Table 4: Child health indicator trends in Saidpur and Parbatipur (KPC) and BDHS comparisons (urban or national average) Indicator 1999 2004 99-04 diff 2007 2009 04-09 diff Child Health Complete immunization S&P 44% 91% P<.05 90% 91% NS urban 70% 81% 86% Vitamin A Supplementation S&P 37% 78% P<.05 71% 79% NS urban 81% Exclusive breastfeeding S&P 55% 72% P<.05 70% 73% NS nat’l 46% 43% Complementary feeding of children 6-11 months S&P 46% 64% P<.05 64% 65% NS nat’l 79% 90% Additional feeding and fluids for the sick child S&P 25% 44% P<.05 34% 25% P<.05 Additional fluids for the sick child nat’l 50% 51% 49% Proper child ARI identification and referral S&P 24% 34% P<.05 66% 52% P<.05 urban 47% 40% 68% Maternal & Neonatal Health At least one prenatal consultation during last pregnancy S&P 59% 89% P<.05 87% 95% NS nat’l 39% 58% At least three prenatal consultation during last pregnancy S&P 64% 62% 74% P<.05 nat’l 26% 41% 46% At least one TT doses during last pregnancy S&P 46% 89% P<.05 57% 70% P<.05 urban 90% 87% 81% Delivery by skilled attendant S&P 31% 50% P<.05 56% 59% P<.05 nat’l 34% 34% 40% Delivery in health care facility S&P 25% 45% P<.05 49% 57% P<.05 nat’l 26% 26% 30% Immediate breastfeeding S&P ` 26% 57% P<.05 50% 64% NS urban 24% 24% 39% Post-partum vitamin A within 42 days S&P 53% 45% 55% NS urban 21% 24%
Both “push” and “accountability” were terms used by stakeholders. They came during informant interviews in the form of an expressed need for “guidance and motivation”, in addition to financial support. The need for guidance relates to a third issue, derived from the evaluation’s team analysis. Insufficient technical vision—aka an unclear identification of health objectives against which activities are assessed beyond vaccination and the support for special a strategic gap. The lack of technical seniority also plays in terms of implementing training. The dominant culture allows little peer-training. Says one informant: “Training needs to come from superiors rather than counterparts. Sometimes training is not well received from colleague; senior or elders are more respected and thus training and education is better received from such individuals.” A less than enabling environment Saidpur and Parbatipur are and remain disfavored urban environments in Bangladesh. Past exercises provided a quantitative representation of this environment (see 2007 report and Annex 1). By all measures, Saidpur and Parbatipur provide a constraining environment for the development of health promotion. As shown in Table 5, dedicated efforts have allowed some improvement in the environment of the municipalities, notably on sanitation where important efforts have been made and coordinated between central and municipal levels. In the 2007-2009 period, daily commodities saw their price increase to their highest level in the last two decades. Given high unemployment and reported decrease in daily labor work opportunities in urban areas, this continues to constrain most poor families for below appropriate nutritional intake. There have been perceived improvements in the economy since 2004 (less in food security). Nearly half the respondents in our opinion survey for example thought that the economic and food security situations had improved since 2004, and another quarter to third of respondents thought it had stayed the same. The years since 2004 have been marked by political instability, which has constrained work, including at WHC level. Following the power conflict in 2007 Bangladesh declared an emergency and commissioners and other social leaders were arrested. Other commissioners took to hiding to avoid arrest. Recent resolution should improve the environment and encourage municipalities to increase their efforts in health promotion. The resulting picture, however, is a far cry from political stability. Central structures, whether it be the MOLGRD or whether this responsibility were to be transferred to the MOH for example, have a fundamental role to play, which is now lacking.