ANNEX D: GHI and Bangladesh (Illustrative)

Background and Health Situation:

Bangladesh is the seventh most populous country in the world. Despite a steady 5-6 percent per year economic growth over the past decade, more than 45 percent of its 167 million people continue to live in a state of abject poverty. Over the last 30 years the country made notable achievements in family planning and child survival with a decline in the total fertility rate from 6.3 to 2.7 children per woman in 2007. Mortality of children under the age of five has declined from 220 to 65 per 1000 live births over the same period. Likewise, infant mortality has more than halved from 140 to 52 per 1000 live births. Nevertheless, the levels of mortality and morbidity due to infectious diseases, causes related to childbearing and other preventable conditions are still very high. TB remains a major public health threat; diarrheal, respiratory, and other preventable diseases continue to affect child survival; and the maternal mortality ratio is still high at 320 per 100,000 live births. In addition, Bangladesh's under-five malnutrition is higher than some Sub-Saharan countries. Despite these remaining challenges, Bangladesh has a culture of community-based programming and innovation, and a strong government commitment that makes the time ripe to make tremendous strides in health.

GHI Implementation in Bangladesh:

An intensified GHI focus will scale-up activities outlined in the national health program and ensure special attention to monitoring and evaluation to assess progress and to capture lessons learned for the Government, other GHI countries and U.S. government agencies:

Collaborate for impact: The GHI will deepen its engagement with the Ministry of Health and Family Welfare, and increase collaboration and coordination with other development partners. Potential activities include:

• Integrating currently discrete activities (e.g. MCH, family planning, and nutrition, polio eradication, immunizations and neglected tropical diseases) into a full package of health services for women, newborns, and children.
• Linking GHI health programs with those in the education, agriculture, and food security sectors.
• Facilitating national elimination of lymphatic filariasis along with the control of other neglected tropical diseases.
• Coordinating GHI activities in country across the full complement of U.S. government agencies on the ground.

Do more of what works: GHI assistance in Bangladesh will continue to scale-up proven interventions that address the health challenges of women, newborns and children, including:

• Scaling-up and improving the quality of a package of low cost, effective child survival interventions to reduce under-five mortality, with an emphasis on newborn health. These include wrapping and drying newborns, clean cord care, immediate and exclusive breast feeding.
• Scaling-up and improving the quality of a package of effective maternal health interventions to reduce maternal morbidity and mortality. These include: timely antenatal care; birth planning, maternal nutrition; increasing delivery by skilled birth attendants; obstetric care, especially for the poor; active management of third stage of labor; community management of post partum bleeding; and diagnosis and treatment of eclampsia.
• Reducing unmet needs for family planning by resuscitating the national family planning campaign and increasing availability of long acting and permanent methods, using opportunities to engage men in male sterilization through involvement of religious leaders.
• In conjunction with the Food Security Initiative, mainstreaming nutrition interventions into ongoing primary health care and education programs to improve eating habits and health outcomes.

Build on and expand existing platforms to foster stronger systems and sustainable results: The U.S. government will build on existing health systems and platforms such as the health social marketing program, existing community health workers and community clinics, and the vibrant NGO sector to expand services and improve capacity. Potential activities include:

• Enhancing the sustainability and accountability of the vibrant private sector to meet the demand for low-cost essential health products.
• Strengthening the existing NGO service platforms' ability to provide integrated and expanded services for antenatal and postnatal care; nutrition for mothers and children; basic obstetric care; water, sanitation and hygiene improvement; family planning services and infectious disease control.
• Training public health workers in field epidemiology, surveillance, laboratory practices, and program management to better prevent, diagnose, and control disease, and promote health.
• Expanding training in research methods to build long term capacity in operational and implementation research at existing Bangladeshi institutions.
• Implementing health interventions in education and other sectors by expanding hand hygiene education and using water treatment solution to treat water at schools.

Innovate for results: GHI will work with Bangladesh to explore promising health innovations including:

• Introducing birth dose of vitamin A into the essential newborn care package.
• Testing regimes of different antibiotics in cord care and treatment in newborns at the household level.
• Creating and strengthening incentive programs, such as the maternal voucher program which provides free antenatal care to poor women and their infants, to improve quantity and quality of care.
• Exploring opportunities to encourage local production of nutritious foods/supplements for weaning infants and for pregnant women.
• Expanding new approaches in MDR-TB diagnosis and treatment.