Enhancing the impact of child health activities through the USAID-supported NGO service delivery program (NSDP) in Bangladesh

Two project-level factors impede CH programming: (1) Like its predecessors, the NSDP has not focused on expanding coverage or priority interventions with the most impact on CH. Acute respiratory infections (ARI) and diarrheal disease remain major causes of child morbidity and mortality. (2) NSDP programming is often driven by unofficial policies that encourage NGOs to judge their success largely by cost recovery and emphasize the primacy of static and satellite clinics over community-based services (CBSs). This approach is not conducive to the provision of many critical CH services, especially in extremely low-resource environments. Unless these two issues are resolved, the NSDP is likely to spend a great deal of money but have little impact. Other program findings are as follows: (1) The NSDP lacks clarity regarding its objectives and benefits, especially for efforts to introduce new strategies (e.g., integrated management of childhood illness [IMCI], community integrated management of childhood illness [C-IMCI], and essential newborn care [ENC]). (2) Reliance on training as the main CH strategy is not sufficient. The current focus on developing capacity to conduct training internally is also not optimal, since many CH programs also offer these capabilities. (3) CARE and Save the Children Federation are the NSDP"s primary partners, but have very small roles in the project. (5) NGOs are usually not included in decisionmaking, and processes affecting them are not transparent. Organizationally, NSDP is strongly vertical, creating barriers to integrated CH efforts. Additionally: the Clinical Services Unit, where most activities are located, does not have a community health approach or management perspective to support CH efforts; the NSDP lacks a senior-level CH technical expert; there is no specific plan to help NGOs operationalize activities over the long term; management information and monitoring and evaluation systems need to be adjusted; institutional development is excessively linked to financial concerns; and current logistics plans may be unrealistic. The NSDP"s technical approach features separate interventions introduced through training. The project has no systematic plan for integrating new strategies nor has it analyzed the costs and benefits thereof. There is a common perception that some technical initiatives "belong" to specific NSDP partners. Those having a bigger share of management and resources are able to push forward their favorite initiatives, while initiatives championed by less influential staff have not gained much traction. The Essential Service Package (ESP) appears to have worked well for NGOs, but has limited capacity and cannot respond well to emergencies. The NSDP has differing views about how this limited emergency capability should be overcome. Many see improved static clinics and community education as the answer, while others believe that only improved treatment options in the community will adequately address the problem. Clinical IMCI is the main mechanism through which modern CH is being implemented in the NSDP. Under a joint program with the Government of Bangladesh (GOB), the NSDP has 15 pilot clinics in urban areas where IMCI is being initiated as a national strategy. There is much internal pressure on the NSDP to implement IMCI rapidly. The current plan calls for establishing up to 55 clinics this year, and similar scale-up is planned for the following years. It is clear that clinical IMCI is the future for project NGOs, but a number of issues will need to be resolved: (1) There is no clear understanding of the advantages of IMCI in NGO clinics. Current expectations may not be realistic. (2) NGOs may be unaware of the complexity and costs of an IMCI clinic system and may not be able to assume these costs when the NSDP ends. (3) Clinical IMCI is currently considered largely a training issue. There has not been adequate thinking and planning about recurring costs, logistics, and other support systems. The C-IMCI strategy is closely aligned with that of the GOB and current plans are to initiate NSDP activities in 9 pilot areas in 2003. Over the next 3 years the NSDP hopes to roll out this program to approximately two-thirds of its 278 clinics and 7,000 depot holders. Although C-IMCI is potentially NSDP"s most important CH intervention, it lacks a clear mandate, a strategic framework, and a detailed implementation plan. Also, it has not had strong senior management support nor been widely discussed and embraced by the NSDP as a pivotal intervention. A careful examination of the far-ranging implications for community-based programming and services is overdue. NSDP lacks a neonatal component and the current service delivery system is not well positioned to deliver ENC. There are no plans to intervene with neonates at the community level, although C-IMCI may provide more focus on newborns in the home. The proposal to adapt successful strategies from the Saving Newborn Lives (SNL) initiative places meaningful neonatal activities at least 2-3 years away. Improvements in neonatal care are closely linked with better maternal health, but except for a plan to improve the referral process, there are no strategies to move forward in this area. Likewise, nutrition is underrepresented. Finally, behavior change communication (BCC) activities are not well aligned with CH needs. Current plans focus on expanded community awareness of NGO services, household prevention, and community mobilization to support C-IMCI. The Bangladesh Center for Communications Programs is a good resource, but will have to support this program area to a greater extent than currently anticipated.