the opportunity for cross-subsidies to the very poor, particularly for free
ante natal and birthing and post natal services.
127..Staffing costs will be monitored using comparative ratios: staff costs to total costs, ratio of staff
to patients; doctors to nurses to patient ratio. Staff turnover will be monitored to ensure skills loss is
minimised.
1. Marie Stopes Urban Health Programme
128..Marie Stopes Bangladesh (MSB) is part of Marie Stopes International, London, UK. It is one of
the foremost organisations in delivering quality sexual and reproductive health services, especially
for the poor and vulnerable. MSB was registered in Bangladesh as a local NGO in 1988. Since then
it has established 132 clinics, including 43 referral clinics, 74 up-graded mini-clinics, 3 specialised
maternity clinics and 3 premium clinics. The organisation also has extensive outreach activities
providing services through around 450 outlets per month supported by more than 1500 staff in
country (paramedics, factory health workers, roving teams and slum-based satellite service points).
Client visits have grown by 160 % since 2001 to around 1.6 million in 2011. MSB are one of the few
large-scale providers of safe menstrual regulation, with around 37% of the market share.
129. The MSB programme was selected on the basis of experience in urban health in Bangladesh,
quality of service delivery, managerial track record, leadership, value for money and capacity to
deliver. Towards this, MSB was independently assessed for their capacity to go to scale rapidly and
ensure high quality service delivery57.
130. A complete due diligence58 was conducted on Marie Stopes Bangladesh and audit reports
reviewed by independent assessors from HLSP. See Annex 4 for detailed summary. Audit reports
revealed no unacceptable risks and the due diligence confirmed that MSB is a well-managed
organisation59. In addition, MSB are the only major provider of quality MR services other than the
Ministry of Health and Family Welfare in Bangladesh. MS International is a DFID preferred provider
of health service in the DFID Global Health Framework. MSB will be supported with £15.492 million
over five years.
2. USAID’s Smiling Sun/HSDP Programme
131. USAID has been funding NGO networks to support health service delivery for over 30 years,
starting with commodities distribution, and expanding in the late 1990s to a clinic-based model for
one-stop centres providing the Essential Services Packages. The two most recent iterations of this
activity are the NGO Service Delivery Program (NSDP, 2002-2006), and the Smiling Sun/HSDP
(2007-2012). The latter supported a franchise model integrating family planning and health service
through 22 NGOs, 323 static clinics, 8,700 satellite clinics and more than 6,300 Community Service
Providers (CSP) in both rural and urban areas. Overall, these clinics account for approximately 28
million service contacts a year. By 2010, 60 % of clinics (i.e. 193 clinics) were in urban areas.
Through user fees and the development of a franchise, under which clinics are licensed to use the
Smiling Sun/HSDP brand. The new programme starting in 2013 has been adjusted to refocus on
service provision to the poor following review findings that recognised cost-recovery targets had the
potential to skew the poorest people’s access. Pathfinders have won a publically tendered process
and will be the implementing agency for the coming 4 years (from 2013), valued at US$51 million
over four years of USAID’s own resources
132. The USAID relationship will be formalised through a Memorandum of Understanding (MoU),
drafted in Annex 8. The UK Aid support will supplement USAID’s own funds and be based on
results attributable to urban areas through a £19.613 million investment over five years, thus an
approximate 34% attribution to DFID of the results.
Due Diligence Summary of USAID’ is included in Annex 4. In undertaking this, a review of the
following was completed: Performance Management Plan (June 2012), draft agreement on
Delegated Co-operation (Annex 8) and ADS Chapter 351 (Agreement with Bilateral Donors (31 July
2012).
3. The BRACManoshi Project
133. BRAC is a local Bangladesh NGO, one of the largest of its kind in the world, with a long track
record in community-based primary, MNCH, and family planning services. DFID supports BRAC
through a Strategic Partnership Agreement, 2012-2017. BRAC has over 7300 community-based
health workers who assist mothers and new-borns, including in the urban slums. It is the largest
network of outreach in Bangladesh. In addition they have built a network of local ‘birthing huts’ to
improve safe and hygienic deliveries accessible to the poorest. In rural areas they have built an
efficient referral system when emergencies occur, but the challenge in urban areas continues and
their link to comprehensive care clinics through this programme will help to tackle the needs of the
58The due diligence assessments undertaken by DFID were drawn from the following documents: HLSP Urban Health project
document (Annex 15), USAID Performance Management Plan, Performance Monitoring and Evaluation plan (Quest: 3917568
and Quest:3917573), and MSB financial controls, monitoring and audit arrangements and Monitoring and Evaluation plan
(Quest:3917601)
poorest. They will not be a financial recipient of this programme, but will play a key partnership role.
134. The key cost drivers for these three organisations are as follows:

Staff – leadership, management and technical advice on clinical, policy and advocacy
issues. National staff for service delivery (and similar functions as international staff).

Service and Programme Direct Costs – Provision/refurbishment of clinics and rental of
facilities, costs of delivering services, transport including supervision, contraceptive
commodities, drugs and supplies, and demand side finance.

Training costs - plus subsequent supervision and monitoring costs

Advocacy & Communication - external and internal, communications, participation on
several committees and working groups, the production of nutrition and hygiene awareness
materials.
135. Treatment costs are likely to remain unchanged (subject to inflation) over the programme
period, drug costs could come down as volumes increase while space (rent) and staff costs are
likely to follow an upward trend. The programme will also use its business interface to ensure local
market capacity for procurement and distribution is created and left behind.
136. Costs may vary according to city location in Bangladesh. In a number of cities, set up costs for
the programme may be material, but this means that unit costs (i.e. per procedure/ training) will fall
over the course of the programme as set up costs are absorbed, systems become more efficient
and economies of scale are realised. In several cities all three partners are already well established,
and so unit costs will be lower from the start.
137. DFID acknowledges that the unit costs in the larger cities may be substantially lower than in
cities more distant from Dhaka, and that costs will be higher in areas where infrastructure is poor or
in short supply and there are no existing services on which to build. Because of the strategic
importance of service delivery, we are keen that suppliers do not operate solely in the ‘lowest cost’operating operating environment.
4. Financial Case
A. What are the costs, how are they profiled and how will you ensure accurate
forecasting?
138. The total DFID investment in this programme is upto£38 million over five years (2013-2018).
The table below summarise funds to the partner organisations. A detailed projection of funds is
provided in Annex 9.
Financial requirements for whole programme 2013 – 201860/ £ - by Proven Partner
Line items
Year 1 £
Year 2 £
Year 3 £
Year 4 £
Year 5 £
Total £
1
USAID
2
MSB
4,226,040
3,273,634
4,648,644
2,724,730
5,113,508.4
2,927,889
5,624,859.24
3,139,870
3,426,032
19,613,051.64
15,492,155
3
HSS
566,867
575,100
586,326
604,824
561,406
2,894,523
Total
8,066,541
7,948,474
8,627,723.4
9,369,553.24
3,987,438
37,999,729.64
Note: USAID support is only for four years
139. The programme will be managed from the DFID Bangladesh Office. The Stage 1 Business
Case was approved in July 2012.
140. There is an expectation, however, that if delivery is good in the first two years, DFID may wish
to further incentivise this with a payment by results component that would require variable amounts
of additional resource in years 3-5 of the programme. It is possible that funding will increase – as
other donors contribute directly to the programme – and activities with BRAC may be extended to
include additional activities, and additional areas.
141. The Health Systems Strengthening (HSS) budget accommodates line items for annual reviews,
mid-term reviews, research and evaluations. Auditing costs are included as part of each partner’s
internal management costs.
B. How will it be funded: capital/programme/admin?
Financial requirements for the whole programme 2013-2018/£ - by allocation
Line items
Year 1 £
Year 2 £
Year 3 £
Year 4 £
Year 5 £
Total £
Programme
direct costs
6232706
7058092.8
7659744.88
8374790.668
3339437
32664771.348
Programme
capital
1031331
119805.2
146674.12
156349.132
38929
1493088.452
802504
770576
821304.4
838413.44
609072
3841869.84
Admin and
management
60 This proposed programme will go beyond the DFIDB’s current OP period(2011/12-2015/16)
Total
8,066,541
7,948,474
8,627,723.4
9,369,553.24
3,987,438
37,999,729.64
C. How will funds be paid out?
142. Funds will be disbursed (1) via a contract with MSB; (2) via a MoU with USAID and (3) via a
contract between DFID and the Health Systems Strengthening provider.
143. USAID payments will be disbursed against an agreed schedule to be detailed in a MoU (Annex
8, draft). Funds will be transferred directly from the UK to the US.
144. MSB, payments will be disbursed monthly in arrears upon receipt of a detailed statement of
expenditure incurred and acceptable performance against agreed performance indicators. In line
with DFID guidelines (for non-profit organisations), it is not considered Value for Money to issue
large sums in advance of need. However, there is justification for MSB to receive disbursements
more frequently than quarterly and in the case of the first two disbursements, in advance in order to
kick-start the set – up costs of new clinics. Procurement for clinics (40 % of operating costs) will be
done via the MSB Corporate and Finance Unit. This cycle requires frequent orders and
payments.(Annex 5, Accountable Grant Proposal)
145. For the HSS contracted provider, it is anticipated that the payments will be disbursed quarterly
in arrears upon receipt of a detailed invoice and statement of expenditure. (Annex 12, ToR draft)
146. Overall, there will be stringent tracking of unit costs and inputs to outputs to ensure funds
remain secure and provide VFM. In both the Accountable Grant Agreement and the MoU
arrangement, there is stipulation for with/holding or suspending finance, reclaiming and cancelling
agreements (see Annex 5 and 8). Consideration was given to financial risk including the risk of
funds not being used for their intended purposes, that expenditure may not be properly accounted
for and/or it does not represent good value for money. These are safeguarded in the agreements
through clauses enabling access to information by DFID.
147. A due diligence process has also been undertaken for Marie Stopesand USAID (see Annex
4). This would also apply to the OJEU tendering process for theHSS provider. This assessment
attempted to gauge the potential exposure to loss, fraud or corruption and the systems and
procedures in place to mitigate the risk.This also considered disbursements to suppliers and the
flow of funds through the relevant systems of MSB and USAID. It included an assessment of the
financial management and accountability systems of MSB and USAID and their underlying capacity
and capability. The due diligence exercise revealed sound organisations.
Annual audits
148. The USAID portion of the programme will be subject to USAID's required auditing process and
USAID will make these reports available to DFID. This includes annual independent audits within 6
months after the end of the financial year. Details are provided in the MoU draft and Agreement
Arrangements with bilaterals (see Annex 8).MSB will submit Annual Audited Accounts for each of
the financial years covered by the programme. These will be signed by their Finance Officer and
certified by their independent auditors. In line with best practice, annually audited reports will
separately report receipt of DFID funds and associated disbursements, together with unspent funds.
Current MSB audits revealed no material issues and a satisfactory financial position.
149. The HSS contracted provider will submit annual independently commissioned audits to DFID
as required in standard DFID contracting arrangements.
150. DFID has reserved the right to commission independent audits, or forensic audits and verify
expenditure through random spot checks on any of the above partners and contracted providers.
D. What is the assessment of financial risk and fraud?
151. Although implementation is primarily through partner organisations with proven track records,
this is a complex programme, operated across cities & municipalities, working on sensitive services
in a challenging environment. As such the overall programme risk is medium. Each urban area,
especially the slums, has its own risk profile and may require special risk mitigation strategies – and
many risks will be managed at this level.
152. The risk analysis is summarised below – segmented into political, institutional, financial,
operational, social and environmental risks.
Programme risk matrix showing probability of and impact of risks that could compromise programme
performance, and mitigation strategies.
Risk
Financial & Fiduciary
1.1 Further financial
Prob.
Impact
Mitigation
Low
Med
Low
Medium
DFID and USAID are the two largest bilaterals in health, and together may be
able to encourage others to unify behind
this programme to scale-up urban health
support; in the medium term (potential
phase 2) public and private resource
streams form within Bangladesh should be
explored
Delivery partners currently have strong
financial systems + internal audit.
DFIDProg Managers will monitor this to
ensure due diligence is maintained. Some
financial training to ensure understanding
of each organisation’s financial tracking
systems may be needed. This should form
part of the early work done by the third
strand (HSS).
crisis constrains
donors
1.2 Fraud, corruption
and
misuse/misdirection
E. How will expenditure be monitored, reported, and accounted for?
153. Day to day monitoring of expenses will be the responsibility of the Implementing partnersMSB, USAID and the Health Systems Strengthening contractors.
154. DFID will monitor expenditure based on reports from the three partners receiving UK funds.
Monthly reports (MSB),and quarterly reports (USAID and HSS) will be expected. Independent
annual audited statements will be provided by each of the organisations within six months of the
end of the financial year. Financial reports will separate receipt of DFID funds and associated
disbursements, together with unspent funds.
155. Additionally each of the 3 partner organisations will provide quarterly narrative activity reports
which outline progress. The reporting format will be agreed with DFID. Milestones for results will be
set which are linked to disbursements, and the logframes (Annex 7a-d), and the Health System
Strengthening provider will consolidate narrative reports and provide them to DFID.
156. Each partner will be expected to maintain an asset register, maintain an inventory of all
equipment, and ensure conflict of interest registers. DFID will undertake regular spot- checks to
ensure these are maintained and accurate. At the end of the project all equipment and assets will
be formally handed over to the partner organisations.
157. An exit strategy in which further funding is suspended if fraud is identified will be ensured
through written agreements with each organisation (see Annex 5 and 8). DFID has the right to
suspend/ pause fund allocation in the event of fraud or mismanagement and inform Corruption and
Fraud Unit for investigation. Equally funding may be stopped if the project is not achieving expected
results, or if progress against milestones is not satisfactory. This will be stated in writing to partners
and decisions will be made during annual and mid-term reviews.
5. Management Case
A. What are the Management Arrangements for implementing the
intervention?
158. The Management Case describes the arrangements for the delivery of the programme
including the governance, management, research, monitoring and evaluation, risk and the
sustainability of the value.
1. Oversight
159. Below is a chart of the institutional arrangements of the programme. DFID oversight of both the
service delivery part of the programme and health systems strengthening will be through a steering
committee, incorporating country management representatives from implementing partners,
government officials from the Ministry of Health and Family Welfare and Local Government and
funding donor partners. This body will have responsibility for strategic programme oversight.
160. To mirror this, the donor partners are represented on a MoHFW national Urban Health Working
Group (UHWG), which has strategic oversight towards a more organised and sustainable national
response. The UHWG includes Government officials from the Ministry of Health & Family Welfare,
the Ministry of Local Government, senior government officers, service delivery partners and donor
partners as members.
161. In addition, there will be monthly meetings between delivery partners through a Programme
Coordination Group. The purpose of this group is practical coordination of activities along the value
chain, starting from the front-end demand through BRAC’s community health workers, through to
the referral to partner clinics, delivering of services and referrals to tertiary providers when needed.
Below is the architecture of the programme oversight.
162. Draft terms of reference for the proposed Programme Coordination Group are provided in
Annex10.
163. The Service Delivery Partners and the Health System Strengthening each have separate and
specific log frames and operational plans based on their commitments and context (see Annex 7ad).
164. The lead DFID team will include a Programme Manager and the Health Advisor (HA) in the
DFID Bangladesh office in Dhaka, who in turn report to the Team Leader for Human Development.
The team will be responsible for DFID’sMoUs, Accountable Grants and contract oversight with the
delivery partners and the health systems contractor. They will review work plans and budgets, and
will be sensitive to the risk of micro-management.
Governance, stewardship and linkage with Government's health interventions
Relationship levels
National level
health task
groups
LG Health
Committee
City Health
Committees
HSDP
Managing
Agent
Levels of work
‘Policy level’
Working
group
Strategic policy level
conversations on urban
health
Urban
specific
steering
committee
Programme level
conversations on
performance & compliance
Programme
Coordination
Committee
MSB
HSS Team
(Secretariat
to PCG)
Coordination conversations
around work plans, referrals,
standards, services and
locations
BRAC
Strategic Policy level
165. Policy discussions on urban health in Bangladesh take place in the national level Health Task
Group chaired by Ministry of Local Government along with Ministry of Health and Family Welfare;
participants include the main actors in urban health from both Government and non - state actors. It
is hosted by Ministry of Health and Family Welfare and links to the National Health Sector
Development Programme. Each partner in this programme, along with DFID, will be members on
the National Health Task Group. This is already the case for all partners. With the exception of
Health Systems Strengthening contractor.
Programme level
166. The Steering Committee for the USAID programme is currently chaired by the Senior
Secretary, Ministry of Health and Family Welfare. In order to streamline systems, the partners have
agreed that this vehicle be adapted and used for oversight of the DFID funded programme, USAID
programme, MSB, BRACManoshi and the Health Systems Strengthening component. This will
reduce transaction costs, and harmonise programming. The other members of this committee
include:



Local Government representative (Planning Head)
DFID and USAID Health Advisors, Programme Managers and Team Leaders
Invited Delivery Partner Directors, including the head of the Health System and
Strengthening Contractor.
167. The Steering Committee will meet on a six-monthly basis to review and approve the sixmonthly updates, agreed indicators and milestones of progress and major strategic changes to
annual action plans. The Steering Committee will review evaluation findings and ensure that there is
appropriate co-ordination between the programme and the health system strengthening and
coordination team.
168. The partner organisation’s Directors will present and explain findings when required. The group
will be aware of political and reputational risks associated with the programme (including in relation
to the sensitivities resulting from the US Government’s position taken at the Mexico
Cityconvention)– and ensure that these are appropriately communicated both internally and
externally. Important emerging issues will be flagged/or discussed with relevant advisors and/or City
heads as appropriate.
Coordination level
169. This will be Chaired by DFID, and include the active participation of DFID Programme Manager
(Health) and the DFID Health Adviser. It will include programme managers from the USAID
programme management agent, MSB, BRAC and the Health Systems Strengthening Contractor.
170. The Programme Coordination Group will:
 Provide leadership for good functioning of the partnership by inspiring and requiring
programme innovation, communicating results, strong synergies, economies of scale and
VFM.
 Coordinate the location and efficient management of the service value-chain, ensuring that
systems are in place as well as information sharing through monthly reports.
 Ensure appropriate engagement with the HSS team, on monitoring, operational research
and information sharing with Government.
 Provide oversight of technical quality and ensuring standards are adhered to and service
provision is consistent.
 Serve as a senior communications channel within the partnership and externally for
dissemination of learning and evidence-based practices.
171. The Programme Coordination Group will hold quarterly meetings and other meetings as may
be needed to ensure good coordination of partners’ efforts. The HSS will assist in coordination
including by providing secretariat functions for all meetings. (Annex 10, ToRs, draft)
Implementation level
172. This programme is a partnership between DFID, MSB, USAID, BRAC and the HSS contractor.
All are independent organisations with robust internal financial, operational and quality management
systems. The strength of MSB, USAID and BRAC’s systems and the confidence that the partners
offered around delivery of results is one of the key reasons for selecting this configuration and these
organisations.
173. Each entity will retain the strong vertical management structures of their own organisations.
The HSS strand and the Programme Coordination Group will complement these to coordinate
delivery of the programme and for maximising the synergies associated with collaboration.
174. Each partner will have Programme Managers responsible for the implementation of the
programme. Each partner will ensure adequate delivery staff across the referral chain. The table
below gives some idea of the likely staffing and clinic infrastructure over time.
Partnership Staff and Facilities now and at the end of the programme.
Partner
MSB
Number of
Urban clinics
107
Number of
staffing Clinic
(now)
656
Outreach staff
present
By 2018
Staffing
258
2122
Number of
Clinics
2018
168
SSFP/NHSDP
193
3200
1200
3620
213
BRAC
390
810
8143
**
**
**Regarding the projected numbers (Staffs & Clinic in 2018) – BRAC is in the process of closing down some
of the Delivery centres and also upgrading some of them. Therefore, it would not be proper to do a projection
for 2018 at this moment
175. These estimates are based on clinic increases in Marie Stopes (12 comprehensive) and
additional clinics in USAIDs programme (15 ultra).
Management processes and structure within DFID
Core Programme Team
176. Specific responsibility for oversight and management of the programme willbe within the
Human Development Team. This will include a Programme Manager and lead Health Advisor. They
will report to the Human Development Team Leader on all aspects of progress of the programme.
177. The DFID Programme Manager and Health Advisor will be responsible for administration and
financial oversight from a DFID perspective. The Health Systems Strengthening Partner will
coordinate information from the implementing agencies in relation to the dashboard of performance
indicators and milestones (Annex 6), actual and planned activities, and regular reviews. DFID will
approve the release of funds as per the contract management section in the commercial case.
B. What are the risks and how will they be managed?
178. Given the sensitivities of some activities in this programme (e.g. MR and gender violence),
managing communications is particularly important to all partners. Communication teams from all
partners will meet regularly to determine public messaging and information flows to non-partners.
The Programme Coordination Group will lead on this.
Risks to successful delivery:
Risks
Management
1.1
Lack of continuity
in Government
leadership at
Steering
Committee level
(especially in the
Probability
Impact
High
Medium
Mitigation
Ensure Steering Committees
continuity of meetings before
and after national elections;
briefing of new Government
officials and active efforts to
familiarise and engage them
months prior and
after national
elections);
Lack of perceived
benefits of
coordination
meetings by
partner agencies
Ensuring
dedicated staff
across the referral
chain for
expansion
Political
Lack of coordination
2.1
through field visits and
innovative reporting.
Medium
High
Network for active quality
leadership from DFID staff and
partners; put HSS in place soon
after approval; focus on practical
and early wins
Monitor change carefully; ensure
staffing is a routine agenda item
in coordination meetings; hinge
payments to results on this if
necessary.
Med
High.
The HSS strand of the
programme will include a focus
on ensuring this coordination
takes place via Urban Health
Working Group (UHWG) which
is already established by
Government. The programme
will actively engage in
policy/strategy development,
role clarity, and resources for
systems strengthening. Current
relations between partners and
Government are good.
UHWG will keep government
and other sector players
informed of scale-up strategy
and the willingness to
cooperate.
Programme Coordination Group
(PCG) will interaction and share
information frequently with other
players; DFID Health Adviser
will play an active role on this
with others.
Active management by DFID
advisers to ensure partners are
not at risk of inaccurate publicity
may be needed.
or differences
between Ministry of
Health and Family
Welfare and
MoLGRDC61
2.2
Competitive
programmes (e.g.
UPHCP Phase 3)
lobby against this
new initiative
Med
Low.
2.3
Anti-MR support
gains traction in US,
UK and/or
Bangladesh
Low
Med
Med
Med
Med
Med
Institutional
Weak public health
3.1
delivery, and tertiary
care for
emergencies
3.2
Human resource
turnover & skills
shortages
Increasing the number of
comprehensive clinics should go
some way towards mitigating the
increased pressure on public
health facilities.
Programme partners will need to
jointly review how to ensure
adequate HR in the short term,
61The relationship between NGOs and City/Municipal Health Managers could also constitute a key risk that this programme
should manage – partly through relationship building and partly through information sharing.
and how to build stability in the
medium term. The PCG will offer
the forum for this.
Social
Gender, inequality
4.1
Med
Med
and social exclusion
factors restrict
women & girl access
4.2
MR service stigma
restricts up-take
Low
High
4.3
Urbanisation and
urban slums grow
faster than cities can
cope
High
Med
Med
Low
Environmental/climate
Flooding
5.1
Partners will actively promote
gender equality through
community based Manoshi
workers. Both MSB and USAID
have active gender policies
which are rights based and
inclusive of adolescents needs
(see Annex 14 example).
Community level
communications will be tailored
to inform people of the public
health importance of safe
abortion and family planning
Additional Government and
donor support may be needed
on the basis of a health
emergency. Advocating with
others via the Urban Health
Working Group will be central to
success
The Programme Coordination
Group may need to liaise with
humanitarian organisations, and
respond to Ministries to ensure
and maintain access to poor
areas.
C. What conditions apply(for financial aid only)?
179. There are no special conditions or conditionalities that apply to this programme.
D. How will progress and results be monitored, measured and
evaluated?
Programme Monitoring:
180. The progress of the programme will be monitored at the outcome and operational levels
through outcome and output level indicators respectively measured against targets described in the
logical framework (Annex 7a-d). At the partner level routine data generated from their MIS systems
will, for example, measure progress on the number of facilities maintaining, and agreed quality/ no
of facilities working 24/7. Outcome level data such as proportion of babies delivered by skilled birth
attendants will be collated and reported by the partners. The MIS data from each partner will be
collated by the HSS on a quarterly basis.
181. Implementing partners will carry out monitoring visits following their own internal system at
clinic level; DFID staff responsible for the project will undertake regular spot-checks. Partners will be
reporting on agreed results quarterly and progress will be tracked based on agreed mile-
stones.DFID representatives and partners will meet to discuss quarterly progress reports and take
decisions on adjustments to implementation.
182. The service for Health System Strengthening (HSS) will be contracted out and they will provide
a service to the programme independent of the Implementing Partners. They will consolidate
programme performance data against logical framework indicators, develop and promote qualityrelated ‘branding’/standards with partners, conduct applied research (including client satisfaction
surveys and profiles)and provide system strengthening both inside and outside the partnership.
These may include the development of capacity building tools or MIS platforms for key partners.
The HSS team will be the cross-partnership facilitators of active monitoring, quality-checking and
pragmatic research. They will provide a partnership standards accreditation, keep the urban health
mapping up to date and engage in policy discussions with Government counterparts. There may be
need to investment in linking the programme MIS with Government MIS systems, and this could be
considered at the mid-term review point.
Programme review:
183. We will undertake annual programme reviews through independent consultants, reviewing how
the programme is performing and agreeing how the design could be modified to increase results
and impact. Data reviewed will include data from the health system strengthening and evaluation
team, client profiles and client satisfaction feedback. This will ensure that the views and needs of
primary stakeholders are reflected in programme implementation. These reviews will be
independently contracted, yet organised and managed by the HSS Unit in order to minimise
transaction costs on DFIDB.
184. For independent annual reviews, the Global Framework Agreement and PEAKS will be used
for procurement of services. HSS will be expected to have the information on the logical framework
and dashboard (see Annex 6)ready and shared with the team well before the review team arrive in
Bangladesh. It will also be important to link these programme reviews to the broader health sector
reviews by using the UHWG as a platform.
Evaluation
185. To determine whether or not a full independent impact evaluation should be carried out an
assessment has been made against the criteria in the DFID Bangladesh Evaluation Strategy:
Criteria
Strategic importance
Size
Innovation
Risk
Response
Addressing gaps in urban service provision to ensure the needs of
the most vulnerable is an important part of DFID’s strategy in
Bangladesh.
The programme will create one of the two largest urban health
delivery systems in Bangladesh for the 20.7m poor people. It is
important for the delivery of DFID Bangladesh’s headline results
on births attended and family planning users.
This is a transformative programme which aims to create a large
scale unified and harmonised ‘system’ of maternal and new born
health care for urban poor, and in doing this to create a seamless
referral system for mothers and new-born children. The
programme will bring together diverse NGO service delivery
organisations under one agreed set of standards of care. It will
test branding of quality standards of services for the urban poor;
and monitor the “pull” factor in improving quality among nonpartners (private sector and UPHCP3 partners).
The risk of failure of the programme is moderate because it is
Ability to evaluate
building synergies between existing proven partners.
It is possible to evaluate the programme. The monitoring systems
being put in place will allow questions around the impact on health
outcomes to be answered.
186. Baseline information will be collected at the start of the programme and the evaluation will be
carried out at midway and at the end of the programme to measure the progress and impact.
Evaluability of the innovative element (see chart above) of this programme will also be assessed
early in the programme. This will involve consideration of the method to be used to determine the
extent to which a ‘system of care’ has been established which unifies service delivery, increases
demand, and has a transformative effect. Findings from this assessment will be used to steer
any additional data collection necessary to undertake the evaluation. The key users of
evaluation will be DFID, the implementing partners, other urban health providers and the
Government of Bangladesh
187. Given the strategic importance and the size of the programme applied research will be carried
out to test the theory of change, determine impact of the programme and assess the value for
money of delivery. Key evaluation questions will include but not be limited to –does a unified
system of quality of care, and branding increase clients demand for services? Does rapid scale up,
branded quality, and effective referral systems impact on the headline results?
.
188. Evaluations and reviews will be managed under the HSS component. Both qualitative and
quantitative methods will be used in designing the evaluation. The implementing partners will be
involved in the process of design, and dissemination of results. The result of the evaluation will
further strengthen the evidence base on health interventions in an urban slum context. For further
details see the Terms of Reference for HSS (Annex 12).
189. Both USAID and MSB programmes also have systems of programme reviews and evaluation
and cover both the rural and urban areas. Information from these will supplement our direct
programme evaluations.
The Health Systems Strengthening (the Third Strand of the Programme):
190. The HSS stream will provide a service to the programme independent of the Implementing
Partners. They will be central to the M+E function of the programme by consolidating performance
data against logical framework indicators for reporting to DFID, conduct applied research and
system strengthening both inside and outside the partnership. The HSS team will be the crosspartnership providers of active monitoring, quality-checking and pragmatic research. They will
provide a partnership standards accreditation, keep the urban health mapping up to date and
engage in policy discussions with Government counterparts. Terms of Reference for HSS (Annex
12).
191. HSS Competencies:





Active monitoring, performance aggregation, quality checking, and accreditation.
Pragmatic applied research, knowledge leadership on technical and operational issues of
Research, Monitoring, Evaluation and Innovation; tool and protocol development and
dissemination, sharing of knowledge; providing knowledge storage services
Updating and sharing the urban health mapping and providing analysis and advice.
Policy Support- providing technical assistance to advocates, support for advocacy and the
provision of legal, regulatory and policy analyses support to ULBs.
Systems Capacity building tools for Implementing Partners and City counterparts
Logframe
Quest No of logframe for this intervention:
Urban Health Business Case: List of Annexes













Annex 1A:
Annex 1B:
Annex 2:
Annex 3:
Annex 4:
Annex 5 A:
Annex 5 B:
Annex 6:
Annex 7A:
Annex 7B:
Annex 7C:
Annex 7D:
Annex 8:
Key results and deliverables
Detailed results calculations
Services of the Programme
City Corporation Statistics
Assessment of the Partners- Due Diligence
Accessible Safe Maternal and Neonatal Health Services in Urban Areas
Payment Profile for MSB: Why advance funding is needed for the project
Dashboard for Strategic Tracking
HSSLogframe
Combined Logframe (USAID&MSB)
USAID/SS Logframe
Marie Stopes Log frame
Draft MOUDFIDUSAID






Annex 9A:
Annex 9B:
Annex 9C:
Annex 10:
Annex 11:
Annex 12:
Budgets for the Urban Health Programme
USAID Budget
MSB Budget
Draft ToRs of Programme Coordination Group
Partnership Arrangements - Principles of Engagement
TORs for Health System Strengthening contractor

Annex 12 A:
Performance Monitoring and Evaluation Plan

Annex 13:
Documents and sources


Annex 14:
Gender Policy- Marie Stopes Bangladesh
Annex 15:
HLSPProgramme Document: Urban Health in Bangladesh, strengthening
care for poor mothers’ and babies
iUltra’s
are the clinics which will be providing fully comprehensive safe delivery services 24/7.
Department for International Development; Project Memorandum for BRACMNCS project. QUEST 2000971:16, 15
iii
Koblinsky M. et al, Reducing Maternal Mortality and Improving maternal Health: Bangladesh and MDG 5. J Health, Population
and Nutrition, ICDDRB, 2008; 26:280-94
ii