Commonwealth Journal of Local Governance
Issue 29
October 2024
POLICY AND PRACTICE
Engagement of Local Government to Promote Maternal and Newborn Health Services: The Case of Faridpur District in Bangladesh
Faridul Julfiker
Save the Children in Bangladesh, Gulshan 2, Dhaka 1212, Bangladesh, julfiker77@gmail.com
Corresponding author: Faridul Julfiker, Save the Children in Bangladesh, Gulshan 2, Dhaka 1212, Bangladesh, julfiker77@gmail.com
DOI: https://doi.org/10.5130/cjlg.vi29.8812
Article History: Received 13/09/2023; Accepted 13/03/2024; Published 09/10/2024
Citation: Julfiker, F. 2024. Engagement of Local Government to Promote Maternal and Newborn Health Services: The Case of Faridpur District in Bangladesh. Commonwealth Journal of Local Governance, 29, 145–152. https://doi.org/10.5130/cjlg.vi29.8812
© 2024 by the author(s). This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International (CC BY 4.0) License (https://creativecommons.org/licenses/by/4.0/), allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercial, provided the original work is properly cited and states its license.
Abstract
In rural Bangladesh, local government institutions, especially union parishads, play a key role providing essential services for community development. They help connect people with primary healthcare, along with providing nutrition and water, sanitation, and hygiene (WASH) services that reduce the burden of poverty. However, most union parishad officials are not engaged in the promotion of maternal and newborn health (MNH) services in rural areas. Lack of information about their mandated role and responsibilities prevents them from providing MNH services for poor and marginalised communities. Even if they are informed, without the necessary skills to fulfil their role and responsibilities local government officials are struggling to promote quality MNH services within the public facilities in rural areas. To address this problem, Save the Children International engaged local government institutions in a systematic manner to ensure their engagement and contribution to MNH services for rural communities.
Abstract
Maternal and Newborn Health; Union Parishad; Public Health Facility; Local Government Engagement; Capacity-Building; Union Health and Family Welfare Centre
Introduction
Many local government institutions around the world promote maternal and newborn health (MNH) through intersectoral action, but to date there has been little evidence of this approach in Bangladesh. Over a decade ago, in 2011–2013 the World Health Organization Centre for Health Development conducted a study on intersectoral actions for health at local government level and evaluated 25 best cases, which revealed a lack of engagement of local government in promoting MNH services (Rantala et al. 2014).
In Bangladesh, local government has made a significant contribution to the promotion of public health issues such as primary healthcare, water and sanitation, waste management, nutrition, and emergency response during natural disaster; and the engagement of local government in public health is growing in urban areas (Govindaraj et al. 2018). However, at the rural level there is little engagement of local government in MNH services. This paper assesses a systematic effort by Save the Children International to address this problem, at both national and local level, by establishing an engagement mechanism to ensure local government institutions contribute to MNH services within public health facilities.
The specific objective of this paper is to examine the role of union parishads (UPs – the lowest level of local government in Bangladesh) in promoting MNH services within rural areas. It also reviews capacity-building initiatives for UPs, and the support provided by district local government to enhance MNH services in rural areas. In addition, the study also provides some examples of what UPs can do to promote MNH services, which may be replicable throughout the country.
Methodology
The research took a case-study approach, focusing on Faridpur district in Bangladesh, where local UPs have contributed to expanding MNH services within public health facilities. The research mainly involved collecting data from various primary and secondary sources. The secondary sources literature review included evidence-based reports, articles, case studies and success stories. In addition, some primary data and information was obtained through public health facility visits, and discussions with UP officials, members of the community, healthcare providers and district administration staff. Some meetings, workshops and training sessions for UP officials were also observed.
Role and structure of union parishads
UPs are Bangladesh’s lowest-level administrative unit of local government and work closely with rural people. A UP consists of a chairman and 12 members, three of whom must be women. Each UP is divided into nine wards (generally, a village represents a ward). One member is elected from each ward through direct election and another three women members are elected to women-only reserved seats.
According to the Local Government (Union Parishad) Act 2009, the UP is responsible for coordinating the extension of services provided by the district and sub-district (Siddiqui 2008). UPs are expected to carry out 39 listed functions and have 13 standing committees specifically designated to run these functions. One such committee is the Union Education, Health, and Family Planning (UEH&FP) standing committee, which is responsible for advising the UP on education and health issues including MNH (Islam 2017).
Specific UP responsibilities for health include ensuring health services are responsive and accountable to the people, especially poor and marginalised groups. The UEH&FP standing committee is responsible for the following activities related to healthcare:
• informing the local community about the health services available to them, including primary healthcare and an immunisation initiative called the Expanded Programme on Immunisation (EPI)
• increasing UP funds for health and family planning
• assisting the UP to design health and family-planning-related activities
• working with other bodies in the area implementing health-related initiatives (Sohel 2018).
Save the Children’s approach
Save the Children International (SCI) has a strong track record of working with UPs in rural Bangladesh to promote MNH through both policy advocacy at national level and implementation of activities at local level (Taylor et al. 2017). Over a number of years, it has engaged local government institutions in a systematic manner to ensure their participation in and contribution to MNH service delivery. At the national level, coordination with Bangladesh’s National Institute of Local Government (NILG)1 included a session in the UP training manual; while at higher local government levels SCI has coordinated with zilla parishads (district councils) and upazila parishads (sub-district councils); and it has developed links between the national Ministry of Health and Family Welfare (MOHFW) and local governments at all levels.
SCI also helped expand the capacity of MOHFW managers to seek support from local governments, as well as facilitating the district government’s Deputy Director – Local Government (DDLG)2 – to provide guidance to UPs to allocate more annual budget for MNH services, and especially to local-level public health facilities.
At the rural level, within Faridpur district SCI supported 78 Union Health and Family Welfare Centres (UH&FWCs)3 to provide quality services for pregnant mothers and newborns along with a 24/7 normal vaginal delivery birthing service, which operates under the supervision of the UPs. SCI reorganised the UH&FWC management committees4 with the active participation of UP Chairs and other UP officials. SCI also strengthened the capacity-building process of the committees and facilitated a bi-monthly meeting to develop the committees’ monitoring and supervision system.
This work in Faridpur district builds on earlier maternal and newborn health projects by SCI in Bangladesh. For example, from 2013–2017 SCI implemented USAID’s MaMoni Health Systems Strengthening (USAID’s MaMoni HSS)5 projects in six districts of the Barisal, Chattagram and Sylhet regions to increase the use of integrated maternal, newborn, child health, family planning and nutrition services through local health and family planning departments. Strengthening local government planning and engagement in MNH service provision was one of the key priorities of the project.
Following USAID’s MaMoni HSS, SCI created the USAID’s MaMoni Maternal and Newborn Care Strengthening Project (USAID’s MaMoni MNCSP)6 in 18 districts in Bangladesh to address Goal 3 of the United Nations Sustainable Development Goals (UN SDGs), with a particular focus on reducing maternal and newborn death.7 Again, one of the key priorities has been to promote the engagement of local governments, especially UPs, to provide responsive, quality MNH services which are widely available in rural areas, and fully supported by local government.8
SCI has worked with local government institutions in Faridpur district to build capacity so it can play a significant role in promoting MNH services. The SCI project has also acted as a catalyst to strengthen coordination between local governments, the Department of Health (DGHS) and the Department of Family Planning (DGFP) to increase service coverage and improve MNH outcomes.
Specific work in the case study area
Faridpur is one of 64 districts in the south-west region of Bangladesh. It is located 140 km from the capital city, Dhaka, and has an area of 2,053 km². Within the district are nine sub-districts, 81 UPs and six urban municipalities (Bangladesh Bureau of Statistics 2022).
Faridpur has 525,877 households and a population of 2,232,772, of which 76.8% live in rural areas. The population density is 1,088 per square km. The literacy rate (age seven and over) is 72.13%, compared to the national average of 74.80%, and the population is 51.4% male and 58.6% female. The majority of the population is Muslim (91.5%), and the rest are Hindu, Buddhist and Christian. Farming is the main occupation, along with manual labour and small business. Women mainly engage in household activities, alongside cow and goat rearing (Bangladesh Bureau of Statistics 2022).
Health services provision by government comprises one teaching hospital, one district hospital, three maternal and child welfare centres (MCWCs), eight upazila (sub-district) health complexes, 78 UH&FWCs and 198 community clinics across Faridpur district. All these facilities provide MNH services, and UH&FWCs are the main public health facility offering MNH services at the rural level.
Consistent with the UN SDGs, the Government of Bangladesh has set a target of lowering the maternal mortality rate (MMR) to 70 per 100,000 live births and lowering the neonatal mortality rate (NMR) to 12 per 1,000 live births by 2030. However, in Faridpur district, maternal and newborn deaths are still high; 163 per 100,000 live births and 17 per 1,000 live births respectively (Bangladesh Bureau of Statistics 2021).
In the Faridpur district, SCI focused on increasing local government engagement in MNH services with a strategy of interventions, coordination, and advocacy at three levels: district, sub-district and UP. SCI worked at both district administration and grassroots (UP) levels. At the UP level, it used capacity-building, coordination, and advocacy tools to promote MNH services by focusing on:
• increasing participation, engagement, and supervision of local government in MNH services
• developing the capacity of UP officials to perform their mandated role and fulfil their responsibilities for delivering quality MNH services from public health facilities
• supporting existing community groups, the UH&FWC management committee and UEH&FP standing committee with their MNH service provision mandate
• influencing UP budget allocations to ensure MNH services are suitably prioritised
• building awareness among local government institutions on the need to contribute to UN SDG 3 by reducing maternal and newborn death
• increasing the effectiveness of relationships between local government institutions and health and family planning departments at community level.
Inputs
To achieve the above goals, SCI collaborated with the Efficient and Accountable Local Governance (EALG)9 project to specify key actions which would increase the engagement of district authorities in local initiatives to promote MNH services. For example, it:
• developed planning coordination between UPs and the DDLG
• developed a training module incorporating MNH issues for UP officials
• trained and guided 380 UP officials, including Chairs, on their role and responsibilities to promote MNH services within rural public health facilities
• helped 81 UPs develop annual budget-setting processes, incorporating an allocation for MNH services
• organised field visits to UH&FWCs for 30 UP officials, so they could learn first-hand about local MNH services
• briefed the DDLG about the budget training processes and field visits
• organised a bi-monthly meeting of 78 UH&FWC management committees, to discuss implementation and ongoing MNH issues.
Key outcomes
A key finding of the programme to date is that UPs’ success in supporting MNH services relies very heavily on the initiative of the UH&FWC Chair. Chairs are in a position to mobilise effective support, resulting in the following outcomes:
• 21 UPs contributed finance, logistics, medicine, and monitoring support to 21 union level-facilities (UH&FWCs) enabling them to offer 24/7 MNH service provision
• three UPs provided ambulance services for pregnant mothers and children free of cost
• 13 UPs provided free rickshaw van transport to UH&FWCs for pregnant mothers
• one UP established UH&FWC services, including normal birthing services, using the UP complex; it also appointed a midwife to serve hard-to-reach areas where the UH&FWC building had been demolished by river erosion
• 17 UPs constructed roads to UH&FWCs, enabling transport for pregnant mothers to reach the facility
• 21 UPs provided medicine and equipment (eg examination bed, delivery table, fan, furniture, blood pressure machines etc) for UH&FWCs, satellite clinics and other health facilities
• 13 UPs provided transportation costs for extremely poor families referred to a higher-level MNH facility
• 21 UPs provided support to health workers doing outreach work to encourage the local community to accept and utilise the services available to them
• all 81 UPs allocated BDT34,095,000 (US$316,056) to improve UH&FWC facilities in order to provide more MNH services.
Findings
Most of the UP officials are still not aware of their role, responsibilities or mandate to engage with providing MNH services. Therefore, capacity-building initiatives along with advocacy with UPs are essential to promote accountability and boost MNH services within public health facilities, especially in UH&FWCs. Follow-up and monitoring supervision of UPs by the DDLG is also important to ensure they deliver as MNH service providers: UP engagement in UH&FWC activities can promote MNH service coverage and facility readiness.
Challenges identified
• Lack of linkages between DGHS, DGFP and local government institutions at district, sub-district (upazila) and UP (union) levels.
• Lack of coordination between union-level service providers and DGFP and DGHS staff or local government representatives.
• Lack of resources within local government to strengthen MNH services effectively.
• Ensuring the accountability of union-level providers and personnel to the UP, especially participation at UDCC10 meetings and standing committee meetings.
• Frequent staff transfers at management level that lead to a loss of institutional knowledge.
• Sensitising the newly elected bodies after elections takes considerable time.
• Ensuring functioning UH&FWC management committees with UP chairs and conducting bi-monthly committee meetings.
• Though UPs get an annual government grant for development activities it is not sufficient to cover the cost of ensuring MNH services meet demands.
• UPs lack appropriate plans for resource mobilisation and recurring costs need to be covered from other sources, such as revenue and tax collection.
• Sustaining MNH services and quality over time will be a challenge without further strengthening of structures and accountability.
Conclusion
Although the UP has a significant role and mandate to promote and support MNH services in rural communities, lack of information and capacity along with coordination difficulties mean that UPs are not sufficiently engaged in these activities. They need more facilitation to increase their support for union/village-level facilities, especially UH&FWCs. This study found that coordination between UPs and the Department of Health and Family Planning’s representatives at district and village level can significantly help to promote MNH services. But, although advocacy work with district-level local government officials is important, UPs must also allocate and deploy more budget funding, logistics and medicine for village-level health facilities.
Additionally, it is important to ensure citizen engagement in planning and implementing MNH services, to enhance accountability. This case study thus highlights two key factors in MNH service delivery improvement at UP level: strengthening capacity-building and ensuring citizens’ participation in decision-making processes through regular engagement and social monitoring.
Declaration of conflicting interest
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author received no financial support for the research, authorship or publication of this article.
References
Bangladesh Bureau of Statistics. (2021) Report on Bangladesh sample vital statistics 2020. Dhaka, Bangladesh: Ministry of Planning, Government of the People’s Republic of Bangladesh.
Bangladesh Bureau of Statistics. (2022) Preliminary report: population & housing census 2022. Dhaka, Bangladesh: Ministry of Planning, Government of the People’s Republic of Bangladesh.
Govindaraj, R., Raju, D., Secci, F., Chowdhury, S. and Frere, J.-J. (2018) Health and nutrition in urban Bangladesh: social determinants and health sector governance. New York: World Bank. https://doi.org/10.1596/978-1-4648-1199-9
Islam, M.T. (2017) Understanding the effectiveness of Union Parishad Standing Committee: a perspective on Bangladesh. London: London School of Economics and Political Science (LSE). Available at: https://blogs.lse.ac.uk/southasia/2017/11/07/understanding-the-effectiveness-of-union-parishad-standing-committee-a-perspective-on-bangladesh/
Rantala, R., Bortz, M. and Armada, F. (2014) Intersectoral action: local governments promoting health. London: Oxford University Press. https://doi.org/10.1093/heapro/dau047
Siddiqui, K. (2008) Local government in Bangladesh. Dhaka: University Press Limited.
Sohel, M. (2018) A positive role of Standing Committees to improve the service delivery at grassroots. Dhaka: Democracywatch. Available at: http://www.dwatch-bd.org/prc/html/A%20positive%20role%20of%20standing%20committee.pdf
Taylor, M., Manuel, D.F., Bhattacharjee, A. and Al, A. (2017) Bangladesh MaMoni health systems strengthening (HSS) project midterm performance evaluation. Dhaka: USAID. Available at: https://www.academia.edu/40388777/Bangladesh_MaMoni_Health_Systems_Strengthening_HSS_Project_Midterm_Performance_Evaluation [Accessed February 2017].
1 The NILG is a national training and research institute which provides training to local government officials, both elected and appointed, in Bangladesh.
2 The DDLG is the supervisory official overseeing UPs, and reports to the Deputy Commissioner in each district.
3 To ensure health and family planning services are uniformly available to the rural populations, the Government of Bangladesh operates one UH&FWC in nearly every union jurisdiction. One of the main services at the facility is MNH services for rural women and newborn babies.
4 A UH&FWC management committee is the management and supervisory authority of a UH&FWC. The Chairman of the local UP is the president of the committee.
5 The MaMoni Health Systems Strengthening (HSS) project was implemented by SCI with financial support from USAID: https://pdf.usaid.gov/pdf_docs/PA00TF9C.pdf
6 United States Agency for International Development (USAID) provided financial support for the project.
7 The current maternal mortality ratio (MMR) is 163 per 100,000 live births, and the neonatal mortality rate (NMR) is 17 per 1,000 live births as per Bangladesh Sample Vital Statistics 2020. The UN SDG goal is for a maternal mortality rate below 70 and a neonatal mortality rate below 12.
8 Project brief available here: https://resourcecentre.savethechildren.net/pdf/MaMoni-MNCSP-Project-Brief-updated-2021_English.pdf/
9 Efficient and Accountable Local Governance (EALG) is a project by the United Nations Development Programme in collaboration to build the capacity of Bangladesh’s UPs https://www.undp.org/bangladesh/projects/efficient-and-accountable-local-governance-ealg
10 The Union Development Coordination Committee (UDCC) reviews all development-related activities of a UP. It meets bi-monthly and is headed by the UP Chairman, with all UP officials and government department representatives in the area being members.