Addressing the Reproductive Health Needs and Rights of Young People since ICPD- The Contribution of UNFPA and IPPF
Publication date: 2003
Bangladesh Country Evaluation Report Add re s s i ng t he Re p ro d uc t i v e He a l t h N e e d s a nd R i g h t s o f Yo u ng Pe o p l e s i n c e I C P D – T h e C o n t r i b u t i o n o f U N F PA a n d I P P F DFID Department forInternationalDevelopment Addressing the Reproductive Health Needs and Rights of Young People since ICPD: The contribution of UNFPA and IPPF Bangladesh Country Evaluation Report September 2003 Written by: Alanagh Raikes Malabika Sarker Hashima-e-Nasreen For: UNIVERSITY OF HEIDELBERG UNFPA and IPPF Evaluation: Bangladesh Country Report i CONTENTS Acronyms. . . . ii Acknowledgements. . . . iv Analytical Summary . . . .1 Key Findings and Recommendations. . . 8 Introduction . . . . 12 Section 1: The Country Specific Context . . . 14 Section 2: The Country Programmes’ Strategic Priorities . . 24 Section 3: Institutional Arrangements. . . 41 Section 4: Enabling Policy Development and Reform. . 57 Section 5: Strengthening Sexual and Reproductive Health Services. .62 Section 6: SRH Information and Education . . .70 Annexes Annex 1: Programme and Key People Met and Site Visits Annex 2: Stakeholder Workshop: agenda and participants Annex 3: List of UNFPA and FPAB current projects Annex 4: UNFPA Youth Forum Advertisement Annex 5: FPAB Organogram Annex 6: Aide Memoire Annex 7: Methodology Annex 8: References Annex 9: Terms of Reference UNFPA and IPPF Evaluation: Bangladesh Country Report ii ACRONYMS 1CP First Country Programme 2CP Second Country Programme 3CP Third Country Programme 4CP Fourth Country Programme 5CP Fifth Country Programme 6CP Sixth Country Programme ADPO Assistant District Project Officer AYSRH Adolescent, Youth Sexual Reproductive Health BCC Behaviour Change Communication BDHS BDRCS Bangladesh Demographic and Health Survey Bangladesh Red Crescent Society BGMEA Bangladesh Garment Manufacturers & Employees Association BMRC Bangladesh Medical Research Council BRAC Bangladesh Rural Advancement Committee CEDAW Convention on the Elimination of All forms of Discrimination Against Women CO Country Office CP County Programme CPD Centre of Policy Dialogue CPR Contraceptive Prevalence Rate CST Country Support Team, UNFPA CST/CASA Country Support Team for Central and South Asia CSW DD(Youth) Commercial Sex Worker Deputy Director Youth DNFE Directorate of Non-Formal Education (DNFE) DPO District Project Officer ET Evaluation Team FPAB Family Planning Association Bangladesh FPAs Family Planning Association FWC Family Welfare Officer FWV Family Welfare Visitor GoB Government of Bangladesh HPSP Health and Population Sector Programme ICPD International Conference Population and Development IEC Information, Education, Communication IPPF International Planned Parenthood Federation IRC Islamic Research Cell KAB Knowledge Attitude and Behaviour KAP Knowledge Attitude and Practice M&E Monitoring and Evaluation MCWC Maternal and Child Welfare Centre MIS MO Clinic Management Information System Medical Officer Clinic (govt) MO MCH Medical Officer Maternal & Child Health (govt) MOHFW Ministry of Health Family Welfare MOWCA Ministry of Women’s and Children’s Affairs MSCS Marie Stopes Clinic Society MTR Mid Term Review NGO Non Government Organisation UNFPA and IPPF Evaluation: Bangladesh Country Report iii ACRONYMS contd… NPPP National Professional Project Personnel PD Population and Development POA Plan of Action PRSP Poverty Reduction Strategy Paper PSE Personal Social Education RBM Results Based Management RRs Reproductive Rights SCF-UK Save the Children Fund – UK SC-UK Save the Children UK SRH Sexual and Reproductive Health STI Sexually Transmitted Infections UFPO Upazilla Family Planning Officer (govt) UHA Upazilla Health Administrator (govt) UNDAF United Nation’s Development Assistance Framework UNF United Nations Foundation UNFPA and IPPF Evaluation: Bangladesh Country Report iv ACKNOWLEDGEMENTS We would like to express our thanks and gratitude to everyone who assisted us in the evaluation, especially all the staff of the UNFPA Country Office and FPAB who gave up so much of their time and were enthusiastic and positive in discussions with us about adolescent and youth sexual reproductive health and rights. We would also like to give a very special thanks to the Research and Evaluation Division at BRAC who welcomed us, carried out the three local studies, completing most of the work while we were in country. It was a difficult time for them with the recent loss of a colleague, but they looked after us, facilitating the workshop and our visits and also giving us the opportunity of meeting some of the key people in the organisation and hearing first hand about their recent innovations in working with young people. We also wish to establish that the views expressed in the report are ours alone and not those of the evaluation sponsors. UNFPA and IPPF Evaluation: Bangladesh Country Report 1 ANALYTICAL SUMMARY The German Ministry for Economic Co-operation and Development (BMZ), the Danish Ministry of Foreign Affairs, the UK Department for International Development (DFID), the Netherlands Ministry of Foreign Affairs, and the Norwegian Ministry of Foreign Affairs have sponsored an evaluation of the contribution of the United Nations Population Fund (UNFPA) and the International Planned Parenthood Federation (IPPF) to address the reproductive rights and health needs of young people in the period since the finalisation of the Programme of Action (POA) developed at the International Conference on Population and Development (ICPD) in 1994. The goal of the evaluation is to contribute to a better understanding of the conditions necessary for achieving best practice, and to draw strategic lessons for the future; the purpose is to assess the performance of the UNFPA country offices and the FPAs in six selected countries in promoting the reproductive rights and health of adolescents and youth. This analytical summary presents the main conclusions and lessons from the evaluation of the UNFPA Bangladesh Country Office and FPAB (the Bangladesh IPPF affiliate) against the five evaluation themes of strategic focus, institutional arrangements, policy and advocacy, service strengthening, and information and education. The summary highlights key findings against 10 key questions set out in the original TORs for the evaluation under the following headings: Strategic Focus: The extent to which UNFPA and FPAB: · Recognise and articulate the country-specific, socio-cultural factors that impact on the reproductive rights and health of young people · Recognise and articulate the diversity of needs of young people · Promote the concepts and practice of reproductive rights; and · Are gender-sensitive in addressing SRH needs and rights of young people. Institutional Arrangements: The extent to which UNFPA and FPAB: · Contribute to the response of government and civil society to the reproductive rights and health needs of young people; · Provide quality technical support and promote lesson learning and best practice in young people’s reproductive rights and health; · Promote the participation and empowerment of young people; · Demonstrate complementarity, coherence and cooperation with each other; and · Demonstrate relevance, scope and effectiveness in co-ordination arrangements and partnerships with other actors in the field of reproductive rights and health. Policy and Advocacy: The extent to which UNFPA and FPAB are: · Stimulating enabling environments for policy development in relation to young people’s sexual reproductive health and rights. The above issues are explored in detail in the main report, and further elaborated in the discussions of service strengthening and IEC. UNFPA and IPPF Evaluation: Bangladesh Country Report 2 Strategic Focus The strategic focus of both agencies has shifted since ICPD 1994. Both agencies are engaged in the political agenda and in the process of implementing the changes involved in meeting young people’s sexual reproductive health needs. They have had very different access to resources and have different working modalities. Both organisations have been hampered by the socio-cultural environment that has limited the extent of real changes in addressing the Reproductive Rights (RRs) of young people, however changes have occurred in both organisations and in the cultural environment since ICPD. Neither agency has addressed all the priority contextual Sexual and Reproductive Health (SRH) and RRs issues that face young people, including gender based violence where women continue to become victims of acid throwing, dowry payments and other harmful practices. However, UNFPA does have a new project that includes work on Advocacy to end gender-based violence in the new Sixth Country Programme (6CP). UNFPA The Fifth Country Programme (5CP) was the first country programme developed after ICPD. The overall goal of the 5CP was to contribute to the improvement of the sexual reproductive health and family welfare of the people of Bangladesh and to the achievement of population stabilisation. To meet the goal of the 5CP, the planning processes of three sub-programmes, Sexual Reproductive Health, Advocacy and Population Development produced strategies for achieving the overall country goals. The Reproductive Health Sub-Programme and the Population and Development Sub-Programme were designed to carry on with the necessary and fundamental support work to the national health services and the population programme. The Advocacy Sub-Programme’s main strategy was to use a multi-sectoral approach that involved collaboration with ten ministries, the private sector and a number of NGOs and youth clubs. A large part of the Advocacy Sub-Programme was designed to work with the new initiative of adolescent and youth SRH. In the projects that targeted adolescents and youth there was an awareness of the socio-cultural factors that impact on the rights and health of young people. The strategy was based on the recognition of the cultural diversity of youth, with attention paid to youth both in- and out-of-school. For those in school, the programme targeted Secondary, Higher Secondary, Technical/Vocational and the Madrasah System. Out-of-school youth were reached through a variety of different channels including the Non-Formal Education Programme and the Youth Clubs. Work was also carried out in the private sector amongst garment workers and tea plantation workers. In the 5CP, gender equity is addressed in all three sub-programmes. Gender issues have been integrated into the new curricula for the different schools and training programmes supported through the Advocacy Sub-Programme. In the 5CP two externally funded initiatives, the EC/UNFPA RHI and the UNF/UNFIP provided two important pilot projects that were implemented through a variety of NGOs and youth clubs. This innovative work has informed the Country Office (CO) and influenced the policy and practice of UNFPA in the work of adolescent and youth SRH. Gender equity has been a central part of their strategy during the 5CP. A rights based approach is still a challenge that will be addressed in the next country programme. 6CP follows the Common Country Assessment of Bangladesh and the first Bangladesh UNDAF 2001-2005. This framework adopts a rights based approach to evaluating development achievements. For UNFPA the new programme will focus more on adolescent and youth sexual reproductive health and rights, and will also concentrate its efforts through UNFPA and IPPF Evaluation: Bangladesh Country Report 3 the Advocacy Sub-Programme using a multi-sectoral approach with a broad collaborative strategy. In terms of sustainability for the work in adolescent and youth SRH and RRs, the two variables are the Government of Bangladesh (GoB) and the donors. Where UNFPAs assistance has been requested by the GoB the sustainability is dependent on the needs and interests of the GoB and at present there is no indication that this need or interest is changing and the Government partners are encouraging the collaborative work between themselves and UNFPA. In relation to the donors, their responses have and will vary in relation to the political environment. For example, at the present time the donors have partially suspended their funding support for the Health and Population Sector Programme. The NGOs, with whom UNFPA work, are all aware of the need to address sustainability issues and some have made efforts to operationalise this. FPAB The FPAB has adopted a strategy of including youth in its programme from the 1980s, prior to ICPD. In the early days the work focused more narrowly on family planning, but by 1992 it included SRH through peer educators. In their Strategic Plan (1994-2002) their goal was to reach 5 million youths to prepare them for responsible parenthood with IEC messages on population, sex and sexual reproductive health, STI/AIDS and primary health care. In their next Strategic plan (2001– 2005), the FPAB specifically addressed increasing access to SRH services for adolescents, youth and women. The plan was an expansion of the earlier work, but was also rights based. The FPAB showed a lack of understanding of the different cultural interpretations and influences on RRs. They have a clear and strong understanding of the cultural diversity in which their work on adolescents and youth is implemented, but this is not translated into differentiated services or information for different groups of young people. FPAB declared in their 2001– 2005 Strategic Plan that they would establish equal rights for women and men to enable them to exercise control over their own RRs. In both plans reviewed, FPAB have been gender sensitive in terms of their clients, however, within the organisation itself there is still a strong male dominated hierarchy that is not gender sensitive. Although RRs is addressed in the Strategic Plan, there was no evidence to show that the promotion of RRs has been implemented or promoted in the field. FPAB has included sustainability as one of their important goals in the 2001-2005 Strategic Plan. The plan is to increase local resources from 5% to 25% through collecting donations from the community, charging for services, selling FPAB training facilities and undertaking different fund raising activities. They also plan to reduce programme operation costs by 10% through networking with different development partners including the GoB. Close collaboration and good relationships with community gatekeepers (teachers, parents, Imama, local members, village doctors) and established organisations also enhances the sustainability of youth oriented activities. Institutional Arrangements The two organisations are structurally and historically very different and play very different, but complementary, roles in Bangladesh. The FPAB is an implementing organisation and an established and pioneer NGO that has been providing quality contraceptive care, and other health services, to clients in the rural areas since the 1960s. UNFPA and IPPF Evaluation: Bangladesh Country Report 4 The UNFPA CO is one of the largest in the world, its size corresponding to the country population. It is a non-implementing organisation that works through support to partner organisations. It has a highly qualified, gender balanced and age balanced staff who collaborate with numerous partners in government, NGOs and in the private sector to strengthen their policies, plans and projects. Since ICPD both organisations have been able to respond to the sexual reproductive health needs of young people with their own diverse competencies and with different constraints and have co-operated in a number of joint activities and projects. UNFPA The CO, mainly through the Advocacy Sub-Programme, has played a significant role in supporting the response of GoB to the needs for information on SRH and RRs of adolescents and youth. It has achieved this by supporting population education and SRH in the national curriculum and aiding the GoB to reach the out-of-school youth through a range of different channels (youth groups, scouts, guides etc). The staff at the CO are well equipped to provide qualified inputs into the planning and implementation of young people’s RRs and SRH. However, it appears that there is still room for improvement in practising the promotion of lessons learnt and best practice. Despite being a hierarchical UN organisation, the CO has addressed itself to the new initiative and is working with young people on developing a dialogue about their needs, policies and plans, and the provision of information and of services. Participation of adolescents and youth in the 5CP has been documented in baseline studies, in conferences and workshops as well as in the formation of a National Youth Forum. The Youth Forum, initiated in April 2003, is a good example of the CO attempting to bring youth into the process of articulating their different SRH information and service needs and planning interventions. The effectiveness of this mechanism to amplify young people’s voices in decision-making will need to be monitored, and disseminated if successful. UNFPAs relationship with FPAB appears to be based on a good collaborative experience. The FPAB is recognised as an old and established NGO in the field of the provision of SRH services. UNFPA awarded FPAB a contract to collaborate with them on the innovative EC/UNFPA RHI through a competitive bidding process. The main partnership co-ordination is between UNFPA and the government. The co- ordination arrangements appeared relevant and effective. The strategy of including the EC/SRHI and the UNF funded adolescent girls project in the UNFPA portfolio has added value and strength to the work of the CO in the field of adolescent and youth SRH and RRs. The CO also has partnerships with NGOs working in the field of young persons SRH and RRs and these too appeared to offer good collaborative arrangements. FPAB Despite its strategic objectives to reach young people, FPAB does not appear to have the capacity (particularly at field level) to make a significant contribution to addressing the SRH and RR and needs of young people. This is particularly the case for RRs. The declared goal, set out in the 2001-2005 Strategic Plan, was to establish equal rights for women and to enable them to exercise control over their own RRs and SRH choices. However, the FPAB does not have any project at present that can be considered as rights based. There appeared only a vague understanding of RRs within the organisation. UNFPA and IPPF Evaluation: Bangladesh Country Report 5 FPAB staff have a good reputation and are widely accepted in the community. However, they lack training and capacity in young people’s sexual reproductive health and rights. They have knowledge and experience about the community and community needs, but lack skills to implement programmes focussed on young people’s needs. There is no specific policy to encourage youth participation within the organisation and the selection process in the governing body also actively restricts young people’s participation. However, they do have a network of youth in the community who are part of their programme working as organisers, leaders and peer educators, but they are not involved in the management or planning processes of the organisation. FPAB has a good relationship with UNFPA where it is presently collaborating with the implementation of the EC/SRHI. FPAB has good relationships with the Government and with civil society that are appropriate for the priorities of the organisation. At the community level, FPABs activities are accepted and highly valued, although this is for their quality service provision in the field of SRH in general and not for adolescent and youth, as this work is in its infancy at present. Policy and Advocacy This is perhaps the area where the focus of the two agencies differs the most. Working in the policy arena is one of the main areas of focus for the work of UNFPA, both through its Advocacy Sub-Programme, as well as through its Population and Development sub- programme, and is where a number of significant changes have been made. FPAB, on the other hand, is a small service provider that does not play a role in advocacy and policy development. UNFPA The UNFPA has been effective in bringing the issue of adolescent and youth SRH and RRs into the national policy arena. Through its work in collaboration with a number of ministries, with NGOs and with the private sector, it has spread its influence and also learned from partnerships. The work has been carried out mainly by the Advocacy Sub-Programme, but the work has been supported in terms of population policy and research through the Population Development sub-programme. The work of the Population Development sub- programme is widely recognised as having played a major role in opening up the national debate on population and development including the present roles and expectations of young people in the future of Bangladesh. FPAB Advocacy and policy development is not part of the work of the FPAB. However, it was felt that given the standing of the FPAB, and its place on governmental and non-governmental committees, not being involved in policy development (in relation to adolescent and youth SRH and RRs) represents a lost opportunity. Sexual Reproductive Health Services In Bangladesh there is a major gap in the provision of SRH services to adolescents and youth, particularly unmarried youth. Support to the provision of SRH services for adolescents and youth has been a challenging initiative, given the cultural context (see Section 1). However, there are indications that married adolescents and youth may be accessing services supported or provided through both organisations. Age alone did not appear to be a barrier for access to services, rather a key barrier reported was that UNFPA and IPPF Evaluation: Bangladesh Country Report 6 unmarried young people are unable to use the services. It appears that the age of clients is not monitored with due emphasis in many facilities. UNFPA Under 5CP core funding, the CO did not develop a strategy to initiate SRH services for young people. However, the EC/SRHI project funding did focus on the provision of services for young people in three districts. Support for the provision of SRH services to adolescents and youth is included in the core budget of the CO 6CP, commencing this year. This is a challenging initiative given the cultural context in Bangladesh. However, work carried out in a pilot project supported by the EC/SRHI and also collaborative work with the FPAB in the 5CP, has laid the groundwork for this initiative to be included in the new SRH Sub- Programme. FPAB FPAB is currently running 38 clinics including satellite clinics, which mostly provide contraceptives to women. They also offer antenatal care, counselling and STI services. These services may be provided to youth, but this is difficult to determine because there is no age variable in the MIS. Recently the FPAB started adolescent and youth friendly clinics once a week, but there was little evidence of the effectiveness of this initiative at present. No training has been given to staff in the provision of youth friendly services or counselling for adolescents and youth. Information Education and Communication (IEC) IEC/BCC for SRH for adolescents and youth has been a core part of the work of both organisations. A multi-media approach has been adopted, and a number of innovative materials have been produced, several collaboratively. Problems have been identified with the teaching capacity of peer educators and others who use the materials, where the training has often been too short for effective communication on SRH to take place. Also the distribution of materials is still insufficient where shortages were observed. UNFPA Under the 5CP the majority of the budget allocated to youth in the Advocacy Sub-Programme, focused on three main IEC projects for adolescent and youth SRH. In the first project, youths in school (Secondary, Higher Secondary, Technical/ Vocational and Madrasah system) were reached with focussed inputs into curriculum development. Secondly, for adolescents and youth who have dropped out of school, another focused input has been made for family life education through the Non-Formal Education Programme provided by the Ministry of Primary and Mass Education with the support of UNFPA. Thirdly, a number of out of school youths are reached for gender and SRH education through the non-formal session by the Youth Clubs executed by the Ministry of Youth and Sports. At the same time a number of innovative approaches have been developed through the work of the EC/SRHI and the UNF work with married adolescent girls. These projects have addressed the key aspects of the ICPD Programme of Action in relation to education. They have institutionalised population education in the formal school system, where the issues dealt with address the ICPD priorities and include gender issues, environmental concerns, needs of adolescents, delayed marriage, HIV/AIDS, male involvement in SRH, RRs of all, but particularly girls and women. Through the Youth Clubs, UNFPA and IPPF Evaluation: Bangladesh Country Report 7 youth are reached for advocacy on sexual reproductive health and gender issues and course materials include gender issues, prevention of early marriage, gender-based violence, RRs, poverty alleviation through self employment, HIV/AIDS and participation in the community. In the non-formal system, again the ICPD priorities are addressed through the introduction of Family Life Education, covering topics that include gender issues, early marriage and pregnancy and violence against women. FPAB 95% of the youth budget is spent on IEC. FPAB provides education to the community and has an excellent reputation and acceptance level amongst the gatekeepers and young people. Through innovative approaches like the Islamic Research Cell and the debate competition, they have been able to reach different target groups (in- school and out-of- school young people and students in the religious system). However, within the IEC programme there appeared no input in relation to RRs. Also the method of teaching, providing one– stop education sessions, appeared inadequate. The staff and volunteers engaged in IEC lack sufficient training to make the programme effective. The IEC materials produced are simple and easy to understand but there appeared to be an inadequate supply of these materials in the community. UNFPA and IPPF Evaluation: Bangladesh Country Report 8 KEY FINDINGS AND RECOMMENDATIONS UNFPA · UNFPAs work in Bangladesh is highly valued by the Government where the CO is seen to take the lead in SRH and to be following up the ICPD +5. Whilst 5CP did not have a significant focus on young people, the 6CP is moving to a rights based approach and specifically addresses provision of services to young people. Work to address the wider contextual issues of gender-based violence will be taken up in 6CP. · The CO does not have an overall strategy to address the SRH and RRs for youth and adolescents. The concepts of adolescent and youth SRH and RRs are still very new and work in this area in both 5CP and 6CP was planned without the development of an overall coherent strategy to pull together the various strategies under different sub-programmes. · The strategy of working with a wide range of partners, including 10 ministries, many NGOs and private sector projects has enhanced coverage of youth issues and has been a successful advocacy strategy. Through research conducted under the Population and Development Sub-Programme, and the work of the Centre for Policy Dialogue, UNFPA has had a significant impact in terms of raising the profile of adolescent RH and rights issues with government, the donor community and civil society. · The Country Office is well aware of the cultural complexity of working with adolescents and youth, specifically in the context of rapid urbanisation and the current changes in Islamic culture. However, social restrictions have meant that while there have been advances in addressing the poor knowledge base of young people in relation to SRH (e.g. through national curriculum development and work with Youth Clubs), work in initiating provision of services has been more limited. · During 5CP, initiatives in service provision for young married people have been supported with EC/RHI and UNF funds. Innovations in adolescent friendly services have been supported through funding key NGOs and in four locations. This work has informed the CO and has had a wider impact in terms of demonstrating to Government partners that adolescent friendly services can be provided through the NGO system. It remains unclear, however, how many young people are accessing services, due to the lack of age specific data on utilisation. Further, whilst married adolescents and youth are able to access services, provision for the unmarried remains culturally taboo. · The quality and commitment of the staff at the CO is high combining staff with long Bangladesh experience with young, highly qualified National Professional Project Personnel. In addition there have been numerous visits from the CST office covering a range of trainings on young people’s SRH and monitoring and evaluation. · The CO is well aware of the need to include the participation of youth in the design and planning of programmes. Young people have been encouraged and included in planning for the 6CP and in the EC/SRHI and UNF work in the 5CP. The setting up of a Young Persons Forum and plans for how to integrate the Forum into the on-going work of the CO are innovative and admirable initiatives. · Gender equity and women’s empowerment have been integrated into all aspects of the work of the three sub-programmes in the 5CP and 6CP. Gender issues however appear to have received less attention in the working modalities of a number of the partners. UNFPA and IPPF Evaluation: Bangladesh Country Report 9 FPAB · FPAB is the leading NGO in family planning services in Bangladesh, and has been providing services to married youth for a number of years. The goals in the 2001 – 2005 Strategic Plan include to increase SRH education to adolescents and youth, and introduce provision of SRH services to this group. Limited youth friendly services have only recently been started, and it is too early to assess their effectiveness. · FPAB works extensively with a wide range of young people from different socio-economic, cultural and religious backgrounds, and is sensitive to the needs of young people. However this awareness does not appear to be translated into the provision of differentiated services and information for different groups of young people. Further the provision of RH services to adolescents and youth is difficult to monitor as there is no age variable in the MIS. · CO staff commitment and dedication appeared high throughout the organisation, however there is a lack of field-level human resources for SRH and RR for young people, and staff at all levels in the organisation lack training in the provision of youth friendly services. · FPAB management takes part in the political life of Bangladesh, and has good relationships with the GoB and civil society. However, FPAB has not played a significant role in advocacy in promoting SRH and RRs for adolescents and youth, and there is a lack of collaboration with other NGOs on activities to address SRH and RRs of young people. · RRs for women are included in the 2001-2005 Strategic Plan, however FPAB does not have any specific project that can be categorised as “rights based” and RRs for young people are not incorporated into strategies or programmes. There is a lack of clarity amongst the staff as to the precise meaning of RRs for young people. · Participation of adolescents and youth in programme planning, implementation is poor. Although youth volunteers work in the communities they are not included in any of the decision-making mechanisms, and are actively excluded from the Volunteer Board and the Governing Body. · There is insufficient attention to gender equity in the organisation and no one has received any gender training. The Governing Body is not gender balanced, however, at the field level special attention is paid to gender balance in all youth activities. · FPAB provides SRH education to the community and has an excellent reputation and acceptance level amongst the gatekeepers and young people. They have made a number of innovations (for example the Islamic Research Cell and the Debate Competition in schools and colleges) but these have not been scaled up for wider use. IEC materials are simple and easy to understand, but are in short supply. Training for peer educators and other staff has not been adequately covered. The “one spot” education sessions are inadequate for the retention of sensitive and diverse issues. UNFPA and IPPF Evaluation: Bangladesh Country Report 10 Complementarity of UNFPA and FPAB · There is a degree of complementarity between UNFPA, which has concentrated on working with Government partners in advocacy, national curriculum development, population analysis and, with NGO partners in the EC/SRHI initiative, and FPAB, which concentrates on service provision and IEC work in the community. FPAB will continue to be an implementing partner in the EC/SRHI Phase 2, indicating UNFPAs confidence in FPABs capacity as a national NGO to address adolescent and youth SRH and RRs. · There is little sharing of “good practice” and lessons learnt that could benefit the work of both organisations. Recommendations: UNFPA · An overall strategy for addressing the SRHRs of young people should be developed during the 6CP for the planning of the 7CP in 2005. The strategy should be developed by the CO with the participation of youth, building on the good collaboration already established. · The CO is moving to a rights based approach in the sixth country programme (2003-2005) and efforts should be made to address RRs issues in the appropriate cultural contexts. Moreover, UNFPA should work more closely with rights-based NGOs to gain consensus on RRs in the context of Bangladesh in order to better incorporate this component of ICPD POA into projects in the 6CP in an overall strategy for the 7CP. · The CO should continue its advocacy work in stimulating an enabling environment for policy dialogue and policy development through its wide network of partners – while at the same time exploring ways to link policy to implementation and scaling up “good practice” initiatives. In particular the advocacy work carried out through the Population and Development Sub-Programme, together with the Advocacy Sub-Programme, should be supported and strengthened. · Efforts should be made to support government partners to address issues of gender equity within their organisations for work on adolescent and youth SRHRs. · Collaboration and co-ordination, especially with HPSP donors, GoB and NGOs should be maintained and given priority in the future of work on young people’s SRH and RRs. · More focus should be put on addressing SRH services for young people, supporting work with NGOs and with MOHFW. Moreover, attention should be paid to monitoring the age of users of services. · The organisation of SRH education through Youth Clubs does not appear to be a structured programme, although some designated project areas are better organised and monitored. A review should be undertaken. · Attention needs to be paid to the quality of the communication/teaching of peer educators and school teachers for maximum impact in SRH education. UNFPA and IPPF Evaluation: Bangladesh Country Report 11 FPAB · FPAB should start using RR concepts not only in relation to SRH but also to individual rights including information on age of marriage, number of children and freedom to space one’s children. · FPAB should play a more significant role in stimulating an environment for the establishment of RRs in the SRH field, using its position on national health committees to advocate RRs for young people. · More effort should be made to include the participation of youth in the organisation’s programmes and policies relating to SRH for adolescents and youth, with a special effort needed to encourage meaningful youth participation on to the Governing Body. · Gender balance issues within the organisation need to be addressed at all levels where male to female staff ratios need to be more balanced. · Dedicated human resources with special responsibility for youth activities should be employed at field level. · Training on SRH and rights for adolescents and youth should be carried out throughout the organisation. Training of staff and youth organisers is inadequate. Medical officers, paramedics, youth organisers, peer educators and counsellors are all in need of training on adolescent and youth SRH and RRs. · Age should be included in the MIS format used in the health services to enable future analysis of the number of young people who are clients, regardless of their marital status. · FPAB should develop collaborative work on adolescent and youth SRH and RRs with GoB and NGO partners. Sharing of experiences and “good practice”, for example the Islamic Research Cell and the Debate competition with others working with young people’s SRH should be prioritised. Further, the new adolescent friendly SRH services should be monitored and evaluated, and any “good practice” examples shared with partners. · A review of the different aspects of the SRH education programme should be carried out, to evaluate the knowledge of the educators, the design of the teaching programme and the retention of the SRH messages achieved. The supply of IEC/BCC materials needs to be reviewed to ensure sufficient supply is maintained Complementarity of UNFPA and FPAB · The good collaboration between UNFPA and FPAB should be continued. UNFPA could be pro-active in supporting training needs of FPAB and other NGOs they collaborate with in adolescent and youth SRH and RRs, for example joint peer educator training. UNFPA and IPPF Evaluation: Bangladesh Country Report 12 INTRODUCTION The Ministry for Economic Cooperation and Development (BMZ) of Germany, the Danish Ministry of Foreign Affairs, the UK Department for International Development (DFID), the Netherlands Ministry of Foreign Affairs, and the Norwegian Ministry of Foreign Affairs are jointly sponsoring an evaluation of the contribution of the United Nations Population Fund (UNFPA) and the International Planned Parenthood Federation (IPPF) to addressing the RRs and health needs of young people1 - and especially adolescents - in the period since the finalisation of the Programme of Action (POA) developed at the International Conference on Population and Development (ICPD) in 1994. The evaluation focuses on six country case studies: Tanzania, Burkina Faso, Bangladesh, Egypt, Nicaragua and Vietnam undertaken between March and May 2003. The findings from these six country studies will be synthesised into a final report to be presented at an international workshop in December 2003. Objectives of the Evaluation The overall aim of the evaluation is to clarify how UNFPA and IPPF contribute to the implementation of key aspects of the ICPD Programme of Action, relating to the RRs and health of young people. UNFPA and IPPF have affirmed their commitment to the ICPD framework; central to which are the notions of gender empowerment, equity, and a rights based approach. IPPFs commitment to a rights based approach is outlined in the IPPF Charter on Sexual and Reproductive Rights (1995), and in the objectives and strategies of Vision 2000. The goal of the evaluation is to contribute to a better understanding of the conditions necessary for achieving best practice, and to draw strategic lessons for the future. The purpose is to assess the performance of UNFPA country offices and FPAs in selected countries (see below) in promoting RRs and health (with the aim of achieving behavioural change), with a particular emphasis on adolescents and youth. Composition, Timing and Schedule of the Country Evaluation The local partner for the country evaluation was BRAC. BRAC undertook preliminary studies ahead of the international team’s visit. The first study was a legal status review, planned to investigate the legal status of young people with regard to their sexual reproductive health and rights. The second study was a review of the range and availability of IEC materials produced by UNFPA and FPAB, and the third study was a study on young people’s perceptions on access to and quality of sexual reproductive health information and services conducted by organising focus group discussions with groups of young people in a variety of locations. The international team for the country evaluation was: Alanagh Raikes (team leader), Malabika Sarker (international team member) and Hashima-e-Nasreen (national team member). The international team members arrived on 24th April 2003, and departed 12th May 2003. On 24th April the international team members met at the BRAC headquarters, where the Research and Evaluation Division welcomed the Evaluation Team (ET). The team undertaking the local studies was introduced, and a report on the status of the work was 1 The evaluation adopts UN definitions: adolescents are aged 10-19 years, youths are aged 15-24 years; young people include both categories (10-24 years). UNFPA and IPPF Evaluation: Bangladesh Country Report 13 made. A planning session was then was held in Dhaka on 27th April. This was well attended and provided a very useful introduction to the work and a good way of meeting key partners to plan further discussions. The programme was then further refined with some initial meetings with partners in Dhaka. The work distribution was divided between two teams, with one team carrying out fieldwork in Bogra, Rangpur, Sayedpur and Chittagong and the other team carrying out interviews with partners in Dhaka as well as doing field work in Dhaka. In addition the team carrying out the local studies carried on with their information gathering and planning further Focus Group Discussions with young people. The two teams reassembled in Dhaka on 9th May and held a de-briefing session followed by a planning meeting for the de-briefing sessions with UNFPA and FPAB. Two (Evaluation Team) ET de-briefing sessions were held on 11th May, the first with the UNFPA Country office where members of the sub-programmes attended as well as four partners from different ministries. The second de-briefing session was held with the FPAB where a number of key programme officers were present (for details of the itinerary of the evaluation see annex 1). Report Format The report is arranged in six sections with the first section being the country context. The following five sections review and analyse the questions set out in the TORs against the five themes of the evaluation: 1. strategic focus, 2. institutional arrangements, 3. policy and advocacy, 4. service strengthening and 5. information and education. UNFPA and IPPF Evaluation: Bangladesh Country Report 14 SECTION 1: THE COUNTRY SPECIFIC CONTEXT This opening section considers a range of historical, economic, political, policy/legal, socio/cultural and behavioural factors influencing young people’s sexual reproductive health and rights. The analysis places the status, roles and right of young people within the broader developmental context of Bangladesh. Subsequent sections of the report are informed by and analysed in relation to this section. 1.1 Demographic and Socio-Economic Context Poverty Bangladesh ranks 145th of 173 countries (2000) on UNDPs Human Development Index (HDI) with an estimated per capita GDP of US$ 380 in 2000 (UNICEF 2000). 77% of the population live in the rural areas and approximately 40 million of rural and about 14 million of urban people live below the national poverty line, where people earn less than one US dollar a day. The urban population is growing at a faster rate (6%) than the rural population (less than 2%), mainly because of migration from rural to urban areas. The urban population is expected to grow at an accelerated rate, accounting for over 40% of the total population in 2020. The density of the urban slums is over 5,000 people per square kilometre, and in places rises to as high as 86,538 per square kilometre in Dhaka city alone (UN Agencies in Dhaka, The Dancing Horizon, Human Development Prospects for Bangladesh, Dhaka, 1997). Access to education The adult literacy rate in 1999 was 40% (BDHS 1999-2000) with 52% for males and 30% for females. Although the female/male ratio in primary school is 100:115, in secondary schools and universities this gap increases to 100:131 and 100:322 respectively (Ministry of education 2002). In addition to gender inequalities, inequalities also exist by geographical areas. Only 36% of rural women are literate, compared to 60% of urban women. The problems of primary education include issues of access, equity and equality. Net enrolment is 82% and about 3 million children of primary school age have not been enrolled. Attendance rates, however, are 60%. One third of those who have been enrolled for primary education do not complete. School enrolment rates drastically fall between primary and secondary level. However, female enrolment has increased rapidly over the past few years and is now almost equal to that of boys in the secondary phase (UNICEF 2000). This is because the government has a ‘food for education’ programme, which provides wheat to female students, and at secondary level, another programme provides scholarships to girls (UNICEF 2000). NGOs, meanwhile, have established non-formal education programmes, concentrating on 8-15 years with a special emphasis towards girls. Demographic and health indicators The population of the area that now constitutes Bangladesh has grown from about 42 million in 1941 to about 140.4 million in 2001 (Country menu 2003; UNICEF 2000), making the nation the ninth most populous country in the world and one of the most densely populated. The population growth rate was 2.23% in 1961 and registered as 2.45 in the early seventies. This was a result of high fertility and declining mortality. Bangladesh has undergone a remarkable demographic transition over the last two decades. The total fertility rate has declined from about 6.3 in early 1970s to 3.3 in mid-1990s (Mitra et al 1997:31). Although infant and under-5 mortality rates are declining, they are still high. The infant mortality rate was 150 deaths per 1000 live births in 1975 and fell to 87 in the 1989- UNFPA and IPPF Evaluation: Bangladesh Country Report 15 1993 period (GoB 1994:5; Mitra et al 1994: 92). More recently UNFPA indications show that the rate has now decreased to 57 per 1000 live births (UNFPA 6CP, May 2003). Maternal mortality has declined from 620 deaths per 100,000 births in 1982 to 440 in 1995 and to 320-400 in 2002 (BMMS 2002). This small but important decline is mainly attributed to increased availability of family planning and immunization services, improved antenatal and delivery care, and a reduction in the number of births to high-risk mothers (GoB 1994: 5; BBS 1997a: 144). Because of the mortality decline, there is evidence of modest improvement in life expectancy during the past decade. Life expectancy at birth was 46 years for males and 47 years for females in 1974 (UN 1981:60). Current life expectancy in Bangladesh is 60.6 years for males and 60.8 years for females (State of the World Population, 2002). The higher death rate among girls compared to boys aged 15-19 (1.81 as against 1.55 per 1,000 population) is mainly due to maternal causes. A study analysing the causes of maternal mortality in 1976-1978 found a much higher maternal mortality rate (MMR) among females aged 15-19 years (7.3 per 1,000 live births) compared to those in the low-risk age group of 20-34 years (4.3 per 1,000 live births). Amongst 15-19 year-olds, the main causes of death directly related to pregnancy or childbirth were: toxaemia (18%), abortion (16%), haemorrhage (15%) obstructed labour (6%) and infection (5%). Violence and injuries accounted for a further 17% of maternal death in this age group. (UNICEF Adolescent Girls in Bangladesh, 1999). About 52% of the child population suffers from malnutrition, 11% of all children die in their first year and 19% before they reach the age of five. Major reasons are food shortage, misconception as to the composition of an adequate diet, unsafe water resources, and poor health and sanitation facilities, misconceptions about food for pregnant mothers, feeding colestrum and breast feeding babies. (SC– DK, 2000). Adolescent nutrition shows that throughout adolescence, girls consume fewer calories than boys, 8% fewer at the age of 10- 12, 18% fewer at the age of 13-15 and 28% fewer between the ages of 16-19. In terms of meeting energy requirements, while boys aged 13-17 consume just enough calories to meet their energy needs, consumption among girls of the same age falls 4% short of their needs and 8% short for girls aged 10-12years. Deficiencies in calorie intake are greater among urban than rural girls. Over half of adolescent girls are stunted and the stunting rates are higher in rural than urban areas. Also adolescent girls suffer from iron, iodine and Vitamin A deficiencies (UNICEF, Adolescent Girls in Bangladesh, 1999). Bangladesh has experienced a steep fertility decline in the 1980s. In 1975, the TFR was observed to be 6.3 births per woman, which has declined to 3.4 in 1993/94, and since then has remained almost unchanged, despite the CPR having increased from 40% in 1991 and 54% in 2000. Plateauing TFR at a high level of 3.4 will delay the time by which the country will achieve population stabilization. The GoB goal is to reach a replacement level fertility rate of 2.2 by 2005, which is expected to stabilise the population at 211 million by 2056. However, if replacement level fertility is delayed by another 10 years to 2015, the population will stabilize 25 years later (by 2081) at 250 million. (UNFPA Sixth Country Programme, Population and Development Strategy, January 2003) Young people aged 10-19 years comprise 25% of the population, 40% of the population are under 15 years, and 3% are aged 65 or over. This young age structure constitutes a built-in “population momentum”, which will continue to generate population increases well into the future, even in the face of rapid fertility decline (BDHS 1999-2000). Gender relations and status of women The UNDP gender related development index (GDI) ranks Bangladesh extremely low, at the 121st position (2000) of 146 countries. It implies social inequalities i.e. inequalities in income and education between men and women (Country Menu 2003). Bangladesh is one of the few UNFPA and IPPF Evaluation: Bangladesh Country Report 16 countries where females have historically had lower life expectancy than males, due to son preference and low social status of women; this situation is changing, with current estimates of life expectancy at 60.6 years for men and 60.8 years for women (UNFPA 2002), possibly as a result of better use of health services by women. Participation of women in the political system remains very weak. Women’s affairs were represented in the government through 30 seats (10%) reserved for women in the parliament and a National Council for women’s development, which has the Prime Minister in chair. However, in the current parliament, this policy has ceased and there are only 6 elected female members of parliament, including the Prime Minister and the Leader of the opposition. Bangladesh’s overall gender strategy is based on the National Policy and Action Plan on Women (NAP), co-ordinated by the Ministry of Women and Children’s Affairs. This Ministry has created a gender focal point in each line Ministry (and in the MOFHW there are focal points in Health, FP and Nursing) and the Ministry has also seconded a technical officer to the MOHFW, partly sponsored by the Netherlands Embassy (Bangladesh, HPSP 1998-2033 MTR, Nov, 2000). A recent study on mainstreaming gender equality in four interventions in Bangladesh (including two NFE projects which are also included in the UNFPA Advocacy Sub-Programme) indicated that having gender equality goals was a key component of gender mainstreaming. The two NFE projects have formulated numerical gender equality goals but did not have gender disaggregated data on outcomes, making evaluating changes difficult. Evaluating how gender focal points and mainstreaming strategies has changed underlying gender inequalities in Bangladesh is difficult to assess, however it is apparent that the climate for promoting gender equality through development assistance is conducive in terms of supportive legislation and officially stated priorities. (SIDA, Mainstreaming Gender Equality, Country Report Bangladesh, 2002). The protection of women and female adolescents/youth is an important issue in the country. The 1995 ordinance on the oppression of women and children provides penalties for kidnapping or trafficking women/female adolescents, claiming dowry, committing or attempting to commit rape and acid throwing at young girls. The penalties range from rigorous imprisonment for 7-14 years with fines, to life imprisonment with fines or even death depending on the nature of the crime. Despite the laws, the incidence of violence, including psychological stress, beating, acid attacks, sexual abuse and exploitation of children continues to plague the realisation of rights. Psychological stress and beating as a result of strong traditional dowry system exists both in the rural and urban area (Ahmed 2000). Rape of children and adolescent girls is a significant problem, but remains largely hidden due to stigma attached to the victims of such offences. Acid throwing and trafficking are other serious problems (see 1.4 below). But children who come into conflict with the law do not always receive the protection provided for by law (UNICEF 2000). Gender preference and dowry demands go together. Not only are girls unlikely to contribute to the family income, but their marriage can cause a serious drain on resources. In recent years, dowry has become an important issue in Bangladesh. Often it is not one bride price given at the time of marriage, but rather intermittent demands from the husband and his family whenever they face an economic crisis. The demand for dowry has a negative effect in two significant ways; it can affect gender preference of children and make girls even less desired than traditionally, and the future of the bride in her husband’s home is affected if the dowry is insufficient. Stories of beating and murder for dowry, or lack thereof, are often read in the popular press, whole families can attack the bride and her family if the dowry demands are not met. Suicides of women are also often attributed to inhumane treatment by a husband or his family. There is legal action that can be taken against this type of treatment, but it is seldom taken, more often, both families keep quiet and carry on with their lives. UNFPA and IPPF Evaluation: Bangladesh Country Report 17 Son preference is often highlighted in many Asian countries, but in some studies it is reported that it is not as pronounced in Bangladesh (Nasreen H, 2001). However, other studies have indicated that son preference is a major factor in Bangladesh (UNFPA, 2003). Most families would like a balance of children. This is particularly important in rural families where role definitions are still traditional. Men take care of the land and the contact with the outside world, and women take care of the family and the home. Thus both sons and daughters are needed to continue the traditional roles. While prescribed roles are changing, survey data indicate that women still prefer to have two or three children but at least one son. Sons are seen as future wage earners and providers for the family, daughters may not contribute to the family income as young women and certainly will not be able to contribute to their birth family after marriage. Any investment in girls will, in the long-term, benefit others. Thus traditional families still do not believe in a secure economic future if they do not have a son. Son preference is therefore also a major factor driving high fertility in Bangladesh. Non-Governmental Organisations (NGOs) The role of NGOs in the socio-economic context of the country is significant in any analysis of the processes involved in the provision of services and in the interpretation and implementation of social sector policies and plans. In order to reduce poverty and empower women, the NGOs have played an important role often spearheading initiatives for income generating and awareness raising programmes and, at the same time working closely with the Government and bilateral organisations. The interim Poverty Reduction Strategy Paper acknowledges that Bangladesh has achieved considerable success in catalysing grassroots activism through NGOs and CBOs (MoF, Dec 2002). There are some 13,000 local organisations operating in the field of voluntary social welfare activities in Bangladesh in poverty alleviation. NGOs operate in a comprehensive range of sectors addressing every corner of life affected by poverty. However, NGOs have been the subject of criticism from conservative forces for promoting modernisation, and there has been serious divisions within the NGO movement itself. The MoHFW is in the process of developing a Strategy on Government-NGO Collaboration as an agreed action for reform, but this has been subject to protracted delays due to lack of political commitment. In terms of SRH and RRs, NGOs have taken the lead and developed a number of innovative projects. 1.2 National Policies, Strategies, Programmes and Laws (This section of the report has been written using inputs from the in-country study on laws and policies as the basis for information). National Population Policy and Reproductive Programme The national priority issues in the health sector, as identified in the Fifth Five Year Plan include ensuring universal access to essential health care services of acceptable quality and to further slow population growth. The policy focused on family planning and strong maternal and child health within the framework of sexual reproductive health care including safe motherhood, family planning, prevention and control of RTI/STI/AIDS, maternal nutrition, adolescent care, infertility, and neonatal care. The main aim of the fifth plan is the reduction of infant and under 5 mortality and morbidity, reduction of maternal mortality and morbidity, improvement of nutritional status and reduction of fertility, and improvement in life expectancy, age of women at the birth of their first child, nutritional status and healthy lifestyle so as to reach replacement-level fertility growth by the year 2005. The National Population Policy awaits final GoB approval. UNFPA and IPPF Evaluation: Bangladesh Country Report 18 National Health Policy The major issue raised by the 1995 mid-term review of the Fourth Population and Health Project (FPHP) was that the structure of the Population and Health directorates (with separate cadres at all levels) did not adequately respond to the needs of the child and maternal health and clinical contraception, and limits the potential for increasing the range, quality and effectiveness of services. Inadequate inter-project linkages, poor institutional co-ordination, and poor support within the sector led to duplication of the efforts and inadequate utilisation of services. Moreover, this was not cost-effective and raised questions of sustainability. As a result, the Health and Population Sector Strategy (HPSS) was formulated in consultation with development partners/stakeholders to reform the Health and Population Sector Programme (HPSP) to provide an essential service package (ESP) to the people of Bangladesh. The services should be responsive to the client’s needs especially those of children, women and the poor, and achieve quality of care with adequate delivery capacity and financial sustainability. The HPSP is the fifth five-year plan (FFYP), running from 1998 to 2003, and adopts a sector-wide approach (SWAP). In terms of policy, planning, strategy formulation, implementation, and resource management, the SWAP is intended to improve the performance of the health sector and enhance the efficiency with which resources for health are used. HPSP substituted 128 separately funded and managed projects with one programme implemented through 23 operational plans monitored jointly by the GoB and its development partners. Donor assistance, government revenue and development budgets have also moved from project support to sector development support since 1998. The main feature of the health sector reform agenda under HPSP has been the unification of bifurcated structures (population and health) in the public health system. This has entailed intensive efforts to reorganise and decentralise decision-making, strengthen management capacity and enhance resource mobilisation. However, there is now major controversy between development partners and MoHFW regarding the GoBs expressed desire to de- unify the directorates of health and population, and in relation to domiciliary and static health service delivery. The proposed Health, Nutrition and Population Sector Programme (HNPSP) for 2003-2006 prioritises the population sub-sector, highlighting Bangladesh’s young age structure and the population momentum this brings with it. The GoB proposes to focus on raising the average age of childbearing through delaying marriage and first births. Strategies identified to achieve this include increasing education and employment of women, more effective enforcement of the minimum marriage age law, and targeting BCC to young couples (MoHFW, March 2003). However, the role of male involvement and RRs of young people do not seem to be addressed. Moreover, there is some concern among Development Partners that the MoHFW is moving away from an integrated understanding of sexual reproductive health consistent with the goals set under ICPD, and wishing to selectively strengthen family planning services. HIV/AIDS Policy and Programme In 1997, the Government approved an integrated national policy on STI, HIV/AIDS and related issues with the participation from various communities including NGOs, bilateral and donor agencies. National sentinel surveillance of HIV is still in place and reports are published annually. The second national expanded HIV surveillance report focused mostly on the urban-based high-risk group of population and was published in September 2000. The main focus of policy is on behaviour change communication (BCC) and condom promotion. Recently NGOs and the government have been working together to introduce the UNFPA and IPPF Evaluation: Bangladesh Country Report 19 use of condoms in different high-risk groups. In addition, the Government has identified syndromic management as a strategy for control of STIs with initial emphasis on high-risk groups and piloting in rural and urban areas. Moreover, the Government has introduced the safe blood act in 2002, although very limited facilities are available with only 10 blood banks in the country. Because HIV infection related stigma is prevalent, HIV care, counselling and legislation needs to be an important component of the HIV prevention programme. Thus technical competence should be developed at the institutional level by providing training of different categories of personnel. National Education Policy The GoB has made a commitment to a number of international declarations including the World Conference on Education for All (Jomtien, 1990) which commits the Government to the overall objectives of achieving the goal of “Education for All”. The government has committed itself to remove illiteracy within a given time frame - to increase the literacy rate of adults (15 years and above) to 80% by the year 2002 and to achieve 100% literacy by the year 2006. To meet these commitments, and others, the GoB has planned the delivery of basic education through two parallel systems, the formal and the non-formal. Policy for Women’s Advancement With the approval of the national policy and action plan for Women’s Advancement in 1997, GoB has an excellent framework for follow-up on Beijing PFA. Subsequently WID co- ordination mechanisms were established in every ministry. However, the national machinery to facilitate gender mainstreaming is still too weak in terms of institutional capacity and allocation of resources. The Committee on the Elimination of Discrimination Against Women (CEDAW) There are constitutional guarantees of equality between women and men. The Convention has been popularised and disseminated after being translated into Bangla. The In-Country Study 1 – Legal Status Review, reported that although the GoB confirmed their support and commitment to the CEDAW, the reservation to article 2 – calling for governments to take all necessary measures to eliminate discrimination against women – still remains. The GoB does not consider as binding the provisions of article 2, as they conflict with Sharia law based on the Holy Quran and Sunna. Rights framework in Health As follow-up to ICPD, Bangladesh has adopted the programme of action of SRH International Conference on Population and Development in 1994. To address sexual reproductive health issues HPSS has taken a new approach with a holistic life cycle perspective. Under HPSP, the formulation and dissemination of a “Clients’ Bill of Rights” that complements quality of care improvements from a professional and technical perspective. The aim of the Bill is to raise awareness of clients to their rights to equality, to life, and to quality of care, including such aspects as privacy, informed choice, safety and efficacy of care, and provision of free of charge care or adherence to approved fee schedules. This also provides the opportunity for creating public awareness on the rights of women and children and also for addressing issues such as violence against women and providing a basis for dialogue with the social welfare and legal system. Clients are advised of their related rights through NGO action as well as the media. However, to date, a systematic communication strategy for promoting clients’ rights is lacking. Neither are there mechanisms for monitoring the enforcement of these rights nor for redressing violations of these rights. UNFPA and IPPF Evaluation: Bangladesh Country Report 20 There are human rights commissions in Bangladesh, but their accessibility to places known for human rights violations is limited. Thus, cases of human rights violations are reported in the media, but it is seldom that those responsible are reprimanded for their actions. For example, early marriage is a violation of human rights and contravenes the right to free and full consent to marriage, enshrined in the Universal Declaration of Human Rights in the CEDAW and in many other human rights instruments. However, little is done at present to stop this practice, where parents and guardians have often agreed to the marriage because of dowry considerations (In-Country Study on Legal Status Review). Young people’s participation in policy and programmes With regard to RRs, adolescents are particularly vulnerable. In HPSS adolescent care is one of the prime components. However, in policy and access to health care, adolescent issues are often neglected and there is no strategy to include youth participation in policy and programme planning. HPSS addresses different issues like adolescent health care, education, awareness, and adolescent family life education. Nevertheless, access to health services is restricted and limited to a few NGO providers. Other Policies and Initiatives In addition to the policies and initiatives listed above, other important activities and initiatives (listed in the UNFPA Review of the 5CP) also undertaken since ICPD are listed below: · Development of “National Plan of Action” by the National Committee for the Implementation of POA · Preparation of document titled “Strategic Directions for the Bangladesh National Family Planning Programme – 1995-2005” · Development of National Integrated Population and Health Programme, · Establishing the National Council for Women’s Development chaired by the Honourable Prime Minister, · Formation of National Population Policy Committee chaired by the Minister of Health and Family Welfare · Formulation of the National Health Policy · Approval of National Food and Nutrition Policy · Adoption of National Women Development Policy · Formulation of National Sexual Reproductive Health Strategy · Establishment of Partners in Population and Development and the South Centre · Launching of the National Nutrition Programme 1.3 Sexual and Reproductive Behaviour Early age of sexual initiation Information about sexual behaviour before marriage has not been easy to obtain, partly because of a long-held assumption that young people do not engage in sex before marriage in Bangladesh. However, recent studies and baseline data collection carried out in collaboration between NGOs and the UNFPA (see section 5.1.1) has now indicated that sex before marriage does occur in both urban and rural areas. The information available indicates that the traditional values may no longer protect either male or female adolescents from sexual experimentation, which has potential negative effects on their sexual reproductive health. In most cultures boys are more likely to experiment sexually than girls usually because the consequences are less severe. This appears to be true in Bangladesh, though there are sharp urban and rural differences. Haider et al. (1997) found that by age 19, approximately 88% of urban adolescent males reported premarital sexual intercourse whereas 44% of their UNFPA and IPPF Evaluation: Bangladesh Country Report 21 rural counterparts did. Differences in experimentation were even greater for girls. 47% of under 19 year old urban girls reported they had already experienced sexual intercourse, but only 5% of their rural counterparts had. However, different research shows different results. In an anthropological study, it is evident that pre-marital sex exists in the community between adult and adolescents, and between married and unmarried. There is strict supervision in some communities for unmarried girls by adults but they nevertheless experience pre-marital sex. In most cases, it does not result in marriage and in some cases these relationships lead to pregnancy and to abortion (Nasreen 2001). Marriage In Bangladesh the legal age of marriage is 18 for girls and 21 for boys. However, girls often get married earlier. About 80% of Bangladeshi women marry before the age of 20 years. The 1997-98 Bangladesh Demographic and Health Survey (BDHS) reports the proportion of women aged 15-19 who are married has decreased from 70% to 50% since 1975 (Mitra et al. 1997). This is good news for the 50% who remain unmarried and are able to pursue education or income earning activities. However, 50% still get married as adolescents. Approximately 9% of the population are 15-19 years old, and approximately 45% of the population are below the age of 15. It is estimated that there are 2.5 million married adolescent women in Bangladesh. The population in this age group will continue to grow in the years ahead because of the population momentum. Married adolescents are primarily women, married to men who are older. It is still a relatively rare occurrence to find married adolescent men. The 1996-97 BDHS reported the mean age difference between spouses was nine years. Only 7% of husbands interviewed in the 1996- 97 BDHS were less than 20 years whereas 16% of married women were under 20 years of age. Aziz and Maloney (1985) reported an age gap of nearly nine years between spouses in their rural anthropological work. They further reported the subservient posture of a young wife expected in a rural culture. Furthermore, much of this subservience is based on the concept that a husband is older and therefore, wiser. Early child bearing The adolescent fertility rate is 144, one of the highest in the world (UNFPA, CP6, 2003). Early childbearing particularly among teenagers has negative demographic, socio-economic and socio-cultural consequences. 30% of teenage women in Bangladesh are mothers and another 5% are pregnant with their first child. Thus 35% of teenage women have begun childbearing. Maternal mortality in the adolescent age group is almost double the national figure. However, the percentage of adolescent mothers is decreasing as the age at first birth and age at marriage has increased. In 1975, the median age at first birth among women aged 20-24 was 16.8; in 1989, it had risen to 18, and by 1993-94 to 18.3. While this is a significant improvement, there is no room for complacency. The proportion of childbearing rises rapidly with age. Of the 30% who are mothers, 9% gave birth before the age of 15, 19% gave birth between the ages of 15-17, and 57% of those at 19 years. The median birth interval is 39 months. Abortion, STIs and RTIs The UNICEF paper, Adolescent Girls in Bangladesh, 1999, states that the total number of illegal abortions performed on adolescent girls in Bangladesh is for obvious reason, not readily available. However, they quote a study undertaken over a twelve-month period in eight different government hospitals, where a half to two thirds of the admissions were for UNFPA and IPPF Evaluation: Bangladesh Country Report 22 illegally induced abortions. Of all the induced abortion cases 13% were aged 15-19 years and 1% were unmarried. In terms of STIs and RTIs adolescents are also vulnerable. Another study quoted in the UNICEF paper, found that 45% of unmarried adolescents and 43% of married adolescents suffered from RTIs (no total sample was provided) (UNICEF, Adolescent Girls in Bangladesh, 1999). 1.4 Priority sexual and reproductive health issues facing young people Access to sexual reproductive health services Contraceptive use rate among the adolescent (married) women is only 25%. About 65% of married adolescent women (as compared to 25% in the reproductive age group) have never used family planning (UNFPA, 6CP, 2003). Almost all of the currently married couples (99.9% women and 100% men) know about modern contraceptive methods. Alauddin and Khan (1997) found contraceptive use among newly married couples (aged 15-19) increased from 19 to 39% in the Pathfinder International Project areas during 1993-97. Haider et al. (1997) also found that 43% of female adolescents were current contraceptive users. The most common modern method used by teenage females (15-19 years) is oral pill (45.5%) with only 18.8% using the condom in this age group. However, the national condom use rate is 4.8%. About 20% of teenagers and 28% of older women report contraceptive use prior to any child bearing. Nevertheless, access of unmarried young females to family planning services is limited and socially stigmatised. Participants in the In-Country Study Focus Group Discussions, said it would be difficult to receive services if you were unmarried. They said that out of shyness, the very young would not seek treatment or any other service. They also mentioned that although one could have a MR free of charge or with a minimum charge at a government clinic or hospital if you were married, it would be very costly for an unmarried girl to get MR. About 28% of pregnant women have at least one antenatal contact from trained health personnel and 92% of deliveries occur at home. About 7% of deliveries are assisted by qualified medical practitioners, 22% by relatives and almost half by traditional birth attendants (TBAs) (BDHS 1999-2000). Only 14% had trained assistance during delivery. Choice of birth attendants was not related to age but to income. Gender– based violence There are no reliable statistics on the magnitude of violence against girls because of the low level of reporting. However, information collected from newspaper reports and examination of national data on deaths of females by cause give some indication of gender-based violence. For example, a 1989 study showed that out of a total of 21 unspecified causes of death, “suicide, murder and burns” is the eighth most important cause of for females of all ages accounting for 5% of deaths (three times the number of deaths from pregnancy-related causes (UNICEF, 1999). Rape accounted for more than half of reported violent incidents involving adolescents in 1998. 57% of rapes of girls between the ages of 13-18 were gang rapes and there were reports of a number of these being carried out by police and military personnel. Acid attacks are on the increase, with one reported every three days. Acid throwing is a form of violence, which affects adolescents more than any other age group. The motives include rejection of UNFPA and IPPF Evaluation: Bangladesh Country Report 23 romantic advances or marriage proposals, family feuds and the inability of a wife to meet the dowry demanded. Dowry is still practiced although it is illegal and the amounts of dowry demanded are on the increase. Young wives whose families cannot meet their husband’s dowry demands, may be abandoned, divorced, tortured, attacked with acid or even murdered – and others are pushed to the point of taking their own lives. The consequences of violence against girls extend from the physical to psychological, social and economic realms (UNICEF 1999). Commercial and transactional sex amongst young people Commercial sex work is almost entirely dominated by girls. Again accurate information on the number of existing sex workers (including the proportion of adolescent girls) is impossible to obtain, although studies and surveys give some indication. There are sixteen registered brothels in Bangladesh. In one brothel in Dalutdia, 3,000 commercial sex workers (CSWs) were registered and 40% were under 18. The police in Dhaka have estimated there are between 15,000 to 20,000 CSWs (1990) and another study estimated half of these were between 10 and 20 years old. A number of different factors force children into sex work including extreme poverty, false marriages, promises of work, family abuse and neglect. A grim picture is painted of the fate of former street child sex workers, where few had found a better life, only 8% were married and a tragic 23% had died. (UNICEF 1999) Trafficking There is extensive trafficking in women and children within Bangladesh as well as to other Asian countries. Again the exact numbers are not known. One source estimates that 200- 400 young women and children are smuggled out of Bangladesh every month, mostly to Pakistan. Another source estimates that 200,000 women and children have been trafficked to the Middle East in the last 20 years. Regional gangs, who are well organised and have links with the law enforcement agencies, carry out trafficking. The high proportion of young girls who are handed over to individuals engaged in trafficking by their parents or guardians, often unknowingly, reflects the depth of poverty so many families face (UNICEF 1999). Risky practices (e.g. alcohol and drug abuse) There is evidence of increasing rates of drug abuse in Bangladesh. Again accurate figures are not available but a study carried out in 1997 estimated the number of drug abusers to between 100,000 and 2 million. Amongst the known drug abusers there has been an increase in adolescents and also an increase in adolescent females. Ganja was the most widely used drug, followed by alcohol and then heroin with “Tidigesic”2 use the most widespread amongst slum residents, unemployed youth and transport workers. Nearly 30% of the special sample had injected drugs and 12% reported sharing needles (UNICEF 1999). 2 “Tidigesic” (temgesic) or burenorphine injection UNFPA and IPPF Evaluation: Bangladesh Country Report 24 SECTION 2: THE COUNTRY PROGRAMMES’ STRATEGIC PRIORITIES 2.1 THE UNFPA COUNTRY PROGRAMME 2.1.1 Relevance Strategic objectives and priorities: overview of UNFPA assistance to Bangladesh The UNFPA has provided assistance to Bangladesh since 1974. Its primary objective is to improve the quality of life of both women and men in Bangladesh by reducing maternal mortality, morbidity, infant mortality, and provision of contraceptives to reduce unwanted pregnancies, and stabilising population growth in the country. The UNFPA made a major shift in its programme approach when it adopted the POA, emerging from the 1994 International Conference on Population Development, as the basis for all its programmes. The POA gives cognisance to the vital link between population and development and emphasises the necessity to meet the needs of individual women and men to achieve demographic targets. With gender and environmental issues cutting across all areas of focus, UNFPA interventions now concentrate on sexual reproductive health, family planning and sexual health, population and development strategy, and advocacy. Other areas addressed by UNFPA include HIV/AIDS, the consequences of rapid urbanisation and the provision of sexual reproductive health care in emergency situations. There have been five Country Programmes since 1974, with a sixth forthcoming, and the focus of these are summarised below: · The first Country Programme (CP) (1974-1979), UNFPA supported family planning activities, population education and communication activities, and preparations for the 1981 census. · In the second CP, (1980-1985) support was provided to the Government’s Maternal and Child Health (MCH) and Family Planning (FP) programme through the supply of contraceptives and equipment. · During the third CP (1985-1990) support was given to basic data collection, MCH/FP services and training and Information, Education and Communication (IEC) and other activities such as support to logistics and supplies, advisory support to the MOHFW, support to population research and salary support to field workers. · The fourth CP (1991-1997) focused on MCH, FP and Sexual Reproductive Health Programmes, IEC, basic data collection, population dynamics and on a special population and development related programme for women. Expenditure US$35,481,981. · The fifth CP (1998-2002) has focused on sexual reproductive health including family planning and advocacy on sexual reproductive health and gender issues with additional budgets from the European Commission’s Sexual Reproductive Health Initiatives in Asia and the United Nations Foundation grant, allowing a broadened population policy, increased support to SRH and RRs (the 5CP strategy is elaborated further below). Expenditure US$31,967,181. · The sixth CP (2003-2005) seeks to contribute to improving the sexual reproductive health status of the people of Bangladesh thereby leading to sustainable social development and poverty reduction. Budget US$16,878,243. The reduction in budget since 5CP is made up by the addition of the two extra funding mechanisms: the EC/SRHI and the UNF project (see below). From the early 1970s to 1994, Bangladesh saw a total fertility decline from 6.3 to 3.3. It has now reached a plateau despite an increased CPR. The support provided by UNFPA to the UNFPA and IPPF Evaluation: Bangladesh Country Report 25 Government to analyse this stall in the fertility decline led to a technical review and stakeholder consultation which highlighted an apparent decline in quality of care, reduced client satisfaction and limited contraceptive choices. The review indicated that there was a need to operationalise BCC to promote a wider choice of contraceptives, address adolescent fertility and promote gender equity and equality. The 5CP was the first country programme developed after ICPD. The preparation of the programme coincided with the Government’s preparation for the HPSP and with the country’s devastating floods (where donors including UNFPA had pooled resources to assist in the emergency relief). The Health and Population Sector Strategy (HPSS, 1997) which outlines the rationale for prioritising public expenditure (including donor support) in favour of an Essential Service Package (ESP) of public health, reproductive and child health and limited curative services. The Programme Implementation Plan that started in July 1988 envisaged a series of reform measures that included the unification of the bifurcated structures in government for health and population (where these had been split into two structures in 1974). UNFPA provided technical assistance to the Government and the World Bank Consortium in the preparation of the HPSP. The sub-programmes were developed to incorporate the activities outlined in the PoA, and at the same time the Government gave due consideration to the PoA in its preparation of the HPSS. The SRH strategies included improving quality of services, ensuring informed choice and provision of information and services for youth, including adolescents. The ESP within the HPSS gave prominence to BCC. This was planned to motivate people regarding the shift of service delivery from domiciliary to a health facility based system. The rest of this section focuses on the most recent Country Programme (5CP) and the new programme (6CP). Strategic focus and priorities in the 5CP The overall goal of the fifth country programme (5CP) was to contribute to the improvement of the sexual reproductive health and family welfare of the people of Bangladesh and to the achievement of population stabilisation. The main purpose of the programme was (a) to increase the accessibility and utilisation of SRH services, especially for vulnerable and hard- to-reach population groups, (b) to improve the quality of SRH services, (c) to facilitate positive behaviour changes and create a supportive environment for improved SRH and family welfare and (d) to contribute to increased national technical capability and capacity to implement population policies and programmes. The 5CP was the first CP developed after ICPD. GoB’s commitment to ICPD is clearly evident from the fact that a National Committee for the Implementation of the PoA was constituted just immediately after ICPD. Within less than two years of establishing this committee, the National Plan of Action was developed, disseminated and approved by GoB. The 5CP was organised through three sub-programmes, Sexual Reproductive Health, Advocacy and Population Development and addressed itself to the wider mandate of SRH set out in ICPD POA as follows: The Advocacy Sub-Programme The second largest expenditure under 5CP was for the Advocacy Sub-Programme, at US$7,925,197. There were two outputs planned in the 5CP; 1) increased support of influential religious, political and local leaders for SRH and RRs and 2) increased positive attitudes and behaviour of vulnerable and hard-to-reach groups on issues related to gender, UNFPA and IPPF Evaluation: Bangladesh Country Report 26 SRH and RRs. These were planned to facilitate positive behaviour changes and create a supportive environment for improved family welfare. The sub-programme activities were carried out in a multi-sectoral approach that involved collaboration with nine ministries, the private sector and a number of NGOs. The sub-programme design meant that they reached a large number of diverse audiences. This has been the main sub-programme for the initial work in adolescent SRH and RRs. A number of innovative interventions were planned and activities put in place during the 5CP that will be carried on into the 6CP: · Using a multi-sectoral approach by working with partners, including nine government ministries · Integrating SRH and gender into the training curriculum through ministries · Reaching out-of-school youth · SRH in Family Life education spread throughout the country through literacy programme · Population education institutionalised in all primary and secondary schools, Madrasah, vocational and technical institutes · Distance education courses for schoolteachers and Madrasah teachers. · SRH education to key occupational groups · SRH education to Private sector · Mass and group educational and motivational meetings, orientation workshops, through mobile teams. · Emerging advocacy issues integrated into training curriculum of the participating ministries · Disadvantaged girls and women provided with skill training alongside SRH education While there have been criticisms of the size of the sub-programme there have also been commendations about the scope and innovations that have been put in place given the difficult environment for this initiative. The main outputs and activities under this sub- programme are listed in detail in Section 6.1 of the report. The main strategy of the sub-programme was to address the lack of information concerning SRH for adolescents and youth. Prioritising lack of information would seem appropriate, given the findings of the Focus Group Discussions (FGDs) reported in the Local Studies No 3., where the young people interviewed stated they needed more information on SRH, that they would prefer this if it was in textbooks and that it should be a compulsory subject at school. This is also in line with two baseline studies carried out with adolescents and youth (see section 4.1.1) where lack of SRH information was widely reported and the desire to get information through a variety of channels, including the youth clubs. Another strategy in the 5CP was to address different occupational groups, targeting tea plantation workers and the urban garment factory workers. In the latter case, the ET visited and observed a SRH session being taught during the lunch break at a garment factory that employs 350 workers in Dhaka. Several of them were below the age of 24 years and 5 of the women out of 30 were unmarried. The session was taught by a peer educator. The factory management were reviewing this strategy as the peer educator was not sufficiently trained to be able to answer the numerous questions that the workers asked about SRH, despite the production of the SRH green book that the peer educator was using. This innovation, of addressing the SRH information needs of young people in their workplace and providing services was one that could be replicated given the growth of garment and other factories in the present process of rapid urbanisation and employment of young workers (see section 1, Introduction). UNFPA and IPPF Evaluation: Bangladesh Country Report 27 The consultative process for establishing priorities and moving from the 5CP to the 6CP in the Advocacy Sub-Programme involved a number of consultative meetings. These included a consultative meeting on BCC/Advocacy as well as a consultative meeting on Youth and Adolescent Health, both held in Dhaka in October 2001. Partners worked together with UNFPA staff to identify needs for the programme and to brainstorm on a strategy for developing the direction for future work. In summary, the strategy of the Advocacy Sub-Programme appeared diverse and comprehensive in terms of the partners that it supported and collaborated with. However, given the range of problems facing adolescents and youth, including adolescent malnutrition, social issues like dowry deaths, suicides, acid throwing, trafficking, (see Section 1) it appeared to the ET that the range of priority issues that the programme addressed was rather narrow. However, it was also noted that the strategy of working through NGOs, did mean that support is given to some of the organisations that are addressing the priority issues for adolescents and youth listed in Section 1. And, secondly, in the 6CP the programme is being expanded to include a project on gender-based violence. The Sexual Reproductive Health Sub-Programme There were seven outputs for the SRH sub-programme under the 5CP: 1. SRH service delivery points expanded in selected rural and urban under served areas 2. Efficient procurement and distribution of contraceptives and other SRH commodities 3. SRH service providers trained to deliver high quality services 4. Increased technical capacity of selected facilities in provision of clinical contraception 5. RTIs, STI management and maternal care 6. Improved interpersonal communication between service providers and clients 7. Functioning national quality assurance system for contraceptives and SRH commodities 8. SRH service providers/managers basing good practice on recent SRH research. The SRH sub-programme is the largest of the three sub-programmes in terms of expenditure (US$ 221,255,066), and is the drive behind improving provisions, access to and quality of SRH services. In terms of SRH services for adolescents, it did not appear to have projects that were directly related, or adolescent friendly. The CO staff indicated that work on adolescents and youth is addressed through the EC/SRHI and now the EC/SRHIYA, and also through the Advocacy Sub-Programme activities, and that this was an appropriate response to the ICPD POA. The work of the sub-programme in the 6CP will include eight MCWCs for excellence in adolescent services in collaboration with the government The process of establishing priorities and future directions was through a collaborative process that included a number of brainstorming sessions with partners. The workshop on UN Joint Safe Motherhood Initiative and Future Directions in SRH in Bangladesh focused on arriving at a consensus for future directions in SRH for the 6CP. 179 participants attended, reflecting the number of partners that the CO collaborates with. In addition, two other consultative meetings were held, one on Youth and Adolescent Health, and one on Urban Sexual Reproductive Health Services, BCC and MIS, and both focused on brainstorming ways ahead for the 6CP. The ET felt that the presentation of the processes involved in developing a strategy for work in adolescent and youth SRH and RRs was appropriate and realistic. The important phase of scaling up the work to include support work in Government services for adolescent friendly services is crucial and is one that will be addressed in the 6CP. UNFPA and IPPF Evaluation: Bangladesh Country Report 28 The Population and Development Sub-Programme There were five outputs planned: 1. The scope of population policy broadened 2. Population variables integrated into overall and sectoral planning 3. Policy research undertaken 4. Population teaching and research at Universities/Institutions strengthened 5. Databases for population and development planning improved The Population and Development Sub-Programme is the smallest of the three sub- programmes, with only US$ 2,128,385 expenditure, however it is a cornerstone for the work of the other two. The scope of population policy in the past has been confined within the narrow limit of achieving population stabilisation through reduction of fertility, except that the approach of reduction of fertility has changed from a narrow family planning focus to a broad based sexual reproductive health approach. However, policies on population issues, according to the ICPD-POA go beyond the narrow limit of reduction of fertility to encompass other equally important population and development issues, which have a bearing on the quality of life of the people. These include issues such as poverty, ageing, urbanisation, migration, population distribution, environment and utilisation of natural resources. This calls for a broadening of the scope of the population policy. The process of establishing priorities included participation in the UN Joint Safe Motherhood initiative and Future Directions in Sexual Reproductive Health. The ET did not see documentation on other consultative processes. In summary, within the area of adolescent and youth, there are many aspects of the population and development (PD) programme that have influenced the work of the other two programmes. The awareness of the size of the adolescent and youth population and their future demands on education, health and SRH services and their need for work has been based on the Programme’s support to research activities. It appears that given the importance of the plateauing of the TFR and the implications for the future, together with the rapid urbanisation and the accelerated population growth rate in urban centres (see section 1), the strategies of the PD sub-programme to train, research and inform on PD issues is valid. Alongside the three sub-programmes in the 5CP, two important additions to the UNFPA portfolio have been the EC/SRHI and United Nations Foundation (UNF) project. Their activities and strategies are particularly relevant to the total work carried out for adolescent and youth during the period 1989 – 2002. The EC/Sexual Reproductive Health Initiative The EC/SRHI goal adopted for Bangladesh Phase I was “to improve the Sexual Reproductive Health of women, men and adolescents in the urban and peri-urban areas of Bangladesh, by improving the quality of SRH care for vulnerable groups”. The overall budget for the first phase, corresponding to the UNFPAs 5CP, was US$ 2,720,955. The major strategies adopted were: · Increased access and utilisation of SRH services, · Capacity building of NGOs and interlinkages Five projects were launched with four local partnerships. The partnerships were formed with Marie Stopes Clinic Society (MSCS), Save the Children UK (SC-UK), Bangladesh Red Crescent Society (BDRCS) and FPAB, all of which have collaborative arrangements for technical support and capacity building with European NGOs. A fifth project, the EC/SRHI umbrella project, was implemented by UNFPA Bangladesh field office and had as its UNFPA and IPPF Evaluation: Bangladesh Country Report 29 mandate to strengthen the NGOs capacity and linkages to improve SRH services and information. The United Nations Foundation Grant The UNF grant established a project to support an initiative to meet the basic needs and human rights of adolescent girls initially in three rural districts of Bangladesh, and currently operating in ten districts. Part of the grant was for UNICEF to work to improve the social and economic situation of adolescent girls by developing and enhancing their livelihood skills through internships and employment opportunities. UNFPA received the other part of the grant to address the issues of adolescent sexual reproductive health care for married adolescents by exploring the concept of Personal Social Education. Interviews held with UNICEF suggested that the decision to contract UNICEF for the project that focussed on unmarried girls, was because of their comparative strength in this area, with more expertise in children and child rights. The overall budget for the project corresponding to the 5CP was US$200,000. The strategies in the Project included the following: · Address the educational needs of the adolescents through non-formal educational channels · Access to life skills · Livelihood or vocational skills · Enabling environment, where community society and friends understand the special needs of adolescents · Adolescent friendly services · Participation The UNF has targeted adolescents with a project aimed at adolescent girls. The project started with a baseline survey that was a cutting edge piece of work in the context of Bangladesh, for increased awareness and understanding of married adolescent girls’ SRH needs. Based on the survey findings in three Districts, interventions were planned and implemented to meet the needs of the adolescent girls and their husbands. The work was understood by UNFPA and the Ministry of Youth and Sports to be focused on human rights and security of young people and appeared to the ET to be a good example of a supportive intervention that appeared to address a wide range of the needs of the adolescents. Strategic focus and priorities in the Sixth Country Programme (6CP) 2003-2005 The overall budget for the 6CP is US$ 16,878,243. The budget is split between the three sub-programmes, with the largest share allocated to the SRH Sub– Programme US$ 9,474,541, the second largest allocation to the Advocacy Sub-Programme US$5,603,702 and US$ 1,500,000 to the Population and Development Sub-Programme. There is also an allocation of US$ 300,000 for the umbrella project. The overall goal of the 6CP is to contribute to improving the sexual reproductive health status of the people of Bangladesh thereby leading to sustainable social development and poverty reduction. The Programme will run from 2003– 2005, a short programme cycle to harmonise the programme cycles with other UN organisations. The three sub-programmes of the 5CP are to be continued with adjusted focus, outputs and strategies. The changes in focus relate to a wide range of issues and policy developments both within Bangladesh and also in the international policy arena. The strategic focus on young people’s SRH and RR will be increased - budgetary allocations to youth will increase from 5% to 10% in the SRH Sub-Programme (see section 3). While the Advocacy Sub- UNFPA and IPPF Evaluation: Bangladesh Country Report 30 Programme allocation will remain almost the same, they have expanded their portfolio and adjusted their priorities to include a project on Advocacy to end gender-based violence. However, given the range of problems facing young people, outlined in section 1, it appeared that even in the 6CP while the range of partner support and cooperation is comprehensive, the range of issues addressed is narrow. In the international policy arena, the UNDAF has influenced the 6CP. The UNDAF is both a product and process-oriented document. It places major focus on developing and institutionalising process for enhanced collaboration and co-ordination and eventual harmonisation. The UNDAF is based on the Common Country Assessment (CCA) of Bangladesh and adopts a rights based approach to evaluating development achievements. The conceptual framework identifies four clusters of rights – survival, livelihood, protection and participation. Proportion of UNFPA CP devoted to policy development During the 5CP the proportion of UNFPA CP devoted to Policy and Advocacy was 25%, to Service delivery 66%, to PD 7% and to Programme Co-ordination 2% (figure 1). These allocations have changed for the 6CP where the allocation to Policy and Advocacy is 33%, to Service delivery 56%, to PD 9% and to Programme Co-ordination the same at 2% (figure 2). In the 5CP, according to the CO, 5% of the SRH expenditure, 9% of the Advocacy expenditure and only 1% of the PD expenditure was allocated to youth (see table 4, section 3). These allocations seemed appropriate to the CO at the time of planning the 5CP. Revisions for the 6CP however, have shown that the budget has expanded for adolescent and youth allocation in the SRH Sub-Programme, that it has reduced by only 1% for the Advocacy Sub-Programme and has stayed the same for PD. The ET recognised the shift in focus for the 6CP, where the new emphasis will be on supporting the introduction of adolescent and youth friendly services, rather than expanding the advocacy work on youth. A number of the projects will be continued in the 6CP for advocacy and policy development, where it is apparent that the multi-sectoral approach including working with a number of sectoral ministries, has been effective in raising awareness of a number of adolescent and youth SRH and RRs issues, including legal age of marriage, dowry payments, acid throwing and gender violence. A new project in the Advocacy SP for the 6CP is Advocacy to end gender based violence (BGD/06/03/P12) which will implemented through the Ministry of Women and Children Affairs, a new partner in the 6CP. UNFPA and IPPF Evaluation: Bangladesh Country Report 31 While the budgets for youth have increased in all sub-programmes (see section 3.1) the actual increases are far greater given the extra funding mechanisms of the EC/SRHI and the UNFIP. Proportion of overall expenditure allocated to different activities in 5th CP Figure 1 25% 66% 7% 2% Policy and advocacy Service Delivery Pop and Development Programme Coordination Proportion of overall budget allocated to different activities in the 6th CP Figure 2 33% 56% 9% 2% Policy and advocacy Service Delivery Pop. Development Programme Coordination UNFPA and IPPF Evaluation: Bangladesh Country Report 32 UNFPAs strategic role in sectoral and sub-sectoral national programmes The HPSP provides the strategic framework for the health and population sector in Bangladesh (see section 1.2). UNFPAs country programme falls primarily within the HPSP but uses a parallel funding arrangement rather than a pooled fund. Under the HPSP there is no specific focus on adolescent and young people’s SRH and RR, although married adolescents would be included under the SRH package, as there is no age discrimination. However, unmarried young people do not have access to government SRH services. In the recent controversy over the stalled Health Reforms and the donor policy on partially suspending funding, UNFPA played a significant role in ensuring that support to the ESP, including contraceptive supplies, is maintained. The UNFPA has played a key role in co- ordinating the monthly meeting to monitor and exchange information on health sector developments. Addressing the diversity of needs of young people There has been good collaboration in the work with the GoB, the NGOs, and the private sector in initiating activities for adolescent SRH (see 3.1.1 and 6.1.2), but this appears to be a very new area, where an inclusive strategy involving the work of the three Sub- Programmes at the CO has not been developed. The CO discussed this with the ET and explained that the timing of the new focus on adolescent and youth SRH and RRs coincided with the planning of the 6CP and developing an inclusive strategy would be a useful tool for shaping the 7CP. A review of the project documents, the work of the sub-programmes and the information collected by the ET on the collaborative work with a number of Bangladesh NGOs working in different communities indicate the COs keen awareness of the socio- cultural and economic factors influencing young people’s SRH and rights. The issues of dowry customs, son preference, legal age of marriage, violence again women, and the lack of information of SRH and RRs were discussed with the UNFPA CO and have begun to be addressed in the 5CP. The UNFPA Annual Report for 2001 states “the overall law and order situation was deplorable. Gender based violence continues at a shocking rate. Women continue to become victims of acid throwing, dowry and other social evils”. Support to reverse this pattern has started with a project directly focussed at addressing violence against women in the 6CP (BGD/06/03/P12 – advocacy to end gender-based violence). In the EC/SRHI evaluation (2002), the team pointed to the different needs of specific groups of adolescents some of who might be termed as “high risk”. For example in Kurigram, due to unemployment a large number of adolescents migrate to Dhaka, Bogra, Rajshahi, Chittagong and other places. These groups are at risk of STI/HIV/AIDS, drug abuse and other health problems. In addition, there are working adolescents, residential college students staying in hostels and vocational training centres all of whom have different needs. Despite the numerous activities and outputs that have been outlined in this section, it was clear that there was a lack of an overall strategy to address adolescent SRH and RRs in Bangladesh, (however, it was noted that the EC/SRHIYA has developed a draft strategic framework). The diversity of adolescent needs, (outlined in Section 1.2) requires a strategy that will encompass their needs and the different approaches possible within the country context. This need was identified in the 6CP project document for the SRH Sub-Programme. 2.1.2 Integration of Rights The ICDP and ICDP+5 are the building blocks for both the 5CP and the 6CP. However, in terms of the eleven rights listed as components of Reproductive Sexual Rights in CEDAW Article 16, many of the rights listed are new concepts in Bangladesh and even newer when applied to adolescents. The CO has clearly worked within the national context, and UNFPA and IPPF Evaluation: Bangladesh Country Report 33 recognised that many of the ideas are quite new and will require a considerable amount of time and work in advocacy. Within the 5CP core budget, the main work on young people’s RRs has been carried out in the Advocacy Sub-Programme. The mid-term review (2001) analysed this input, and reported progress and achievements, while recognising the difficulties of the work involved. In discussions with the CO it was confirmed that the 5CP had focussed on Advocacy and on the lack of information of adolescent and youth SRH and to a lesser extent on RRs, because this was a new and sensitive area in Bangladesh where progress would have to be made slowly. Rights appear more central to the work of the 6CP, where the main goal of the programme is based on a rights perspective. This is outlined in the CCA where it is stated “Reproductive health focuses on matters relating to contraception and population growth, while the more recent RRs approach emphasises the basic right of couples to decide on the number, the spacing and the timing of childbirth, and to have access to the means that enable informed decision making” (CCA, 2001 - 2005, 4.2) This definition is used by the CO in its sub- programmes and is integrated in the 6CP, In conceptualising the RRs of young people, discussions with the staff at the CO indicated that they are aware of the path they have taken to get to RR for A&Y and that they have worked within a process that has been entirely appropriate in the context of Bangladesh. UNFPAs main focus in historical perspective 1960s Birth control 1970s Family planning 1980s MCH and WID 1990s SRH and Gender 2000 RR as Human Development A rights based approach is more clearly defined in the work of the two separate funded projects, the EC/SRHI and the UNF project. Under the EC/SRHI, Gender and SRH and RR manual and under the UNF project, the PSE curriculum has introduced a module on RRs. For example, the Personal and Social Education (PSE) curriculum includes a participatory session on RRs, young people’s role in availing their rights, constraints in achieving their RRs (individual, family and society levels) and the role of married adolescent girls in availing their RRs. Within SRH and PD sub-programmes, there is also work that is focused on youth and SRH, although the relationship to rights based work seems more oblique. For example, the support for SRH in the SRH programme, includes developing new guidelines for providing youth friendly services for health and family service providers of different levels. Nothing is specified as being rights based, however, this may well be part of the intervention. It may also be that a number of the projects and activities in the sub-programmes are rights based without specifying that they include rights based work. For example, the support to provide services to the garment workers is addressing the rights to information and access to services of young people, although specific rights are not articulated. It may be necessary, when an overall strategy is developed to go through the programme of work of the three sub-programmes and identify activities that are rights based without having been defined as such. In the majority of activities reviewed and in discussions with key partners, rights based work is interpreted to mean rights to information about SRH. It was expressed that this was a very new area for Bangladesh to work in and any new development the government facilitates UNFPA and IPPF Evaluation: Bangladesh Country Report 34 would have to be cautious. However, it was well known that NGOs already supplied services to adolescents and youth. The timely work of both the EU/SRHI and the UNF fund for adolescent girls has enabled UNFPA and partners to move ahead with addressing RRs to include access to adolescent friendly SRH services in a wider arena than was possible at the beginning of CP5. However, taking this further and exploring, for example, freedom from violence and sexual abuse, It can also be argued in relation to other rights issues, that the CO NGO partners are often directly engaged in the work and can impact on the future work of the UNFPA. For example, the work of the Save the Children Alliance and UNICEF in relation to children on sexual abuse and exploitation. The work of UNFPA in the sub-programmes and projects reviewed appears gender sensitive, although this varied between the sub-programmes. For example, in the PD sub-programme, under output 1, promoting female enrolment, UNFPA awarded research fellowships to 5 female and 5 male students in the first year, and 10 females and 10 males in the second year, and plans for 45 female and male graduates in population sciences. In the Advocacy Sub-Programme, under the curriculum development, there are modules on gender sensitivity and gender awareness, and in the 6CP there is a project that addresses Advocacy on Sexual Reproductive Health and Gender issues through Youth Clubs. In the SRH Sub-Programme, the project documents state that it was planned in consultation with a number of partners and that “particular attention has been given to gender issues and on the particular sexual reproductive health concerns of women”. In discussions with the CO they felt that they had focussed on gender in all their programmes during the 1990s, and particularly in the 5CP. The mid-term review (MTR) described the SRH Sub-Programmes’ work on gender equality as being too bio-medical. There was not sufficient time for the ET to follow up on this comment except to say that the CO said this will be remedied in the 6CP. 2.1.3 Sustainability The UNFPA works in countries, where the host has requested their assistance. Therefore sustainability of the programme is dependent to a large extent on the GoB needs and relationship with UNFPA and the donors. The budgets for the Country Programmes have increased over the years from US$ 10m for the First Country Programme (1974-1979) to US$ 35 million for the 5CP (1998-2002). UNFPA is supported entirely by voluntary contributions, the major donors being Japan, the Netherlands, Denmark, United States, Germany, Norway, Sweden, United Kingdom, Finland, Switzerland, Canada, Belgium, Australia, Italy and European Commissions. Additional funding in relation to the work on adolescents and youth has come from the EC/SRHI and from the UNF during the 5CP cycle. Funding for the EC/SRHIYA is secured for the 6CP period and beyond, where the EC Ambassador in Bangladesh recently assured UNFPA of the continuous support from the EC. Funding for the UNF Adolescent Sexual Reproductive Health is secured for three years. Most of the established NGOs who are partners with UNFPA have strategies to address sustainability. While a number of the plans for sustainability appear to be viable the political situation in Bangladesh often means that there are a number of influences that impact on the success and sustainability of the NGOs. In the case of NGOs that supply information and services to young people, a decrease in funding available to NGOs would have serious consequences for adolescent and youth access, where the NGOs are at present the only providers of adolescent friendly SRH services. While there have been projects that have addressed adolescent and youth SRH in the 5CP and SRH and RRS in the 6Cs, no overall strategy to address the SRH and RRs of young people has been developed by the CO. In discussions with the CO it appeared that this UNFPA and IPPF Evaluation: Bangladesh Country Report 35 would be a logical next step and that work to produce a strategy for implementation in the 7CP should be developed during the 6CP. Such a strategy could address issues of incorporation of NGO and other programmes into GoB programmes, scaling up examples of “good practice” and working out operational plans and budgets. The GoB has indicated that “it is very difficult to address adolescent SRH due to social stigma, and the social/cultural/religious barriers in discussing the issue”. However, there are indications that achieving a turning point in the population growth rate, and the need to address the plateaus of the total fertility rate decline, will influence GoB to encourage more support for these issues in two to three years time. This will require political commitment as well budgetary commitment for some time to come. 2.1.4 Summary of UNFPAs Strategic Priorities In the 5CP, the key strategy to address the SRH and RRs of young people was developed through the Advocacy Sub-Programme, and the focus was on the provision of knowledge of SRHs to a wide range of young people, both those in and out-of-school and through a number of different organisations. In addition, the strategy was to engage with a wide variety of partners in Government, the NGO sector and in the private sector to advance the policy agenda on addressing the SRH needs of the adolescent and youth population. The work of the 5CP has informed and influenced the 6CP where the strategy has developed to include a broader rights-based remit to include, for example a project on violence against women in the Advocacy Sub-Programme, and support work to the MoHFW for developing eight MCWCs for excellence in adolescent services through the SRH Sub-Programme. The strategy of including the two additionally funded projects, the EC/SRHI and the UNF funded work in ten districts, where work has been piloted in providing SRH information and adolescent friendly services, has been useful and informative for the CO. The pilot work has informed and strengthened the knowledge base and has been accepted by the GoB as a way forward for embracing adolescent friendly services, i.e., through the NGOs. The concepts of adolescent and youth SRH and RRs are still very new in Bangladesh. The CPs work with young people was initiated in the 5CP and has been addressed further with a broader remit in the 6CP. This was planned without the development of an overall coherent strategy to address adolescent and youth SRH and RRs. The ET felt that the development of an overall strategy would benefit the work of the CO and would offer an improved basis for the work in the 7CP. 2.2 FPAB 2.2.1 Relevance Overview of FPAB assistance to Bangladesh The Family Planning Association of Bangladesh (FPAB), the oldest NGO in Bangladesh was formed in 1953 to pioneer a family planning movement in East Pakistan. In 1954, the FPAB, formerly called the Family Planning Association of Pakistan, became a member of the International Parenthood Federation (IPPF), and started its activities with the following objectives: · To popularise the concept of FP · To motivate the Government to frame a national policy · To provide services to those who voluntarily want to adopt FP The activity of the association was mainly focused on motivation and limited services through a model clinic at Dhaka. UNFPA and IPPF Evaluation: Bangladesh Country Report 36 The Government recognised family planning activities by an act of Parliament in 1958. This was followed by the introduction of a national programme in 1960 as an experimental project and a fully-fledged programme in 1965. In 1965 the association redefined its role to supplement and complement the national programme with emphasis on: · Popularising the FP concept with the help of modern communication media and folk media · Filling up gaps in the provision of services · Mobilising community support, and · Demonstrating new and innovative approaches. In the late sixties, the Association expanded its coverage and moved from the urban to rural areas. During this period the association received funds from other donors as well as government grants. After the liberation war in 1971, the name was changed from the Family Planning Association of Pakistan to the Family Planning Association of Bangladesh and it became the pioneer family planning service provider in Bangladesh. In 1980, FPAB initiated its youth programme aimed at imparting SRH education to youth by peer organisers. Initially it provided education about Family Planning and later in 1992 it included SRH education. In their Strategic Plan 1994-2002, FPAB included SRH education to prepare youths for their future parenthood life. The goals were: · Provide FP/MCH services to 2.5 million eligible couples with emphasis on rural, under served areas to achieve CPR of 60% in FPAB project areas by the year 2002. · Continue to play FPABs pioneering role in family planning information, education, and communication as functional specialities · Impart education on population, SRH, STI/AIDS and primary health care to prepare 5 million youths for responsible parenthood · Enable 50,000 women to play an effective role in decision making for family welfare including planning the size of their families · Promote community ownership of the family planning programme by encouraging greater participation of people at the grass roots level · Improve managerial and institutional capability with emphasis on gender parity for better programme performance · Demonstrate innovative, cost effective and collaborative approaches in family planning through operational research · Assist the Government of Bangladesh and other agencies in co-ordinating training activities and contraceptive logistics · Foster balance between population, resources and environment in collaboration with the Government and other agencies for sustainable development · Increase locally generated income to 25% contributing towards self-reliance. The emphasis of ICPD on sexual reproductive health, sexual rights and the centrality of women in development was the primary focus of FPAB in their country strategic planning. In 2000, a needs assessment on adolescent SRH in Bangladesh was conducted to identify the current sexual and reproductive needs of adolescents and youth and also to find out the appropriate means and ways to address those needs (Abul Barkat et al 2000). After this survey FPAB launched an operations research project titled ‘Improving the quality of the sexual and reproductive health programme for adolescents and youths’. In 2001 a baseline survey was conducted in four areas (two intervention and two controlled) to ascertain the status of knowledge-attitude-practice of the adolescents and youths, gatekeepers and service providers. Including and shifting the focus from family planning oriented services to youth was a major change in the programme. In their Strategic Plan for 2001 to 2005, in addition to the youth UNFPA and IPPF Evaluation: Bangladesh Country Report 37 project, FPAB set their goals to address the current context and problems in Bangladesh, like male involvement, RTI/STI/HIV/AIDS, women’s RRs, and programme sustainability according to the country needs. However, RRs of youth were not envisioned as one of the goals of the 5-year strategy. In the Strategic Plans 2001-2005 the goals set by FPAB are: · Respond to increased unmet needs for FP-MCH services, in particular needs of the marginal and disadvantages groups of the community · Increase access to SRH services for the adolescents, youths and women: o To increase coverage of SRH education for adolescents, youths and women from 0.5 million to 2 million and introduce provision of SRH services to this group o To increase awareness of 1 million parents of adolescents/youths on need for SRH education for adolescents o To increase access to SRH education and services for 500,000 women through a group approach, satellite clinical services and referrals · Establish equal rights for women to enable them to exercise control over their own RRs and reproductive and sexual health choices o Prevent incidence of RTI/STI/HIV/AIDS o Create awareness by providing information and education on mode of STI and HIV/AIDS modes of transmission to 2.5 million youths, adolescents, truckers, CSW and drug addicts through mass media and interpersonal communication o Reduce RTI/STI/HIV incidence by 20% from the level by addressing the most vulnerable groups through clinical services o Eliminate incidence of unsafe abortion/delivery · Promote community ownership of the SRH programme · Increase male involvement in improving SRH · Improve the nutritional status of people with particular emphasis on mother, child and adolescents · Attain programmatic, financial and institutional sustainability FPAB priorities FPAB determined its priorities mostly in the context of the country. In this highly populated country the organisation has made a major contribution to the reduction of the fertility rate through their family planning programme. Later FPAB expanded their focus from family planning services to SRH including a nutritional programme and income generation activities. Addressing adolescent and youth SRH became a priority project goal, reflected in 1994-2002 Strategic Plan. In terms of budgetary commitment, the focus on adolescents and youth is given priority. FPAB has seven programmes components excluding the health service departments. These are youth, women, community based distribution of family planning methods, management information system, Islamic research cell (IRC), information education and communication (IEC) and training. At present 15% of overall budget is devoted to the youth component. In addition to this 15%, other cross cutting departments also contributes to the youth programme like IRC, IEC and the health service department. In spite of the budget commitment, staff resources are insufficient for the provision of a high quality programme on adolescent and SRH (see section 3.2.1). In last couple of years the overall annual budget has been decreased gradually as shown below. As the total annual budget has decreased, this has had a direct impact on the youth budget. UNFPA and IPPF Evaluation: Bangladesh Country Report 38 Table 2: Total annual budget and proportion of youth budget of FPAB from 2000- 2003 Year Annual Budget ($) (Total ) Youth Budget ($) Youth Budget ($) (% of Total) 2000 2,154,178 323127 15 2001 2,098,278 314742 15 2002 1,702,420 255363 15 2003 1,567,351 228932 14.6 Proportion of FPABs budget devoted to different activities FPAB is implementing their youth programme only in 70 unions out of 5000 unions (the lowest level of administrative structure) in Bangladesh. The population in one union is 20,000 – 25,000 people. The programme is primarily focused on information dissemination among adolescents and youths. FPAB also addresses adolescents and youth through two other programmes, 1) Islamic Research Cell and 2) BCC. In their youth activities (and national programme as a whole) FPAB does not devote significant resources to advocacy. In the national organogram FPAB does not have any component for advocacy. No staff member has direct responsibility for advocacy, hence the role played by FPAB in advocacy tends to be passive rather than active. Table 3: FPABs regular proportion of annual and youth budget allocated to different programs* Category Annual (%) Youth (%) Advocacy 1.4 1 IEC 5.6 38 Service 93 61 * Excluding salaries FPABs strategic role in influencing/implementing the National Programmes FPAB is a member of family planning sub-sectoral committee of HPSP, where they contribute to policy processes regarding family planning. FPAB receives family planning methods from government and currently it is one of the few organisations who are responsible for providing Norplant. Norplant is becoming popular in Bangladesh and FPAB is playing a key role in encouraging the Government to expand this programme. However, given that significant resources are not devoted to advocacy, the focus is on maintaining liaison with government officials rather than influencing policy and government programmes. FPABs understanding of diverse needs of young people FPAB has a clear understanding of the socio-cultural and economic factors related to SRH of adolescent and youth. During discussion with the field workers and at the central level, staff have mentioned about the diverse needs of young people. For example, overcoming barriers to access to SRH information, access to services (financial reasons, and judgmental attitude of the health providers). FPAB has conducted a needs assessment (Abul Barkat 2000) on young adults and adolescents to find out their knowledge, perception and need for UNFPA and IPPF Evaluation: Bangladesh Country Report 39 SRH services. This study addressed all issues related to health particularly on SRH, STI/HIV/AIDS, FP, maternal health, abortion, violence against women primary health care, access to information. The programme is targeted to both males and females irrespective of economic status, both in school and out-of-school youth, and also specifically addresses students in the religious education system. However, the programme is only limited to 70 rural unions in Bangladesh, which excludes the marginal groups such as the urban poor youth, ethnic minorities, and those who live in geographically less accessible areas like Chittagong Hill Tracts. FPAB mentioned that, despite the need, due to financial constraints they are unable to expand the programme to other vulnerable groups in Bangladesh. FPAB is not very keen to offer FP services separately to unmarried youth because of social stigma as mentioned in the FGD conducted as background information for this evaluation3. FPAB staff mentioned that as the clinics offer FP methods to anybody with out asking the marital status, all youth should be able to have access to family planning methods in their clinics. However, this is contradicted by the FPAB information system that specifically mentioned the term eligible couple (ELCO). The negative impact of distinguishing between married and unmarried youth was reflected in the messages from the FGDs, where youth mentioned two common places to get contraceptives are shops and the pharmacy, notably omitting the FPA. 2.2.2 Integration of rights The CO of FPAB has declared in their 2001-2005 Strategic Plan that their goal is to establish equal rights for women and to enable them to exercise control over their own RRs and reproductive and sexual health choices. However, adolescent or youth RRs are not specified in the Five Year Strategic Plan. FPAB does not have any project that can be considered as rights based. Although women’s rights is accepted as a part of the strategic focus for 2001-2005, in reality there is no clear concept of rights within FPAB, and no plans to implement any rights based projects. During discussion with different FPAB workers it became clear that there is no discussion about the rights issue within the organisation. The definition of rights was not clear to many staff. However, one exception was noted in Bogra where the Deputy Project Officer and Project Officers mentioned that rights for women include access to heath care, choice in number of children they want and the right to receive abortion care if they want to. A few mentioned that working on rights based projects, particularly in youth and adolescents, is not appropriate in the Bangladeshi cultural context because of fear of misinterpretation. For example, there is a fear that if access to modern methods of contraception is considered as a right, unmarried young people will engage in sexual activities. Also, it is feared that the right to marry will encourage young girls to make wrong decisions about their life and not listen to their parents. 2.2.3 Sustainability FPAB has included sustainability as one of their important goals in the 2001-2005 Strategic Plan. The objectives includes: · To increase local resources from 5% to 25% through collecting donations from the community, charge for all kinds of services, selling FPABs training facilities and undertaking different fund raising activities for financial sustainability · To improve the programme management and service delivery capacity of the staff and volunteers by providing needs based training to 5,000 staff and volunteers 3 See separate report: Bangladesh In-Country Studies, conducted by BRAC. UNFPA and IPPF Evaluation: Bangladesh Country Report 40 · To reduce programme operation cost by 10% through networking with different development partners including government In the youth programme 75% of the budget is externally funded and time bound. There is no specific strategy to incorporate external funded time bound activities in the regular programme. However, it was mentioned that the IEC materials developed in these externally funded projects are normally used in the regular IEC programme. FPAB has received a financial grant to support youth programmes, which is used to pay the honorarium for youth peer leaders. The fact that these peer leaders are drawn from the community ensures that those who have been trained to deliver the education sessions on SRH can continue to use their knowledge even after the withdrawal of the programmes. FPAB has also engaged community gatekeepers like, parents, teachers and local leaders in the ongoing IEC programme. Moreover, the organisation uses local club and schools for the IEC programme and has supplied some learning materials like posters, leaflets, so that any young member of the community can read or look during their visit there. Working in close collaboration with key members and organisations in the local community improves the chances of the programme benefits being sustainable in the longer term. 2.2.4 Summary of FPABs Strategic Priorities FPAB is one of the oldest pioneer organisations in Bangladesh. In 1980 it started the youth programme primarily through dissemination of family planning education. Later, in 1992 they included SRH education, which was expanded later to SRH education. The annual budget for youth programme is 15% of the total budget, along with this, FPAB is also capable of attracting other donors to fund the youth programme. Policy development and reform is not a priority of the FPAB (the annual budget for policy and advocacy was only 1.26%). The organisation has a clear understanding of socio-cultural factors influencing SRH in young people, but this awareness does not appear to be translated into the provision of differentiated services or information for different groups of young people. RRs is a new concept in Bangladesh as well as in the FPAB. The CO does not address RRs directly in the community and there is a lack of understanding of RRs among the staff. FPAB has specific plans for future sustainability, which are reflected by the cost recovery of 13% in 2002. Close collaboration with community gatekeepers and established community level organisations also promotes programme sustainability. UNFPA and IPPF Evaluation: Bangladesh Country Report 41 SECTION 3: INSTITUTIONAL ARRANGEMENTS 3.1 THE UNFPA COUNTRY OFFICE 3.1.1 Relevance Organisational structure The UNFPA CO is one of the largest country offices and is presently increasing its staff for the start up phase of the 6CP. A Resident Representative, with a Deputy Representative responsible for HPSP, the Population Development Sub-Programme, and Procurement and finance, heads the CO. There are two Assistant Representatives, one responsible for Sexual and Reproductive Health and the other for Advocacy and BCC. There is a JPO who is responsible for BCC and HIV/AIDS. There will be three levels of staffing with three separate funding structures. The core staff (8) is paid from core funding. The number represents an decrease from 15 posts in the 6CP. In addition there are proposals for 13 locally contracted staff for the 6CP who will get local contracts and be paid for by the project budgets (see organogram, figure 4 for clarification). In addition to the staff who are responsible for sub-programmes, there are a number of NPPPs employed for the sub-programme on SRH. There are also NPPPs employed to work on Gender, Advocacy and Policy/Violence Against Women. There is one NPPP employed on the EC/SRHI projects and another NPPP employed on the UNF. Both of these work exclusively with youth. There is also an NPPP employed to work on PD. The current staffing level has been scaled up for CP6 and seems relevant for the size of the CO. There are two posts that are exclusively for youth, while the Assistant Representative for Advocacy also spends time on youth work. In addition to the CO staff, the Country Support Team for Central and South Asia (CST/CASA) has provided support to the CO for a variety of needs. In 2001-2002, the last year of 5CP, there were 37 CST missions to the CO. Of these 9 missions were for PD, 7 for SRH, 8 for Advocacy, 5 for development of log-frames and 4 were for Youth. UNFPA Resource Allocation The overall expenditure for the 5CP was US$ 31,967,181 for 5 years, and for the 6CP the budget is US$ 16,878,243 for 3 years. The resource allocation and financing of SRH for young people has increased since the 5CP. During the 5CP the funding allocation for youth represented 15% with an increase to 19% of the core budget for the 6CP (see table 4). Two extra funding mechanisms support youth, the EC/SRHI and the UNF fund. Both of these were in place in the 5CP and are again in place in the 6CP, and both allocate 100% of their funds to AYSRHs. See table 4 for estimated allocations in UNFPA core budget for Youth by Expenditure in sub- programmes with additional non-core funds allocated for Youth. Figure 4: UNFPA Office Organogram Bangladesh 6th Country Programme 2003-2005 UNFPA Representative Sr. Secretary Asst. Representative (Reproductive Health) JPO (BCC HIV/AIDS) Asst. Representative (Advocacy) NPPP Gender NPPP Advocacy NPPP Policy VAW NPPP EOC PA NPPP CC NPPP CC NPPP UH FA PA FA NPPP EOC FA Driver PA Driver Admin Clerk Drivers Research Co-ordinator NPPP UH Prog Associate Deputy Representative HPSP. PDS. Proc. And Fin. Finance & IT Assistant NPPP EC NPPP UNF NPPP PDS PA Consultant Trainer PO FA FA Prog Associate Operations Manager Procurement Associate Admin Assistant International Core Programme UNFPA and IPPF Evaluation: Bangladesh Country Report 43 Table 4: UNFPA estimated budget & expenditure allocations in the 5CP and 6CP A. SRH Services B. Advocacy C. Population and Development Overall allocation in 5CP UNF EC/SRHI A. SRH Services B. Advocacy C. Nat. Capacity for SRH Overall allocation in 6CP UNF EC/SRHIYA Expenditure for Youth in the 5CP $1,487,855 $2,895,182 $ 458,437 $4,841,474 $ 200,000 $2,720,955 Budget allocated to Youth in the 6CP $1,610,671 $1,466,250 $ 142,541 $3,219,462 $ 187,951 $2,400,000 Proportionate to The 5CP Expenditure 5% 9% 1% 15% 100% 100% Proportionate to The 6CP Allocation 10% 8% 1% 19% 100% 100% The additional budgets of EC/SRHI, EC/SRHIYA Phase II, and UNF/UNFIP have almost doubled the funding for adolescent and youth since these funds were in place. The funds have enabled an important contribution to piloting youth interventions to be made – as well as contributing to putting the concept of youth and SRH and RRs on the political agenda. Monitoring and Evaluation UNFPA supported programme and component projects are monitored regularly through its established mechanisms. These include the quarterly reporting system, Annual Programme Reports (APR) and Mid-Term Reviews (MTR). GoB is actively involved in these exercises, particularly the APRs and MTR. Regular monitoring is carried out by UNFPA and the implementing partners. In addition evaluation of UNFPA follows a number of different approaches including thematic programme and project evaluations. The logical framework tool was used to develop the 3 sub-programmes for 5CP. Goals, outcomes, outputs and indicators were in place in all three. UNFPAs 5CP (1998-2002) was reviewed between February and March 2000, with assistance of the CASA advisors. The recommendation of the MTR in relation to monitoring and evaluation, was the use of results based management (RBM) as a monitoring tool. It also recommended a few thematic evaluations for the 6CP, to identify “critical gaps” and “lessons learnt” which could provide substance for future planning. A thematic evaluation on BCC and Advocacy is planned to take place at the end of CP5 and this is imminent. The final evaluation of 5CP is due to take place in 2004. UNFPA and IPPF Evaluation: Bangladesh Country Report 44 As part of the process of involving stakeholders a series of workshops, consultative meetings and brainstorming sessions were organised by the CO around the sub-programmes to feed into the process of designing the 6CP. The MTR of 2002, states that a RBM tool has been introduced with the log frame as its tool, and this should strengthen the process of monitoring, as it will shift the focus of monitoring away from recording activities to results. It also states that this is new for UNFPA and the implementing partners because the log frame matrices were developed before without adequate stakeholder participation. 50% of CO staff have been trained in use of the log frame in programme management, with training for the rest of the CO planned. The C0 has implemented baseline data collection and it is now in place (with programme indicators) in 49% of the programmes. Partnerships and collaboration The key partner for UNFPA is GoB. In the Advocacy Sub-Programme UNFPA works through 10 ministries, the NGOs and the private sector. However, the modality is complex as the ministries often contract NGOs to carry out specific tasks. To assist this process, the CO has a roster of NGOs, classified by specialisation and competencies and contracts them for specific tasks, or requests GoB to request the NGOs to undertake work e.g. surveys, trainings, workshops etc. UNFPAs comparative advantage is in its multi-sectoral approach, which was initiated, in pilot activities with a number of sectoral ministries in 5CP. Partners in the UNFPA 5CP Sub-Programme Advocacy · Ministry of Health and Family Welfare · Ministry of Education · Ministry of Labour and Manpower, · Ministry of Religious Affairs, · Ministry of Home Affairs · Ministry of Establishment · Ministry of Information · Ministry of Youth and Sports, · Ministry of Local Government, · Ministry of Rural Development and Co-operatives · Range of service and non service NGOs · Private sector partners The SRH sub-programme was designed to achieve it outputs through eleven component projects. Partners in the UNFPA 5CP Sub-Programme SRH · MHFW (7 projects) · NGOs (2 projects) · Ministry of Local Government and Rural Development (1 project) · Other donor agencies (1 project) The identification of the GoB as UNFPAs main partner and the subcontracting of certain pieces of work for adolescent and youth SRH to NGOs, seems entirely relevant in Bangladesh, where Government collaboration with a pool of experienced NGOs has a long UNFPA and IPPF Evaluation: Bangladesh Country Report 45 and successful tradition. The ET interviewed key stakeholders in Government and discussed the UNFPA strategy of working with a number of partners and it was seen as entirely appropriate for the work on Adolescent and Youth and was highly regarded (see also UNFPA ICPD+10 Field inquiry questionnaire, 24th April 2003). Civil Society UNFPA appears to be aware that valuable resource areas of the Bangladesh NGOs and has involved them as partners in their adolescent and youth SRH activities. The 25,000 NGOs in Bangladesh, provide a pool of qualified and experienced professionals. The UNFPA has a roster of NGOs, listed by competencies and areas of focus, is used for sub-contracting work with the agreement of the Project Director of the Ministry involved. This is an effective strategy, given that NGOs are able to work in the field of adolescent and youth SRH services, which the GoB would find very difficult to do so at present. The initiatives by the NGOs in this area are at a pilot phase and will need to be monitored. The CO was working with Civil Society in the 5CP. This individual partnerships with NGOs and with religious leaders, “gatekeepers” (parents, teachers, Imam and village doctors), and primary and secondary schools, Madrasha schools and non-formal education and peer groups. There is an acceptance in Bangladesh of the value of the NGO resource and NGOs are used both as executing and implementing partners in the 5CP and 6CP. In the recent review of ICPD+10, carried out for UNFPA involving representatives of MoHFW, DGH, DFP Line Ministries and the Khan Foundation, best practices were identified in the work of implementing the goals of ICPD POA included UNFPAs involvement of civil society and NGOs. The UN system in Bangladesh UNFPA has taken an active part in the development of the Bangladesh UNDAF. It has gone through a lengthy process that was refined in 2002 to three main sub-goals: 1. promoting the rights of survival 2. promoting the rights of livelihood and 3. promoting the rights of protection and participation. UNFPA led the basic services task force which looked at addressing PHC, SRH, water and sanitation, basic education and shelter for the desired and identified outcomes. UNFPA tried to follow the framework of the UNDAF document, which takes a human rights perspective to country programming. The UNF is collaborating with UNFPA and UNICEF on an initiative for adolescent girls in ten districts. UNFPA is responsible for the SRH component and has initiated a project for improving SRH amongst adolescent girls through peer education and personal social education (PSE). UNFPA takes part in the UN theme groups, (education, women’s advancement, NGOs, evaluation and health). In 2001, UNFPA took over the chair of the UN Theme Group on HIV/AIDS. UNICEF and WHO collaboration is in place in joint programming, particularly in the fields of maternal mortality, adolescent SRH and education. Joint programming will operate in two ways: 1. defining geographical areas and 2. by addressing issues collectively. UNFPA and IPPF Evaluation: Bangladesh Country Report 46 Following on from this, UNFPA will take the lead on Maternal Health, while UNICEF and UNESCO will jointly lead on girl’s education while UNDP will lead on poverty reduction, governance and corruption. Partnerships with Multilateral and Bilateral Agencies The budgets of the UN agencies represent only a fraction of the resources that are allocated from bilateral funds. However, they have a comparative advantage in particular development interventions. Because of their inter-country experience and expertise, UN agencies can play a catalyst role encouraging innovative pilot projects and in building institutional capacity. The UN system also has through its advocacy mandates, comparative advantages in the areas of human rights, good governance, environment, population and sustainable development. The EC/SRHI is a collaborative arrangement between the EC, UNFPA and national NGOs. UNFPA has taken the part of the project that focuses on married adolescents, while UNICEF is working with the unmarried adolescents in the same locations. EC/UNFPA support four executing NGOs: 1. SCF-UK 2. MSCS 3. BDRCS 4. FPAB SCF-UK work with four local NGOs as implementing partners, while the other NGOs link with locals NGOs and GoB. Poverty Reduction Strategy In the GoB Interim Poverty Reduction Strategy Paper (PRSP), the UNFPA strongly advocated for SRH to be integrated as an objective of the PRSP, especially for the allocation of resources for the vulnerable and hard to reach populations. UNFPAs main concern was to put forward a strong argument based on the fact that economic growth and investment does not necessarily lead to improved SRH. Improving SRH, has a positive effect on the household as well as the national economy. Health Sector Reform/HPSP The UNFPA CO is very active in the health consortium, which monitors, from the development partners’ perspective, the programmes of the MOHFW implementing its first SWAP in Health. UNFPA does not pool its funding but runs parallel funding to its partners. It is, however, considering pooling a proportion of its financial support to the SRH sub- programme under the proposed HNPSP. During the evaluation this collaboration was disrupted when the donors partially suspended funding to MoHFW through the HPSP. The programme envisaged the unification of the health and family planning wings of the MOHFW, decentralization of management to district and upazilla levels, hospital autonomy, adoption of a pro-poor health agenda, development of a national essential drugs strategy, development of health insurance, institutionalisation of stakeholder participation in programme development and oversight, preparation of a regulatory framework for the provision of private health services and for Government-NGO cooperation. The funding was suspended because only limited progress had been made on the reforms agreed upon and the unification of the two wings of MOHFW has now been reversed. UNFPA was involved in the donor decision making process and was influential in ensuring that funding to the ESP and the supply of contraceptives was guaranteed. UNFPA and IPPF Evaluation: Bangladesh Country Report 47 SRH and RR complementarity with co-partners Working with partners is the cornerstone of the CPs sub-programme on advocacy. It works with 10 ministries and appears to have strong links with these government departments. There is a co-ordination committee that meets on a regular basis, to discuss issues and problems as they arise. This method of work was praised in interviews held by the ET with a number of ministries, and is also documented in the UNFPA ICPD Field Inquiry (24th April 2003). A great deal of the innovative and cutting edge work is carried out with civil society through NGOs. While much of this is successful, it is apparent that NGO structures and management are often quite different to the hierarchy that characterises a UN organisation. While needing the creativity and innovation of NGOs, harmony between the different working modalities is not always optimal. More attention could be paid to NGO project cycles, treating NGOs as partners, and inviting NGO participation in UNFPA activities. Private sector initiatives have been primarily through work with the garment BGMEA and the tea plantation workers. Both projects were started up in the 5CP and will continue in the 6CP. In the clinics established by the GBMEA, the UNFPA has assisted in building their institutional capacity though providing equipment and training of staff for appropriate SRH services. Relationships seemed optimal. However, there are indications that while these initiatives have been models, the owners of the garment factories are not in need of financial assistance for running clinics and carrying out SRH work. Multi and bilateral donors The donors meet through a consortium on a regular basis in support of the governments HPSP. At present that political situation is clouded by the differences between the GoB and the Consortium members over the planned restructuring of the MoHFW. This affects all health and population work. UNFPA/FPAB The EC/UNFPA initiative has included FPAB as one of its four partners in their work and there appears to be a good collaboration. FPAB was selected on a competitive basis for the second phase of EC/SRHIYA. CO staff have said that this indicates that their capacity as a national NGO is much better than many other national NGOs in addressing adolescents and youth SRH and RRs. During collaboration on SRHIYA the following major achievements were reported: increased access and utilisation of SRH services, improved quality of care, increased involvement of community leaders, effective tackling of gender issues, greater male involvement, and improved linkages between UNFPA/SRHI partners and GoB. The initial collaboration between UNFPA and FPAB covered the period 1999– 2002, and further collaboration is planned for the next period, 2003– 2005. Phase II of SRHIYA includes the GoB, donors and NGOs in the National Advisory Group (where UNFPA and FPAB work together). 3.1.2 Integration of Rights The CO definition and conceptualisation of rights There has been progress in the CO over the integration of rights into programme work. During the 5CP, the CO work focused on sensitising the country to the needs for adolescent and youth information on SRH and for services, and to a very limited extent on RRs issues. There has been progress, with an international move towards rights based work through the development of the CCA which was completed and shared with GoB. The UNDAF was then UNFPA and IPPF Evaluation: Bangladesh Country Report 48 based on the CCA of Bangladesh and adopts a rights based approach to evaluating development achievements. The UNDAF was developed through a series of workshops, group interactions, and completion of structured questionnaires. All resident UN agencies participated at the different stages of the exercise and consultations were held with GoB, civil society organisations and NGOs. Following this, and also the brainstorming sessions for the development of the 6CP, the programme will work more closely in both sensitisation and implementation of both SRH and RRs (see section 2.1.2). The main rights addressed in the country programmes address the rights to information and access to services and addressing the legal age of marriage 21 years for males and 18 years for females. The UNFPA Advocacy Sub-Programme in the 5CP set out the promotion of the ICPD goals of RRs and SRH and empowerment of women in their project document. In relation to RRs, it set the following goal: That all couples and individuals have the right to decide freely and responsibly the number and spacing of their children and to have the information and education and the means to do so. The majority of rights based work for adolescents and youth that has taken place in the 5CP has been through the Advocacy Sub-Programme, where the emphasis has been on rights to information. Pilot work on the introduction of adolescent SRH services has also taken place under the EC/SRHI through the executing partners SCF-UK. However, as one CO staff member stated to the ET, “it is one thing for adolescents and youth to know their rights, but it is another for them to have the negotiating power to obtain their rights” given the harsh social context in which young people live (see section 1, and also In-Country Studies). Gender sensitivity in addressing SRH needs and rights of young people Review of the project documents have indicated that the CO has addressed gender in all three sub-programmes in the 5CP and that gender issues have also been addressed in the work focussed on adolescents and young people. In the Advocacy Sub-Programme all four of the projects reviewed (see section 6) addressed gender issues in the 5CP with continuation into the 6CP. For example, in the 6CP there is a new project on Advocacy on SRH/Gender/HIV/AIDS through Youth Clubs (BGD/06/03/10). In this project to qualify for assistance 30% of the youth club membership will have to be female. Bangladesh is also one of the countries selected for monitoring the Millennium Development Goals and UNFPA CO will play a key role in this for indicators of SRH, maternal health and gender. Internal UNFPA policies and practices The employment criteria for cadres in the CO are the same as those for all UN agencies. With regards to young people, there is a Junior Professional Officer (JPO) Programme scheme that is intended to provide on the job training for young people. The JPOs are selected on a highly competitive basis and they are required to have a Masters Degree, written and spoken capacity in at least two of UNFPAs three working languages, relevant work experience, as well as certain personal qualities such as leadership, initiative and the ability to work under pressure. There is one JPO in the CO at present. There are no adolescents employed at the CO, however during the 5CP there has been an awareness in the office of the need to collaborate with adolescents in the work on adolescent SRH and a number of initiatives have been put in place to facilitate this (see below in this section). UNFPA and IPPF Evaluation: Bangladesh Country Report 49 Gender balance in employment has been addressed at the CO where of the 25 core employees, over a third are women. There is a gender balance both at the top of the hierarchy as well as amongst the junior staff. There was awareness amongst staff of the gender imbalance in many of their partner organisations where, in many of the ministries, almost all of the employees that are employed on the projects in the sub-programmes are male. This reflects the cultural context. At the same time the very opposite was found in the NGO partnerships as NGOs tend to be more aware of gender equity concerns, are gender balanced and treat this as a priority. Example of strengthening gender equity in 5CP Bangladesh: Good Practice: Promoting female enrolment in graduate studies in the Department of Population Sciences in 5CP 3.1.3 Capacity UNFPA CO The work in managing, promoting and supporting the concepts and practice of young people’s SRH and RRs is shared within a team by the CO. Staff with new acquired training and skills, are balanced by staff who have the experience and background for lobbying work with government. The EC/SRHI and the UNF/UNFIP funding has enabled the CO to use the skills available of two NPPP who are trained and experienced in adolescent and youth SRH work. Their skills are not only used on these two projects, but to provide a cross cutting capacity within the CO. The CO has recognised that work in this area requires a fresh approach developing a strategy that involves young people in the new initiatives. Appropriate baseline data has been collected and several efforts have been designed to bring young people into the planning processes. The balance and skills of the CO team seemed entirely appropriate to the ET for future work in adolescent and youth, however within the time frame of the evaluation there was not time for an in-depth capacity assessment. UNFPAs understanding of socio-cultural and economic factors influencing young people’s SRH and RRs A review of the project documents, the work of the sub-programmes and the information collected by the ET on the collaborative work with a number of Bangladesh NGOs working in different communities indicate the CO’s keen awareness of the socio-cultural and economic factors influencing young people’s SRH and rights. The issues of dowry customs, son preference, legal age of marriage, violence again women, and the lack of information of SRH and RRs began to be addressed in the 5CP. The Annual Report for 2001 states “the overall law and order situation was deplorable. Gender based violence continues at a shocking rate. Women continue to become victims of acid throwing, dowry and other social evils”. Support to reverse this pattern has started with a project directly focussed at addressing violence against women in the 6CP (BGD/06/03/P12 – Advocacy to end gender based violence). In the EC/SRHI evaluation (2002), the team pointed to the different needs of specific groups of adolescents some of who might be termed as “high risk”. For example in Kurigram, due to UNFPA and IPPF Evaluation: Bangladesh Country Report 50 unemployment a large number of adolescents migrate to Dhaka, Bogra, Rajshahi, Chittagong and other places. These groups are at risk of STI/HIV/AIDS, drug abuse and other health problems. In addition there are working adolescents, residential college students staying in hostels and vocational training centres all of whom have different needs. Institutional arrangements to enable young people to participate in planning, implementation monitoring and evaluation of CP components There are good examples of the CO developing mechanisms to involve young people’s participation in the CP. The organisation is hierarchical and not experienced in the ad hoc working modalities of FGDs, nevertheless attempts have been made to do things differently with the adolescent and youth projects. Some of the initiatives to bring adolescents and youth into the planning processes are listed below. Examples of Adolescent and Youth Participation in UNFPA activities · Adolescent’s Health and Development: Issue and Strategies, empowering adolescent girls for sustainable human development Sth. Asia Conference on Adolescents July 1998 · Youth and Adolescent SRH Brainstorming for the 6CP – Dhaka, 8th October 2001 · Meeting the Development and Participation Rights of Adolescent Girls 1-6 Feb 2002 · Youth Consultation meetings at six divisional levels, 2002 (outputs of which were used to design programme for young people on AIDS · UNF/ Adolescent SRH Survey in Nawabganji, Sherpur, Chittagong, Dec. 2002 · EC/SRHI/SC-UK baseline on adolescent KAP in Kurigram, Moulivibazar, Khulna and Cox’s Bazar · Development of a Young persons Forum at CO, February, 2003 · EC/SRHI adolescent support groups formed (SCF-UK project) · UNF Focus group discussions with adolescents in preparation of peer education · Development of reader-friendly booklets and videos for adolescents The setting up of the Young Persons Forum (YPF) was quite a unique experience for the CO and a copy of the advertisement for the event is appended to this report (see annex 4). At the time of the evaluation, the CO was still establishing the list of those who had been selected out of 500 or more applicants. The plans of how to integrate the YPF into the on- going work of the CO with adolescents and youth were being developed. It was too early to evaluate the outcome of this initiative, but it is an initiative to raise young people’s “voices” that will need to be monitored and shared with other organisations Evidence based-planning Evidence based – planning is discussed in full in section 6 of the report. UNFPA and IPPF Evaluation: Bangladesh Country Report 51 CST/CASA Support to the CO The CST is closely involved with the work of the CO. In 2001-2002, the last year of 5CP, there were 37 CST missions to the CO. Of these 9 missions were for PD, 7 for SRH, 8 for Advocacy, and 5 for development of log frames and 4 were for youth. CST provided support for the work with SRH and RRs for youth with 4 consultations during the last years of the 5CP. Two of the missions were to assist in the preparation of the log frame and to develop an understanding of how the log frame can be used for the monitoring and evaluation (M&E) systems. Another CST mission reviewed the peer education/FLE projects. The CST, has been a valuable resource for the CO, but the cut backs in the staffing at the Regional HQ will mean that the CO will need to develop and access a Register of International Consultants for technical support – in much the same way as they have successfully run a register for NGOs in Bangladesh. 3.1.4 In Summary The institutional arrangements at the CO appear to be relevant to the work in SRH and RRs for youth. Rights based work is recognised as a new and challenging area, and the CO team are well equipped to work with this challenge. 3.2 FPAB 3.2.1 Relevance Organisational structure The organisational organogram is illustrated in figure 5. The youth programme organisational structure does not appear to be designed appropriately to achieve the objectives of the national programme in relation to addressing youth and adolescent health. At the central level, two persons are responsible for the youth programme, however at the field level there are no human resources allocated exclusively for youth activities. This lack of responsibility in the field is likely to impact on monitoring and supervision, and subsequently on the quality of care (see next section). Adolescent and youth SRH is a sensitive and complex area to address in the socio-cultural context of Bangladesh. It is also a new initiative for the CO and needs special inputs in terms of human resources, ideas, and a programme strategy to achieve the desired outcome. UNFPA and IPPF Evaluation: Bangladesh Country Report 52 Figure 3: Organogram of Youth programme from national level to field level National Headquarters: Director General Director Programme Deputy Director (Youth)* Programme Officer (Youth)* District: District Project Officer Assistant District Project Officer / Field Officer Community: (Volunteer) Youth Organiser Youth Leaders Direct Target Group Contact * Responsible for youth programme FPAB Resource Allocation FPAB allocated a substantial part of their total budget (15%) for their current youth activities, which are limited to 70 unions. In the administrative structure, at district level there is no one assigned to the youth programme and this limits the quality of the programme. The Assistant District Officer, who is responsible for the Youth Programme, is also responsible for other projects. As a result adequate supervision and monitoring of the programme is difficult. Monitoring and Evaluation The current M&E includes direct field visits and monthly reports and is not very effective. MIS system does not give any regular feedback mechanism at the central level. Which UNFPA and IPPF Evaluation: Bangladesh Country Report 53 means there is no regular feedback to the field staff to improve the ongoing programme performance. A couple of studies have been conducted to evaluate the ongoing youth programme including a mid-term evaluation (MTE) of the country programme. These reports were not found in the field level offices and field staff are not aware about the findings. In reality only few suggestions made by the MTE team and study groups were implemented. The field visits by the supervisors are very much limited because of lack of human resources at the field level. In monthly activities reports and MIS, age and sex are not included, which makes it difficult to assess the profile of the service recipients, and thereby limits the MIS to provide information on effectiveness of the programmes in addressing youth issues. Although, the information recording sheet contains a variable called adolescent care, almost all relate to general health care. Variables collected included RTI and STI cases reported, but no specific information about the types of RTI or STI cases. FPAB partnerships FPAB has good relationships with the GoB that are appropriate for their priorities. At the sub district level FPAB is a member of the co-ordinating committee formed with Government and NGOs. From meetings with government officials during field visits it was clear that FPAB has a good reputation with government. FPAB receives contraceptive supplies from the government regularly. FPAB also has received a grant from the government to continue the youth project. At the community level, FPABs activities are accepted and the gatekeepers valued highly the work of the FPAB staff. Meetings with village doctors, the chairman of the local governing body, parents, the imam, teachers and other social leaders indicated their commitment to FPAB activities. In the field level, all educational and information sessions take place in community facilities like local schools, youth clubs, even in private homes. The education sessions observed by the ET were in a youth club (Bogra), youth club and school (Rangpur), in a school (Sayed pur), and youth club, and personal house (Chittagong). In Sayedpur, FPAB is providing health services in an outreach clinic using two rooms provided by a local person in his house. It was evident that FPAB is not well informed about the youth and adolescent programmes run by other NGOs. For example, BRAC has an adolescent SRH and education programmme, which was not visited by any of the FPAB workers. FPABs youth programme is complementary to some initiatives run by the Government and other NGOs, but explicit co-ordination and collaboration is lacking. The best example of this is the work in Madrasah communities. FPAB has introduced a regular SRH education session in which female and male students from Madrasah trained as peer educators and conduct SRH education sessions in the community with youth and adolescents. Addressing the religious education system through the Madrasah based project is a new initiative, not done by any other government organisations or NGOs. However, FPABs approach is not well co-ordinated with other stakeholders. Staff are not well informed about other relevant adolescent and young activities run by NGOs and there is no collaboration with other NGOs to address these issues. The FPAB programme is only limited to 70 unions and FPAB could take the initiative to share this model with other organisations (both government and NGO) and expand it to other Madrasah (see also section 6.2.1). Complementarity between FPAB and UNFPA FPAB has worked with UNFPA on a few projects where the different expertise of the two organisations has been complementary. FPAB, for example, is one of the four partners in the EC/SRHI UNFPA initiative and has been chosen as a partner also for the second phase UNFPA and IPPF Evaluation: Bangladesh Country Report 54 (see section 3.1.1). The relationships in the project are complex with UNFPA as the funder and lead, FPAB as the local NGO, with backup and technical support provided by IPPF. This initiative appears to be well co-ordinated and relationships are complementary. 3.2.2 Integration of Rights FPAB conceptualisation of RRs RRs is a new concept in Bangladesh. It is not widely discussed by stakeholders working in the health field, nor is the concept of SRH widely discussed. As discussed in section 2.2.2, FPAB does not have any rights based projects. Young People and Gender Equality in the CO FPAB is a male dominated organisation with elderly and experienced staff. Among 10 deputy directors, only one is a woman and all the district project officers and assistant district project officers are male. Interestingly in the four clinics the ET visited, all counsellors are female. In relation to youth employment, there are only a few young staff and those work in the computer department. 3.2.3 Capacity Capacity at CO FPAB employees are very committed and hard working. All of them are experienced and had a clear understanding about the community and community needs. However, for a better and more effective programme they require further training and skills. There is a lack of any capacity building programme within the organisation. District and assistant district project officers team met, lacked public health related training (short or long term). Medical officers do not have the clinical training on STI diagnosis or treatment necessary to adequately serve STI patients, in the absence of diagnostic laboratory tests. Counsellors need special counselling training on adolescents and youth. In the FGDs conducted as background material for this evaluation, it was mentioned that young people are afraid of not having sufficient privacy and confidentiality. Without appropriate training there could be the possibility of judgmental attitudes discouraging young people from accessing services at the FPAB clinics. In summary, there is a significant gap in the capacities required to run an effective youth and adolescent SRH programme. Socio-cultural factors influencing young people’s SRH FPAB staff understand the socio-cultural economic and religious factors that influence young people’s SRH. Bangladesh is a Muslim country and a large proportion of poor adolescents are enrolled in the religious education system or find themselves out-of-school. FPAB has a SRH education programme to address this target group by focusing on the religious education system and the community through a peer based youth programme. Although staff understand that economic factors are a barrier to young people accessing health services, there is no special provision to counter this problem in their health service programme. The ET found their RRs is a new concept to the FPAB and clear understanding of RRs was not apparent. Male and Female youth participation in the FPABs programme FPAB has a governing body comprised of volunteers who have supported the organisation for a long time (see figure 5). This excellent strategy allows the organisation to ensure UNFPA and IPPF Evaluation: Bangladesh Country Report 55 community participation and involvement in decision making processes. This body takes part in and contributes to policy making, reforming programme activities and defining priorities. However, in the FPA governing body there is little female representation. Even though women volunteers are in the majority in many districts, few are elected to serve on the Executive Committee. FPAB has few women staff in the top and mid level within the organisation. In the programme it has recruited female peer educators to disseminate the IEC materials to the target groups. One of the pre-conditions for election to the Executive Committee is that candidates need to be 18 years old or over. This obviously restricts the participation of younger people. The nomination and selection process favours the senior experienced males. No young representatives were present in the ETs meeting with the governing body. Figure 5: FPAB Governing Body National: General Body National Executive Committee, 21 Members District: General Body Branch Executive Committee, 15 Members Institutional arrangements to allow youth to participate There are no formal institutional arrangements and mechanisms in place to enable young people to participate actively in planning, implementation, monitoring and evaluation of the programmes (see above). However, informal discussions with young people are conducted regularly, through which they can contribute in the programme. No document or evidence was found to support this informal discussion and staff were unable to answer clearly how these informal discussions are operationalised within the organisation. Coverage to marginalised young people FPAB works mostly with rural young people and not with urban or marginalised or excluded young people. A short term IEC project with urban-based garment factory workers, funded by Japanese donors did not address youth specifically. Capacity for lessons learnt and best practice In the programme there was little attention to capacity building. FPAB staff do not have adequate training on adolescent and youth SRH to enable them to contribute efficiently and effectively to the Youth Programme. However, the staff are well motivated and because of their experience they learn quickly despite the lack of formal training. The staff use their long community based programmatic experience to motivate and mobilize social leaders. One example of good practice that needs close evaluation and documentation is FPABs collaboration with the Islamic Research Cell (IRC) in the Madrasahs that provides SRH UNFPA and IPPF Evaluation: Bangladesh Country Report 56 education to both male and female students. In Chittagong and Bogra, the evaluation team met the peer educators (both male and female) from Madrasah students, who provide reproductive health education either in the classes or in the local youth club once a week. Good Practice: A Madrasah principal, and other teachers, in Chittagong appreciated FPABs efforts to promote RH among Madrasah students. During discussions, one teacher suggested that Madrasah teachers could contribute substantially to changing some social behaviours like early marriage among girls. As social leaders in the community they can educate parents to delay their daughters’ marriage, which can delay early pregnancy and thus promote reproductive health of women. Financial Resources IPPF has been cutting back on the budget to the FPAB every year, as mentioned earlier in this report, and although the proportion for the Youth Programme remains the same, the total amount for the youth project is being reduced. However, FPAB has attracted other donors to fund youth activities outside IPPF funding. FPAB has also started to pay attention to future sustainability. They have made gradual progress in improving their cost recovery system in last few years. However, the IPPF Regional Office should pay more attention to capacity building and training of FPAB staff in this respect. 3.2.4 In Summary FPAB does not have sufficient human resources in the youth programme at the field level to provide a quality service through regular supervision and monitoring. Further the staff that are in post have not received appropriate training to deliver an effective youth programme. However, FPAB staff have a good reputation and are widely accepted in the community and by government officials. The youth programme complements the programmes run by other organisations and the GoB, although the approaches are not well co-ordinated with other stakeholders and opportunities for sharing best practice and scaling up are perhaps missed. FPAB is very gender sensitive at the community level in implementing the programme. However, overall it is a male dominated organisation that does not appear to address the issues of gender equality. There is no specific policy to encourage youth participation within the organisation and the selection process in the governing body also restricts young people’s participation. There is a strong commitment to the organisation from the staff but they need more training to maximise their efforts for such a challenging programme. UNFPA and IPPF Evaluation: Bangladesh Country Report 57 SECTION 4: ENABLING POLICY DEVELOPMENT AND REFORM 4.1 UNFPA COUNTRY PROGRAMME 4.1.1 Relevance Sub-Programmes and projects influencing reform of policies which relate to young people’s SRH and rights Two of UNFPA sub-programmes have had a direct influence on policy concerning young people’s SRH and RRs during the 5CP, 1) the Advocacy Sub-Programme and 2) the Population and Development Sub-Programme. The third sub-programme, Sexual Reproductive Health is interlinked with these two in numerous ways and therefore also contributes to the policy process. In addition, two additional funds, the EC/SRHI and the UNF/UNIP also appear to have had an influence on the policy process. 1. The Advocacy Sub-Programme The purpose of the 5CP sub-programme on Advocacy was to facilitate positive behaviour changes and create a supportive environment for improved family welfare. The two outputs were 1) Increased support of influential religious, political and local leaders for SRH and RRs and 2) Increased positive attitudes and behaviour of vulnerable and hard-to-reach groups on issues relating to gender, SRH and RRs. Influencers were identified as religious leaders especially at grassroots level, locally elected leaders, school teachers, factory and tea plantation owners, trade union leaders, NGOs involved in non-formal education programmes, mass media practitioners, faculty and trainers of training institutes and senior government officials. The goal of the Advocacy Sub-Programme in the 5CP was to create a process that would ensure that over time there would emerge a critical mass of influential persons, many of whom are located at the grassroots level, and in a powerful position to act as pressure groups to promote quality SRH services and gender concerns among the communities. This strategy for influencing the policy process is a long term strategy but has been considered appropriate and relevant in the context of Bangladesh. Furthermore, the support in the sub-programme for government– NGO collaboration is another factor that is relevant in influencing the policy process. 2. The Population and Development Sub-Programme The strategic focus and purpose of this sub-programme was to build national capacity in population and SRH development-related policy formulation, taking consideration especially of the policy implications of emerging issues such as environment, urbanisation, urban planning, ageing populations, migration – in each case linking these to poverty issues. The three outputs of the sub-programme were summarised as: · A broadened scope for population policy · Increased dialogue on population and development among politicians and policy makers · Population variables and gender concerns integrated and addressed in national development. The outputs planned for the PD sub-programmes were linked to projects, two of which were related to adolescent and youth SRH and RRs: UNFPA and IPPF Evaluation: Bangladesh Country Report 58 · Support to the Centre for Policy Dialogue. This Centre has produced a number of state of the art papers and series papers aimed at effecting policy change in population development related areas. It has informed the national debate about population issues, particularly on the critical need to maintain the present fertility decline together with papers on projections and analysis on health, family planning and education interventions. In addition it has addressed gender disparities and the need to promote female education as a top priority. · Support to the Department of Population Sciences at Dhaka University. UNFPA supported the setting up of a new Faculty and a two-year master degree in Population Sciences and has a gender-balanced intake. This institute is planned to stimulate action-oriented policy dialogue and to foster the necessary academic climate for policy enquiry. It is intended to raise awareness of issues that will be pivotal in the policy debate, including adolescent needs. 3. Two other UNFPA projects in the 5CP have a direct link to influencing policies and legislation relating to young people SRH and RRs are the EC/SRHI and the UNF. · The EC/SRHI project (see also 2.1.1) established a baseline through a KAP on urban adolescents (males and females), understanding the SRH in project areas – Cox’s Bazar, Khulna and Kurigram and Moulavibazar. The baseline indicated that adolescents do not have proper information about SRH and that there is a demand for information. It also showed that adolescents are involved in pre-marital sex and know people involved in extra-marital sex. · The UNF – carried out a baseline with married adolescents including both the wives and husbands in three districts, Sherpur, Chapai Nawabanj and Chittagong and the results also indicated continued early marriage of girls, changing sexual behaviours and the need for information on SRH. Both these initiatives have had and will continue to have an impact at policy level, because of the impact of the baseline data (which clearly indicated adolescents lack of SRH information and evidence of pre-marital sex) and the pioneering work with providing adolescent friendly services, counselling and peer group education. The UNF now operates in ten districts. Understanding of policy and laws which affect young people’s SRH and RRs among UNFPA staff and agencies supported by UNFPA. There are no laws and policies in place that are specific to the promotion or protection of young people’s SRH and RRs in Bangladesh. The government does not discourage any campaign to raise awareness of young people’s rights, nor is there any legal restriction on young people receiving SRH services. The legal age of adulthood is 18 for females and 21 for males and linked to this the legal age of marriage is the same. As discussed in the introduction, this law is commonly disregarded, 80% of Bangladeshi women marry before the age of 20 years. In relation to unwanted pregnancies, abortion is illegal without definite medical grounds, however, menstrual regulation is available for up to 3 months – but not if a woman is unmarried. The Convention on the Rights of the Child (CRC) has been signed and ratified by the GoB. This convention has considerable implications in Bangladesh where there is extensive trafficking and child prostitution. Bangladesh has also confirmed their support and commitment to The Convention on the Elimination of Discrimination Against Women (CEDAW) and UNFPA linked the development of its 5CP to CEDAW. UNFPA and IPPF Evaluation: Bangladesh Country Report 59 The staff at CO are fully cognisant of policy and laws affecting young people’s SRH and RRs. They are aware of both the international policy agenda developments as well as the policy and laws that govern these issues in Bangladesh and they appear to work in line with the government’s laws and regulations. 4.1.2 Efficiency In terms of resources devoted to policy development and reform, in CP5 an estimated 25% of the overall core budget was allocated to the Advocacy Sub-Programme. In the CP6 this increased to 33%. A breakdown of the amount of time spent by the two additional projects, the EC/SRHI and the UNF on advocacy or policy reform efforts was not available. It was also difficult to estimate the amount of time the SRH sub-programme devoted to policy reform. Whilst it is clear, as mentioned in the section above, that UNFPA’s work has been influential in opening up the policy agenda on adolescent SRH and RRs, no specific objectives or goals were set and a range of different activities were undertaken. It is therefore not possible to assess the efficiency of the resources invested. 4.1.3 Effectiveness Perception by key partners of UNFPAs impact on national policies, protocols and standards/norms for SRH There is a difference in key partners perceptions of the role of which UNFPA in influencing national policies, protocols standards/norms for SRH. The GoB partners interviewed were appreciative of the support and collaboration with UNFPA and attributed the successes to date to the collaborative effort of the partners. In interviews held between the ET and MOHFW staff UNFPA was praised for its support work with SRH and adolescents, in particular the work in advocacy in the Ministry of Youth and Sports was mentioned. Donors interviewed were more critical and posed a number of questions. One question that came up was that of agencies which led on SRH and adolescents, where UNFPA, WHO and UNICEF all have strengths in this area. It was suggested that UNICEF should lead on EOC, with WHO as the lead on SRH and Safe Motherhood. WHO is in the process of developing a regional and global adolescent health and development framework, listing under this protective factors and risk factors, and they are thinking of contracting a national consultant for Adolescent Sexual Reproductive Health and Development. Of the donor agencies, USAID was seen as the main player in advocacy and SRH and IEC. It was pointed out by several donors that the UNFPA had played a major role in policy development through their support to PD and the work of the Centre for Policy Dialogue. NGOs tended to be critical about the size of the UNFPA interventions, arguing that questions of scaling things up to a population of 143 million had not yet been addressed. They also commented that UNFPA only worked in SRH and not in rights, or at least rights based work was not visible. Generally, there is respect and appreciation for the work that UNFPA does in influencing national policies, protocols and standards/norms for changes in adolescent SRH since ICPD. However, as mentioned above, the issue of effectiveness must be seen in the light of the relatively small number of projects that have been supported in adolescent SRH and the extent to which examples of ‘best practice’ can be scaled up to the national level. UNFPA and IPPF Evaluation: Bangladesh Country Report 60 4.1.4 In Summary UNFPAs role in contributing to stimulating an enabling environment for policy support to young people’s SRH and RRs has been influential since ICPD. The environment for addressing this issue is more favourable than it was ten years ago, and progress has been made in terms of the willingness of GoB, other partners and gatekeepers to accept that there is a need for information and services for adolescents and young people. The two main sub-programmes that have influenced the policy process have been the Advocacy Sub-programme and the Population and Development Sub-Programme. In addition the work of the two projects, the EU/SRHI and the UNF fund have also done work that will have influenced the policy agenda. Under the Advocacy Sub-Programme the strategies and outputs have changed since ICPD. IEC/BCC, in particular, has changed in its nature and content over the period and is in the process of changing again with a clearer focus on SRH and RRs for adolescents and youth. The socio-cultural context in Bangladesh has meant that progress has not been as rapid as was hoped, however with the extensive work undertaken in collaboration with 10 ministries changed perceptions and attitudes. The EU/SRHI and the UNF funded projects have been influential in policy dialogue, particularly useful has been their initial collection of baseline data, that indicated the unmet needs of adolescents and young people for SRH information and services. 4.2 FPAB The FPAB predominately focuses on IEC and service delivery to reach their project goals. Policy development and reform are not priorities in their programme. The annual budget for the total programme and the youth programme allocated for advocacy and policy, is respectively only 1.26% and 1%. This limited amount is allocated for sharing their experiences with Government and other stakeholders. There is no specific cell or person responsible for advocacy or policy reform. FPA staff and volunteers are aware of certain laws like the legal age of marriage, the law against dowry payments but have a lack of understanding of how these policies and laws affect RRs. The FPAB is not involved in work on young people’s RRs. FPAB is an organisation primarily involve in providing FP services to the women. Later they expanded their programme to SRH and other issues like women empowerment, income generation activities. Historically advocacy was not a strength of the organisation and at the organisational policy level there is a lack of interest due to lack of experience of working on policy and advocacy within the organisation and also a lack of the skills necessary to address this issue. 4.2.2 Efficiency As noted above, policy development and reform are not priorities in the FPAB programme. Specific goals and outputs were not set, hence it is not possible to assess the efficiency with which the limited resources devoted to this purpose were used. 4.2.3 Effectiveness FPAB is involved and participates in different national health committees in Bangladesh and has an excellent relationship with government both at national and field level. As the oldest pioneer organisation in the field of family planning in Bangladesh, the FPAB does not currently play a significant role in advocacy for promoting adolescent SRH and RRs, or any apparent role in policy development in the field of SRH and RRs for adolescents and youth. UNFPA and IPPF Evaluation: Bangladesh Country Report 61 The ET felt that FPAB could play a significant role in stimulating an environment to establish RRs in the reproductive field. As FPAB is a member of different national health committees, it could use this opportunity to advocate RRs. In particular, FPAB could share their approaches in addressing young people’s SRH through the IRC and their initiative like the debate competition, with other stakeholders. 4.2.4 Summary Advocacy and policy development is not a priority in the FPABs activities. The annual budget allocated for this is very low (1% for total programme and 1.26% for youth programme) which is mainly limited to the dissemination of the programme information to the GoB and other stakeholders. FPAB has a long term relationship with government and members of many governmental planning committee. This is a missed opportunity for making a substantial contribution to developing and reforming policy for SRH and RRs for young people. UNFPA and IPPF Evaluation: Bangladesh Country Report 62 SECTION 5: STRENGTHENING SEXUAL AND REPRODUCTIVE HEALTH SERVICES 5.1 UNFPA COUNTRY PROGRAMME 5.1.1 Relevance Support to SRH services for young people UNFPA support to SRH services represents the largest of its sub-programme allocations. In the 5CP the allocation to services was 66% of the overall budget, and in the current 6CP the allocation is 56% (or approximately US$ 9,400,000 over three years). Within the SRH sub- programme there is to be an increase in the proportion of the budget allocated to youth. Whereas 5% of the budget was allocated to youth in the 5CP and 10% is allocated in the 6CP. During the First CP and the Second CP, support centred on the family planning programme, but in the Third CP, emphasis was placed on women’s health through strengthening the MCH/FP service delivery system and the institutional capacity of the MOHFW through technical assistance and training. The Fourth CP attempted to address shortfalls in accessibility and quality of MCH/FP services by upgrading Maternal and Child Welfare Centres (MCWCs). Concern over the access and quality of the SRH services remained and formed the background to the 5CP. The goal of the SRH sub-programme was to “contribute to the improvement of SRH” and to do this it would need to address: · the key issues of low accessibility and utilisation of SRH services, particularly by vulnerable and difficult to reach people · introduce measures to improve the quality of SRH services. There appeared to be no direct goal, planned output or project within the SRH Sub- Programme that had an adolescent or youth focus in the 5CP. In the 6CP the project document refers to the recognition by the GoB that adolescents are a critical group if the SRH status of the country is to be improved. One of the focuses of the programme is the development of new guidelines for providing youth friendly service training for health and family planning service providers at different levels. This includes UNFPA, MoHFW joint initiative where eight MCWCs will be dedicated as centres of excellence in adolescent services. Assistance is to be provided to develop an SRH strategy, which will involve all relevant sectors and development partners. In Bangladesh it is very difficult to address adolescent SRH due to social stigma. There are social/cultural/religious barriers in discussing this issue. Widespread ignorance is still prevailing among adolescents on the risks associate with unprotected sexual activities/high risk behaviour. (UNFPA ICPD+10 Field Inquiry Questionnaire, 24the April 2003) While it has been difficult for the MOHFW to address adolescent SRH, support to NGOs has been possible. Under CP5, EC/SRHI initiative, the UNFPA collaborated with Save the Children – UK (SC-UK) (RAS/98/P63) and planned for improved access to SRH services for adolescents “to ensure that SRH services were more sensitive to the needs of adolescents, and allow adolescents more control over the factors that affect their SRH”. Under the EC/SRHI Phase 1 there were three outputs that addressed youth services: UNFPA and IPPF Evaluation: Bangladesh Country Report 63 1. SRH service providers are aware of the need for sensitive services of adolescents and are supportive of them 2. Utilisation of quality SRH services by adolescents in the project area increased 3. Strengthen linkages and capacity of local partners to address the SRH needs of adolescents. In an evaluation of the services provided under this project, lessons learned pointed to the need for adolescents to participate in meetings, that pricing maybe a barrier to use, that, other health services in addition to SRH are needed. Responsiveness to the diverse needs of young people The collaboration between UNFPA and its partners has been beneficial where the experience of NGOs in working with young people has been incorporated into the design of service programmes for the 6CP. For example, the SC-UK adolescent friendly clinical SRH services including counselling on psycho-sexual issues and referral offered in the rural areas of Cox’s Bazar and Khulna. The lessons learnt in the project, included the difficulty in convincing parents to allow their children to participate in the FGDs about SRH, drop outs through marriage (girls) and migration (boys), the demand for non-reproductive services and problems with payment of user fees by adolescents and the need for adolescents to socialise. In another example, Marie Stopes, in collaboration with UNFPA through the EC/SRHI is providing health services garment workers in 150 factories, where SRH is provided through clinics on the factory premises. As discussed above and in sections 2.1.1, 3.3.1 and 3.3.3 the CO has carried out a number of initiatives to elaborate and understand the SRH needs of diverse groups of adolescents and young people and has plans to continue this approach and work with the Youth Forum during the 6CP. The In-Country FGD study section on access to services, indicated diverse responses of males and females where males had different SRH service seeking patterns to females. Males could and did access shops and pharmacies, whereas girls reported that they would approach the female health workers and family planning clinics. Costs were also raised as possible barriers to seeking SRH services for some adolescents, and in particular the costs of menstrual regulation for unmarried girls was mentioned. Evidence base Two baseline surveys addressed evidence base for adolescents and youth SRH services was addressed through information gathered from a number of different sources including. In the case of the EC/SRHI project, the project emphasized the application of participatory approaches. The project started with a process of networking between adolescents, between adolescents and adults (guardians, teachers, leaders) and other service providers. FGDs were then conducted with different groups of adolescents. Attempts were made to analyse the FGDs to form a baseline, but this proved to problematic and eventually is was decided to carry out a baseline to understand adolescents through a KAP SRH in the project areas: Khulna, Kurigram, Moulivbazar and Cox’s Bazaar. The UNF supported ASRH initiative for married adolescent girls, provided research in 2002 that added to the evidence/knowledge bases on lifestyles and behaviours among young people. More young people are sexually active than had been previously thought and few of these young people have adequate access to information, counselling and services. A needs assessment was undertaken using participatory rapid appraisal techniques with adolescents to give them an active role and sense of ownership in planning for adolescent friendly services, (for further details see 6.1.1). UNFPA and IPPF Evaluation: Bangladesh Country Report 64 5.1.1 Integration of Rights Incorporation of concept of rights The ICPD and ICPD+5 formed the building blocks for both the 5CP and 6CP (see discussion in 2.1.2). However in terms of the eleven rights listed as components of Reproductive Sexual Rights in CEDAW Article 16, many of the rights listed are new concepts in Bangladesh and even newer when applied to adolescents (see 2.1.2). Under the core budget, the UNFPA Sub-Programme SRH for 6CP aims to contribute to increase the availability of quality SRH services and counselling for adolescents. Adolescent/youth friendly services will be made available at the centres supported by UNFPA. It also plans to make the services pro-poor and to work with local NGOs/Youth clubs and service staff who will be responsible for sensitising the poor (and adolescents/youth) on the availability of services free of charge. The EC/SRHI has pioneered adolescent services in three districts and is now expanding this in EC/SRHIYA Phase 2 to 20 districts and parts of four metropolitan city areas. Gender equity concepts The CP strategies, since ICPD have been based on the ICPD principles. In the 5CP, the SRH Sub-Programme addressed the issue of gender equity by integrating gender issues into the training of health service providers on SRH issues. The CST review of 5CP made the following recommendation for strengthening the gender components in SRH: · The training of health service providers under the SRH sub-programme in particular is bio-medically biased and does not deal with socio-cultural aspects of SRH. In order to initiate behaviour change in health seeking patterns etc. it is recommended that behavioural and motivational information of SRH issues is integrated in the training. Furthermore it is recommended that gender is considered in a holistic manner, so that gender equality in terms of recruitment etc. is included as well. These recommendations are addressed in the 6CP under output 4.7 SRH where training will be provided to service providers/managers basing good practice on recent SRH research. Good practice: the pilot projects by the EC/SRHI and UNF have shown that adolescent boys have different experiences, knowledge bases and needs for SRH services than girls. Sensitivity to the different needs of males and female adolescents resulted in the provision of services for boys and girls at separate times. 5.1.2 Capacity Competencies and skills of service providers Capacity development, for the provision of services for adolescents and youth, was not a part of the 5CP support to GoB. Adolescent friendly services for SRH is a new initiative planned in the 6CP. Training is in place for service providers and also for gatekeepers who will need to be supportive if increased use of SRH services by adolescents and youth is to be UNFPA and IPPF Evaluation: Bangladesh Country Report 65 achieved. In the 6CP there is also an initiative to support the development of new guidelines for providing youth friendly services at different levels, which will include services and counselling at the government MFWCs supported by UNFPA. Documentation available on the pilot work in the provision of adolescent friendly services by the NGOs has indicated a number of issues that need to be addressed, linked mainly to: · the need for training of the service providers · the need for awareness raising in the communities of the need for the services · the cost of the services. 5.1.3 Efficiency As stated earlier in this section, during the 5CP there was no direct goal, planned output or project with the SRH Sub-Programme that had an adolescent or youth focus for service provision. Therefore the ET was unable to assess the efficiency of the investment in services. It was also noted that no costing studies have been carried out on providing adolescent and youth SRH friendly services. 5.1.4 Effectiveness While the CO is aware goals of ICPD and the need to work with adolescent SRH and rights issues, the environment and culture has meant that progress has been slow. There was no support to the provision of SRH services for adolescents under the core budget during 5CP. The joint initiative with MOHFW to support the eight MCWCs for excellence in adolescent services in the new CP will need to be monitored and evaluated for effectiveness. It appeared from the In-Country Studies that access to services for young people is not a problem if they are married but that it was virtually impossible for unmarried girls to access SRH services. However, the EC/SRHI in the 5CP has initiated the provision of services for adolescents and a number of other NGOs are also starting to provide adolescent friendly services. For example, in the EC/SRHI project executed by SC-UK, an evaluation was conducted one year after the baseline data had been collected. The findings of the evaluation showed that in the project period, 22,832 adolescents had been reached to improve knowledge about SRH. In addition the evaluation made an attempt to analyse the MIS data on health service utilisation by the adolescents. The general observation that can be made from the data is that adolescent girls are utilising SRH services more than boys. UNFPA and IPPF Evaluation: Bangladesh Country Report 66 Table: Distribution of adolescents who have visited clinic for sexual and reproductive health services by project area and sex, January - May 2002 Khulna Kurigram Moulvibazar Total Time Period Boys Girls Boys Girls Boys Girls Boys Girls January 1 21 2 12 - - 3 33 February 16 65 4 10 2 8 22 83 March 8 38 9 5 3 10 20 53 April 1 24 4 30 2 6 7 60 May 23 44 15 19 2 1 40 64 Total 49 192 34 76 9 25 92 293 Source: SC-UK MIS/evaluating adolescent health initiative (ASRHI) project: SC-UK experience in Bangladesh The findings of the evaluation with regard to services, was that the EC/SRHI project had established appropriate referral linkages with other existing health centres in the community for adolescents to access adolescent friendly SRH services. In order to increase the health service utilisation by the adolescents, a number of benefits are offered to the adolescents. These included availability of especially trained service providers (training provided through the ASRHI project) on adolescent friendly services, convenient hours (especially morning hours for girls and afternoon hours for boys), relatively short waiting times (adolescents given preference if there is overcrowding) and subsidised affordable pricing of the services. The quantitative part of the evaluation indicated that 46% of girls in the study visited a service provider for menstrual problems compared to 25% in the baseline. In the In-Country Study FGDs, the young people interviewed said that to access services for contraceptives, the boys would mostly go to shops and pharmacies, followed by doctors and family planning clinics. The females most often mentioned the female health workers and the family planning clinics. Both male and females in the groups said it was not expensive to get SRH services and that condoms and oral pills were the cheapest and cost very little money. For clinical problems, the boys said they would seek help from pharmacists local doctor or the hospital. The girls said they would go to a female doctor or would talk to field health workers. 5.1.5 Sustainability Joint work with partners In terms of strengthening services, the CO works with a portfolio that includes 11 ministries and a number of NGO partners (see section 3.1.1). The experiences gained in this area will assist the GoB to both build on lessons learnt as well as encourage greater use of NGOs as service providers where their work appears to be able to reach out to the target groups. A recent government survey carried out by UNFPA indicated that the GoB recognised that NGOs have proved their excellence in reaching the target group (women, children and the poor) and that this work should be continued and expanded. A National Advisory Committee for Stakeholder Participation in Health, Nutrition and Population Sector has been constituted to ensure a client focused approach. This Committee is headed by the Secretary of the MoHFW and includes representatives from different ministries, agencies, CBOs, academics and NGOs. UNFPA and IPPF Evaluation: Bangladesh Country Report 67 Collaboration and cost sharing There has been an improvement in cost sharing from only 3% of total budget for the 5CP coming from donors to 6% in CP6. Externally funded services and scaling up Funds allocated to the delivery of services for adolescents and youth through the externally funded SRHI Phase I, SRHIYA Phase II and the UNF were incorporated into the work of NGO partners. During the 6CP, some of the funding will also be allocated to working with GoB partners on the provision of services. The SRHIYA project document for Phase II states that sustainability is a key issue in working with NGOs, where there are limited funds for scaling-up successful initiatives, and NGOs are asked to develop exit strategies along with their funding proposals. With the larger NGOs there is more potential for sustainability due to their multi-donor funding base. Phase II of the SRHIYA includes the GoB, donors and NGOs in the National Advisory Group (where UNFPA and FPAB work together to lobby GoB). This networking with government will support the push for scaling up of genuine partnerships with government as well as the NGO networks. In conclusion, it is too early to assess any long-term sustainability for work in adolescent and youth SRH services. While there are a number of supporters for the GoB initiative with partners, there are also a number of those who are still unsure of the new approach, particularly in relation to the attitude of gatekeepers. Although not explicit, there is a scaling up of the work carried out by UNFPA with NGO partners, and funded mainly by SRHIYA, that will be carried out during 6CP. 5.1.6 In Summary Support to the provision of SRH services to adolescents and youth has been a challenging initiative in Bangladesh, given the cultural context, outlined in Section 1. However, under 5CP, with the support of EC/SRHI funding, a creative start has been made in a pilot project. The work has been grounded with a baseline, and is in place with the support and collaboration of SC-UK and with four local NGOs as the implementing partners. FPAB, also in collaboration with UNFPA, is helping to pioneer adolescent friendly services in its 38 clinics. In the public sector there has been little support for adolescent friendly services, but this will be introduced with a training component in the new 6CP. It is too early to assess the sustainability of the support work for the introduction of adolescent and youth friendly services. 5.2 FPAB 5.2.1 Relevance Historically, FPAB has provided clinical services for women in rural Bangladesh since the fifties. Currently FPAB runs 38 clinics throughout the country. These clinics primarily provide maternal and child health services including all types of contraceptive services and treatments for general diseases. The clinic structure comprises one Medical Officer, two paramedics 1 male and 1 female, one staff counsellor (female) and a cleaner. In a baseline study conducted by Professor Abul Barkat in 2001, it was found that the majority of adolescents and youth responded negatively about SRH services and knowledge SRH services was very poor. However, another survey conducted by the same author in 2000, indicated high demand as it appeared that one third of married and one quarter of the UNFPA and IPPF Evaluation: Bangladesh Country Report 68 unmarried girls, had reported RTI symptoms such as lower abdominal pain, abnormal discharge or painful intercourse. Unfortunately the most preferred health services mentioned were rural quacks, kabirajs and homeopaths. FPAB has been supporting and encouraging adolescents and youth to use the existing services at different clinics including their own clinics. However, no specific strategy has been adopted to ensure services are accessible to youth. In particular, no special effort has been given to encourage adolescents and youth to address the factors that influence their negative attitude towards existing health services. During the FGDs with female adolescents, cost of the service and attitudes of health providers were mentioned repeatedly as reasons why FPAB services were not used. The FPAB clinic is historically known as a provider for family planning methods and still it is one of the major family planning service providers in Bangladesh. The introduction of services such as STI services, provision of contraceptive methods for unmarried youth etc, requires a special effort to change the old image. The name Family Planning Association of Bangladesh is itself a barrier for adolescents and youths to access those services. In an interview with a local adolescent girl in Bogra district, she has mentioned that the name FPAB sometimes creates a stigma for a young girl to attend the service. The people who watch her going there become curious about the reason for the visit. FPAB has recently introduced adolescent friendly services in their 20 clinics funded by IPPF. In the four clinics visited, only one had a signboard in front of the clinic indicating a special day (e.g. Monday) for adolescent and youth health care services. Further no counsellor in these clinics have had any training with adolescents and youth counselling. As noted above in discussing capacity (section 3.2 3), there is a concern which was raised during the focus group discussions conducted as part of the In-Country Studies, that the attitude of FPA staff is judgmental, especially to unmarried youth. 5.2.2 Integration of Rights RRs is not incorporated into the FGAB approach to service delivery. 5.2.3 Capacity In the clinics visited by ET, staff had not received any training on adolescent and youth health care. In addition, no counselling training on adolescent and youth care particularly STI/RTI clinical training had been provided to the counsellors and clinical staff. There is no specific annual plan for training clinical staff in the provision of adolescent and youth SRH services. 5.2.4 Efficiency FPAB provides SRH services to youth through their static and satellite clinics, however the efficiency of service provision could be improved by providing appropriate training (youth counselling, STI diagnosis and treatments) to the clinical staff. The MIS system does not have information on young people (age, sex), which could help to develop an ‘evidence based youth programme’, therefore measuring efficiency of the current approach is not plausible. 5.2.5 Effectiveness The FPABs services for adolescents and youth are mostly limited to the provision of contraceptives, including counselling and STI treatments. During discussion with clinic staff it has been found that the clients are mostly married and little provision is made for UNFPA and IPPF Evaluation: Bangladesh Country Report 69 unmarried youth. However, recently they have asked adolescents and youth to come to the clinics on particular days of the week, when SRH services will be provided. The MIS does not collect age specific data and therefore there is no mechanism for assessing the age of the clients. During clinics visit only a few adolescents were found in the clinics (Rangpur, Sayedpur, Chittagong), and they were there for general diseases like fever and diarrhoea. Another concern about effectiveness, is that the IEC programme targeting adolescents and youth is implemented in the rural area, whereas all clinics providing SRH services to the target group are situated in the district town which is several kilometres away from the programme area. This can create major obstacles to access, particularly for young girls. 5.2.6 Sustainability FPAB has introduced reasonable user fees for their services, which should be affordable by adolescents and youth. The cost recovery from user fees works well. In 2002 FPAB achieved 13% cost recovery (total programme) mostly from their clinical services. No cost recovery analysis has been carried out on the youth programme. A concern is that cost recovery can create financial barriers to accessing services. Neither community nor the adolescents and youths are involved in the planning or management of FPAB services. 5.2.7 In Summary In Bangladesh, there is a clear gap in the provision of SRH services to adolescents and youth particularly to unmarried youth. The FPAB is currently running 38 clinics including satellite clinics, which mostly provide contraceptives, but in addition, they also offer counselling and STI services to the target groups. It is difficult to establish the number of adolescent and youth service recipients because the regular MIS does collect any age variables. Recently the FPAB started adolescent and youth friendly clinics once a week. However, to provide quality of care for this new initiative, the clinic staff need training on the provision of family planning services and counselling for adolescents and youth. Also barriers to access (stigma, judgemental attitudes, location of clinics and cost) need to be addressed. Since user fees have been introduced, this has become the main source of cost recovery. Monitoring equity of access to services by young people will be required. UNFPA and IPPF Evaluation: Bangladesh Country Report 70 SECTION 6: SRH INFORMATION AND EDUCATION 6.1 UNFPA In the 5CP, the Advocacy Sub-Programme aims at supporting the Government’s BCC strategy. This complements the HPSPs basic package of services and seeks to change the attitude and behaviour of people in order to improve their health status, and change the attitude of the services providers to a client-centred approach. The sub-programme was implemented through 12 component projects involving 10 ministries and one private sector association. In the MTR, the evaluation team selected four component projects that focussed on youth and adolescent SRH and the present evaluation has followed this same direction. In addition, however, we have included, as in other sections, the EC/SRHI and the UNFIP projects. 6.1.1 Relevance Evidence base for approaches 1. In 5CP, an evidence base was developed for the design of inputs into adolescent SRH IEC/BCC through a number of different channels: · BGD/05/02/01 National Curriculum Development for Population Education in the Secondary, Higher Secondary, Technical/Vocational and Madrasah Systems of Education. Under this project a KAB survey and impact study was carried out. The Impact Study showed that overall there had been a positive impact of the population education programme on various indicators among the students. However, the MTR reported a) the study on adolescent education had shortcomings as all three questionnaires (for parents, teachers and students) were too general, especially the one for students. Information gathered was unlikely to provide the required guidelines for the projects and, b) relevant stakeholders were not consulted in the process of curriculum and material development for the textbooks of the Madrasah system on basic demographic constructs in Grades 7 and 8. · BGD/05/02/05 - Advocacy on Sexual and Reproductive Health and Gender Issues through Youth Clubs Projects. An assessment was conducted to determine the attitudes, skills and relative levels of knowledge of 200 Youth Club members on population, health and income generating activities. · BGD/05/02/02 Introduction of Family Life Education through Non-Formal Education Programme. A survey was conducted with different stakeholders. Workshops were held for the development of the family life education (FLE) curriculum and good preparatory work was in place. Linkages with other partner NGOs and with UNICEF helped with the design. · BGD/01/P01 An initiative for improving the SRH of adolescent girls in Bangladesh through peer education. A workshop was organised for the relevant stakeholders. 2. Under the EC/SRHI phase I, a KAP survey was carried out on SRH needs of urban adolescents and youth in the project areas of Khulna, Kurigram, Moulivbazar and Cox’s Bazaar. The findings from the baseline surveys have been influential in the work of the Advocacy Sub-Programme in supporting the design of the BCC interventions designed for adolescents and the gatekeepers. UNFPA and IPPF Evaluation: Bangladesh Country Report 71 3. The UNF supported ASRH initiative for married adolescent girls carried out a survey that added to the evidence/knowledge base on lifestyles and behaviours among young people. More young people are sexually active than had been previously thought and few of these young people have adequate access to information, counselling and services. A needs assessment was undertaken using participatory rapid appraisal techniques with adolescents to give them an active role and sense of ownership in planning for adolescent friendly services. 4. An ARH working group with UNFPA participation carried out a baseline survey (financed by USAID) with 4000 adolescents in a number of areas in Bangladesh as the groundwork for producing IEC materials on ASRH. The study identified four categories of need for SRH information, 1) Puberty 2) HIV/AIDS 3) feelings and 4) family planning. In addition to these surveys a number of workshops and brainstorming sessions have also been organised with adolescents to help inform the work of UNFPA and their partners (see section 3.1.3) Appropriateness and relevance of information The outputs planned for the Advocacy Sub-Programme were delivered in collaboration with a number of partners, mainly in different ministries (see section 2). All the outputs were linked to projects, a number of which have directly influenced policy development and four projects were selected for review by the MTR, indicating that they were directly focused on youth. 1) BGD/05/02/01 – Population Education in the Secondary, Higher Secondary Technical/Vocational and Madras Systems of Education. This is the latest phase of the UNFPA-funded population education programme in Bangladesh. Population education has already been institutionalised in the formal school system from grade 1-10. The contents are being revised and updated in the light of the ICPD POA. The project has been extended to cover all high secondary schools, all Technical and Vocational Institutions with two year courses of studies at the Secondary School Certificate and Higher Secondary School Certificate and in the Madrasahs from grades 6-10 and grades 11and12. A massive training of trainers and teachers has been undertaken. The special needs of adolescents were addressed initially through a pilot project where parents were educated on the children’s physical, emotional and mental needs. 2) BGD/)5/02/05 Advice on Sexual Reproductive Health and Gender through the Youth Clubs. This is a project that has reached out to 402 Youth Clubs, of which 125 are female youth clubs. The curriculum on SRH and gender issues has been integrated within the existing skill development programme. Through the Project 22,260 unemployed youths were trained on SRH and gender issues, 499 Rover, Scouts and girl guides, 57 sports officers and 38 Sports Club Leaders were trained and they in turn trained 400 sports Club members. 1016 Youth club leaders of 402 youth clubs were trained. 3) BGD/05/02/02 Introduction of Family Life Education through Non-Formal Education Programme. SRH and gender curriculum and materials for NFE were developed. About 40 million are expected to be reached jointly through this project and the Total Literacy Movement. 4) BGD/01/P01 An initiative for improving the sexual and reproductive health of adolescent girls in Bangladesh through peer education. This project involved developing a model of PSE. It aimed to take forward existing initiatives in population education and family life education and general health carried out with the collaboration of GO-NGO-Youth Clubs. UNFPA and IPPF Evaluation: Bangladesh Country Report 72 The MTR for the Advocacy Sub-Programme reported a number of strengths and weaknesses in the four projects and made the following recommendations: MTR of Bangladesh 5CP on Youth and Adolescent SRH (28th April-20th May 2001) recommendations: · More of a personal, social and SRH focus in the curriculum · Use/develop teaching methodologies that are youth friendly · Try out peer education approach in formal sector for SRH education · Intensify and broaden community support · Policy commitment to Young people and ASRH needs to be clear · Young people’s participation needs to be ensured · Inter-sectoral links need to be reinforced and expanded In general the MTR was very positive about the extent of the coverage of the different projects and the introduction of a SRH component into a programme that covers 40 million, youth, adolescents and adults. In terms of the influence of this work on policies and legislation, it is clear that the work of the Advocacy Sub-Programme has succeeded in initiating an expansion of the knowledge base on SRH that will have implications for adolescents and youth. The Advocacy Sub-Programme IEC work has been assessed for appropriateness, to some extent, through the different evaluations and reports of the different components. The appropriateness of some of the training information is summarised below: · BGD/05/02/01 National Curriculum Development for Population Education in the Secondary, Higher Secondary, Technical/Vocational and Madrasah Systems of Education. There are three and a half pages of comments, remarks and recommendations in the MTR, but in summary the report said “the issues dealt with address ICPD priorities. These include gender issues, environmental concerns, needs of adolescents, delayed marriage, HIV/AIDS, male involvement in SRH, RRs of all but particularly girls and women. Admittedly however, some of the content would benefit from greater depth and specificity”. · BGD/05/02/05 - Advocacy on Sexual and Reproductive Health and Gender Issues through Youth Clubs Projects. BGD/05/02/05 - Advocacy on SRH and Gender Issues through Youth Clubs Projects. The MTR reported the training course content and materials contained messages that addressed the ICPD priorities and that the project had had a positive impact on bringing behavioural change to the youth and adolescents of the project area. The success of the intervention has led to thousands of Youth Clubs in Bangladesh requesting to be included in this project. · BGD/05/02/02 Introduction of Family Life Education through the Non-Formal Education Programme. The evaluation concluded that the project was successful and that appropriate and relevant information on family planning, perceptions of education, keeping accounts, empowering women and health care were disseminated to the target groups. However, the MTR did point out that the some messages were given to all age groups (11-45 years) with no special messages developed for adolescents. · BGD/01/P01 An initiative for improving the SRH of adolescent girls in Bangladesh through peer education. This project was in an early stage of development at the time of the Review. UNFPA and IPPF Evaluation: Bangladesh Country Report 73 · EC/SRHI appeared to be appropriate and an exciting initiative carried out in collaboration with a number of NGOs. · UNF also appeared to be an appropriate pilot intervention carried out with NGO collaboration with married adolescents. The appropriateness of the IEC materials was assessed partly though field visits by the ET (though to a very limited extent due to time constraints), through discussions with training staff on field visits, through secondary source evaluation (the MTR) and through the In- Country Study carried out by the Evaluation Unit at BRAC (see Appendix for a list of the materials produced by UNFPA and with UNFPA support through NGOs). A large number of adolescents and youth have been reached through the curriculum development strategy for youth in Secondary, Higher Secondary, Technical/Vocational and Madrasah Systems of Education, Youth Clubs and the non-formal system. However, there is little evaluation of the materials produced and the impact of the curriculum development. Questions have been raised concerning the capacity of teachers to teach SRH including sexuality. The MTR states that “the contribution of the in-school project to bring about positive attitudes and behavioural changed among adolescents and youth in the formal school system of matters related to SRH and gender has been very limited. In the In-Country study on IEC, the team did not find anyone who referred back to the school textbooks as a source of information on SRH. Moreover, the young people said that one of the ways they would prefer to get information on SRH is through textbooks. Most of the youth contacted referred to messages on the TV, messages in books in the hands of health workers and posters on the walls of hospitals and clinics. The Study collected a range of IEC material and concluded that some IEC material appeared appropriate to the diverse needs of young people. Good practice - The EC/SRHI together with FPAB have designed a small SRH booklet to fit in a shirt pocket, the result of FGD with youth. To summarise it appears that the information needed by adolescents must be designed for communication in a transitional society where the older members, parents, teachers and community leaders are relatively conservative and at the same time, there is a growing body of youth who watch Sky channels and use the Internet. The training programmes and the IEC/BCC materials produced have to be approved by the GoB, who are aware of the needs, on the one hand, of modern day youth and, on the other hand, the levels of acceptance and tolerance of the more conservative elements in the community. Thirdly, while designing appropriate materials for adolescent and youth SRH attention needs to be paid to those selected to teach the new curriculum inputs Contribution to coherent polices and programmes The contributions of UNFPAs work with GoB policies in relation to youth and SRH, have been made through the different projects outlined in the first section of this chapter. These projects were entirely relevant and appropriate for the GoB policies on population, education and health. UNFPA support to the Advocacy Sub-Programme and its components include activities in 12 projects and a private sector initiative. These projects include a complex and varied programmes of training, curricula development, Youth Group events, group motivational UNFPA and IPPF Evaluation: Bangladesh Country Report 74 meetings, mass media events, including singers and poets, rallies, quiz events, national day events, and volunteer worker motivators orientation on Advocacy, SRH and gender and the production of IEC materials. The Advocacy Sub-Programme documents reviewed seemed relevant to the work of addressing young people’s diverse needs and were in line with the goals set out in ICPD and the POA. 6.1.2 Integration of Rights All the projects, reviewed (see section 6.1.2 above) had made attempts to integrate the ICPD concepts of gender equity, women’s empowerment, SRH, and age of marriage into curricula and courses. The integration of RRs into the IEC/BCC materials varied considerably with, for example, the success of the Gender and SRH manual on the one hand, and the relatively poor depiction of rights in the posters reviewed in the IEC/BCC In-Country study on the other. 6.1.3 Capacity Competencies and skills of UNFPA staff The large and complex programme of activities and initiatives in IEC/BCC requires a highly competent staff to work with motivated and competent partners. This work is at the cutting edge and needs the best skill mix available to produce the planned outputs. It appears that the strength of the Advocacy Sub-Programme is a combination of good skill mix and collaboration with a wide range of motivated partners. While UNFPA competencies and collaboration with partners are in place for optimal results, there is a need to include young people in the design, planning and implementation of these programmes and projects. However, the role of young people in a hierarchical and powerful UN organisation is limited, and as stated earlier, adolescents and young people are not a homogeneous category. Recognising this, the CO has evolved a variety of mechanisms to bring young people on board in the planning processes (see 3.1.3). One method of involving young people in the process has been to invite young people to a UNFPA sponsored brainstorming session, to develop a Youth Forum. This is a good initiative. However, the most effective way of approaching and involving youth may be through the NGOs who have a less hierarchical organisational structure and are experienced in doing poverty rural assessment and running FGDs in a non-threatening environment. The skills and competencies of UNFPA staff appear optimal. The NPPPs have degrees related to their areas of work, as well as several years of experience in the field. Moreover a continual process of learning is underway with workshops planned throughout the year. The NPPP in charge of Youth is both qualified and experienced in the area of BCC and Adolescent SRH. He has collaborated with USAIDs BCC cell where research and collaboration led to the production of some generic BCC materials that are replicated and used by different NGOs. A major recommendation of the MTR was that a full-time specialist on adolescent SRH is appointed or a consultant employed. It also recommended consultations with medical professionals, adolescents and parents. This recommendation has been addressed. Peer educators Peer educators have been included in the activities of the 5th CP Advocacy Sub-Programme, BGD/05/02/5 Youth Clubs Project under the Ministry of Youth and Sports. However, this UNFPA and IPPF Evaluation: Bangladesh Country Report 75 programme appeared ad hoc, for example, the training provided to the peer educators was 2 days, which the MTR pointed out as being insufficient, and the training given to the youth a “one stop” approach. The programmes are still being developed, very much on “trial and error basis”. There is no systematic monitoring and evaluation system in place. Discussions between the ET and the Ministry of Youth and Sports indicated that further input was required in terms of training. The ET’s observations at the BGMEA SRH session was that the peer educators were also insufficiently trained and that the garment workers who were interested in the topic were demanding more information than was available. Peer educators have also been trained in the EC/UNFPA funded project in four Upazillas. This project is more closely monitored. 6.1.4 Efficiency IEC materials and pre-testing/monitoring Under some of the projects IEC/BCC material for youth have been pre-tested and produced and distributed in a timely fashion. The MTR for the 5CP, reported an acute shortage of all IEC materials both in print and electronic media. The messages are very general and not audience specific. They did not make a comment on youth specific IEC. Youth involvement Adolescents and youth have been involved in the surveys and baseline studies. There are also a number of examples of adolescent and youth involvement in the identification of IEC needs in the 5CP (see section 3.1.3). Cost effectiveness There was insufficient time to evaluate the cost effectiveness of the 5CP sub-programme on Advocacy, which is highly complex, linking back to previous CPs and with its current activities based on numerous projects. In relation to IEC materials, UNFPA has produced a useful bibliography, categorising materials by topic, audience and by medium. This could be considered a cost-effective intervention if it prevents duplication in the country. In general though, statements were made to the ET that the climate for discussion and interventions on adolescent and SRH has changed and that work with adolescents is now possible, whereas at the time of the ICPD this was not the case. 6.1.5 Effectiveness Acceptability and Effectiveness of IEC/BCC approaches The acceptability of the IEC/BCC materials produced has been at the heart of the planning process of the Advocacy Sub-Programme. The mandate of the ICPD and POA, has been to introduce concepts and ideas that were new into a society that was unprepared. While it appeared that the adolescents and youth expressed a need for both information and services for SRH, the preparatory work with the gatekeepers needed to be the first step and needed to be taken cautiously. UNFPA and IPPF Evaluation: Bangladesh Country Report 76 There have been major changes in what is acceptable over the last few years. For example, during the evaluation, a condom promotion appeared on TV for the first time in the history of Bangladesh. In terms of effectiveness the MTR provides a categorisation of youth and their IEC/BCC needs: 1. Youth in formal schooling, technical and vocational training and in the Madrasah system are covered by the Programme. 2. For those who have dropped out of schooling, the NFE is provided through the MoE with support of UNFPA where a SRH component called Family Life Education has now been integrated. This programme combined with the Total Literacy Movement of the GoB, covers about 40 million youth, adolescents and adults. 3. A number of out of school youths are educated and informed about SRH and gender issues through the Youth Club programmes. Providing knowledge and information to young people is done in the belief that this information is wanted and needed and there is evidence of behaviour change in areas where projects have been running for long enough to assess their impact. 6.1.6 Sustainability Financial The work of the Advocacy Sub-Programme is a core part of the UNFPA country programme and adolescent and youth activities will receive more attention (and hence an increased budget) in the 6CP. There are also unspent funds in the Global Programme on HIV/AIDS for further youth work. Capacity Development Capacity development in IEC/BCC as a means of promoting sustainability was a central part of 5CP. The CO assisted the GoB programme in strengthening the country’s capacity to support adolescents and youth through the National Curriculum Text Book Board which included SRH matters in the formal school curriculum including the Madrasha and technical streams. In additional out-of-school youth have been accessed through the Ministry of Primary and Mass Education. In addition, to projects targeting youth and adolescents, IEC material, teachers, government and NGO officials have been trained in population education issues. Support was also provided to the BCC Unit for improving technical and management capacities and the support to this will continue in 6CP. This is expected to enhance the Unit’s capabilities to provide required technical support to other agencies/Ministries linked with BCC/advocacy activities addressing the SRH of adolescents and youth. A second area of capacity building has been the support to capacity development in the PD sub-programme, where the strategy has been to develop local capacity to research and inform GoB and the NGO and private sectors about matters relating to the SRH of adolescents and youth, amongst other issues. Joint work with partners UNFPA has worked with a wide range of partners including Ministries (Education, Youth and Sports), NGOs and the private sector (see section 3.1.1), thus promoting sustainability. UNFPA and IPPF Evaluation: Bangladesh Country Report 77 6.1.7 In Summary Under the 5CP Sub-Programme on Advocacy, three main IEC/BCC projects for adolescent and youth SRH have addressed major issues and changes since the ICPD. Firstly, youths in school (Secondary, Higher Secondary, Technical/Vocational and Madrasah System) have been reached with a major input into curriculum development where SRH and rights have been incorporated into the Population Education component. Secondly, for adolescents and youth who have dropped out of school, a major input has been made through the NFE provided by the MoE with support from UNFPA where a SRH component called Family Life Education has now been integrated. Thirdly, a number of out of school youths are reached care of through advocacy on SRH and gender issues, through Youth Clubs. At the same time a number of innovative approaches have been developed through the work of the EC/SRHI and the UNF work with married adolescent girls. While these represent quantitative improvements, the more qualitative aspects of skills, competencies and impact of the teachers/peer educators still seem to be weak and an area that will need monitoring in the future. 6.2 FPAB 6.2.1 Relevance The FPAB primarily focuses on promoting SRH information and education in the community. It started to provide SRH and family planning to adolescents and youth in 1980. In 1992 it incorporated SRH education into its youth programme. After ICPD in 2000 FPAB conducted a need assessment with an outside consultant. The needs assessment findings indicated the following: · Appropriate BCC materials need to be designed and used to impart messages effectively · Capacity building should be strengthened · Mobile clinical services should be set up · The message that early marriage is illegal should be emphasised Following on from this in 2001, the team conducted an operational research project in two project areas and found that early marriage was still prevalent, there was a gap in knowledge about reproductive organs, sexual behaviour and abuse of sexuality (e.g. rape, teasing, exhibitionism). However, there was widespread knowledge concerning HIV/AIDS in the areas. The research also found that girls were more knowledgeable than boys in relation to most sexual and SRH information. The same findings were also described in another joint study conducted by Save the Children Fund and UNFPA (see also sections 5.1.1 and 6.1.1). Although majority of respondents have high school level education the level of knowledge concerning issues around puberty was low. The findings also indicated a level of pre-marital sex and extra marital sex occurred in the community. Findings of the baseline study conducted by UNFPA and SF-UK in project areas, Khulna, Kurigram, Moulivbazar and Cox’s Bazaar. · Signs of puberty o 43% mentioned the growth of beard and moustache as o 56% body maturity o 53% mentioned menstruation (84% girls, 18% boys) UNFPA and IPPF Evaluation: Bangladesh Country Report 78 · 71% girls were not aware of menstruation before menarche · 65.5 % respondents are interested to know about sex related issues · 47% boys and 19.5% girls know somebody who had premarital sex · 28.8% boys and 14% girls know somebody who had extra marital sex. FPAB has been running adolescent and youth programmes in 70 rural unions (population- 20,000 to 40,000 in one union) with 140 youth organisers (70 male and 70 female) involved. In each union 10 youth leaders (5 male and 5 female) have been trained as peer leaders. FPAB has tried to address the diverse needs of young people and provides appropriate information to the target groups (see also review of IEC materials conducted as part of the In-Country Studies). The IEC/BCC topics on SRH are wide ranging and include information on: · signs of puberty · reproductive organs · STI/HIV. FPAB uses a multi media approach for adolescents and youth including posters, leaflets, a TV serial, a radio talk show, and also video materials for training. The TV spot on SRH issues made by FPAB was very interesting and links with information from FGDs that indicated TV is one of the best forms of media to provide information. Books are only by the literate groups, whereas TV can reach any audience. However, the last TV spot delivered by FPAB was 1997. The quality and contents of video materials prepared by FPAB is good, however there is a major limitation. Video cassette recorders are not always available in rural areas and in many places in Bangladesh either there is no electricity or regular electricity supply. Field staff mentioned that videos are used in different education session but two clubs visited by ET had no electricity supply, so the video materials are have their limitations. The posters have the advantage that an illiterate person can look at the picture and understand the message. However, often posters cannot be displayed for long periods time as they become torn or damaged. Often at the field level, they do not have a reliable supply of posters, books and leaflets to replace lost or damage ones. One of the most effective measures taken by FPAB has been the addition of religious quotations. Some materials contained verses (and explanations) from the Holy Quran and Hadith related to planned pregnancy and family responsibilities. Another very unique approach pioneered by the FPAB is their work through the Islamic Research Cell (IRC), which was started in 1984. The IRC works with religious leaders and students in the religious education system to ensure their participation in SRH education. FPAB has introduced SRH education in the Madrasah school system, which is a remarkable achievement. The IRC uses verses from the Holy Quarn and Hadith in their IEC materials to raise awareness amongst the adolescents and youth in the religious education system. The FPAB also works in girls Madrasah schools and has motivated girls attending the Madrasah to become youth organisers and youth leaders. Crossing the barrier to talk about SRH issues in Madrasah and bringing the young girls to attend the session in a public club is one of the major strength of the programme, as the Madrasah community is normally not in favour of NGO activities. The majority of the Madrasah students come from poor communities and illiterate families who have less access to proper information and are prone to engage in early marriage, the lower use of contraceptives, and less accessing of maternity care etc. Expanding the programme in the religious education system will help to increase awareness among these vulnerable youth groups. UNFPA and IPPF Evaluation: Bangladesh Country Report 79 Another innovative strategy is the debate competition on SRH issues in the schools and colleges. FPAB appears to have an excellent relationship with the community leaders, religious leaders and parents. 6.2.2 Integration of rights RRs are discussed in relation to SRH issues, however, the ICPD components in RRs are not addressed directly as a phrase or concept. No IEC material contained any information on RRs. 6.2.3 Capacity Competencies and skills of the FPAB staff FPAB staff are highly motivated, committed to the organisation and appear to be hard workers. However, there is a lack of capacity building and training within the organisation related to adolescent and youth SRH. It seems that no one in the organisation has received any exclusive training on adolescent and youth, although several members of staff have attended a SRH training including an adolescent and youth component along with other topics. Training of peer organisers and counsellors Youth organisers selected prior to 2000, received 7 days training on SRH. However, after 2000 funding has only been available for 2 day refresher training for the newly recruited youth organisers. This appears to be insufficient. There is no regular refresher training for youth organisers and youth leaders. Counselling training is not part of the training programme limits its quality. Given that adolescent and SRH is a new and sensitive issue in Bangladesh, both staff and volunteers (youth organisers and youth leaders) require more training to develop their capacities and skills. The high drop out rate of female youth organisers and youth leaders is also another shortcoming of the programme. There is currently no strategy to replace peer organisers who drop out. Female peer educators in particular often get married leave the projects, and in some areas male peer educators leave for higher education or a new job. The reason given for lack of replacement of peer educators, was lack of funding to continue the training. However, this could be overcome with a strategy that involved providing training of trainers (TOT) to FPAB workers or youth and continuing the training at the local level. There is a need for regular monitoring to find out peer educator drop out levels. 6.2.4 Efficiency The IEC materials developed by FPAB are very simple (mostly in Bangla), easy to understand and contextually relevant. As mentioned by the IEC study conducted as background material for this evaluation, the FPAB has used local languages in many of their materials which is very easy for people to understand. They are pre-tested and produced and distributed in timely fashion. However, they were not produced in sufficient quantities and many programme areas do not have all IEC materials they require. In addition, regular monitoring of the materials and staff training is weak which influences the quality of the programme. The FPAB regularly involves adolescents and youth before designing the materials. They pre-test and review the IEC materials, although they are not involved in monitoring the programme. The current information system does not allow for monitoring of the quality of the programme. The information from the baseline UNFPA and IPPF Evaluation: Bangladesh Country Report 80 study and operational research conducted in 2000 and 2001 respectively, should have been used effectively to develop a ‘evidence base programme’ to improve quality. Discussions with the adolescents and youth reveal they prefer IEC materials such as video films, audio cassettes, booklets but these are not available in many areas. The findings of the operational research study coincide with the findings of the present ET and include the following: · Capacity building should be strengthened · Mobile clinical services for adolescents and youth should be organised · The illegality of early marriage should be emphasized 6.2.5 Effectiveness The strategy declared by FPAB to disseminate SRH education to adolescents and youth is not very effective. Trained youth organisers and youth leaders conduct a ‘one stop’ educational session on SRH for 2 to 4 hours. One stop sessions for such an important and sensitive topic covering a wide range of issues is not adequate for the target group, if they are to understand and assimilate the information. Moreover, no regular refresher courses are conducted to repeat the topics. The learning materials supplied to the field level were often insufficient; some clubs ET visited could not find any book or leaflets other than a few posters. The TV spot is very effective but it is not continuing. The TV spots should be a re-run and a regular supply of books and leaflets should be assured. The results of the FGDs with youth conducted as part of the In-Country Studies suggested that retention of messages and information was very weak. Although the acceptability of the materials is high, it was found that young people wanted more pictorial or visual materials and repeated educational sessions on SRH. 6.2.6 Sustainability FPAB has received a substantial amount of money from donors and governments and has incorporated these funds into the regular youth programme (table 5). Table 5 Funds received for the Adolescent and Youth EC/UNFPA (3 years) .……… . – $ 375,000 GoB ……… . . ……… . - $ 2,012 Japan International Cooperation (1 year) ……………… - $ 2,900 Agency and Japanese Organisation for International Cooperation in Family Planning In addition, FPAB also uses the funds to address youth and adolescents through other programs like the newly wed seminar, the IRC and the prevention and control of HIV/AIDS/STI. FPAB should share their innovative strategies like the debate competition and their work through the IRC with other organisations and the government to promote SRH in adolescents and youth in the community. 6.2.7 In Summary FPAB provides SRH education to the community and has an excellent reputation and acceptance level amongst the gatekeepers and young people. Through their innovative approaches like the IRC and the debate competition they have been able to reach different UNFPA and IPPF Evaluation: Bangladesh Country Report 81 target groups (in school, out-of-school and students in religious system). A key challenge (as identified above in section 3.2 is to improve co-ordination with partners (government and NGO), share successful experiences such as the work with girls in Madrasah schools, and promote wider replication. In the SRH IEC programme, RRs are not included. In their implementation strategy, ‘one-stop’ education sessions to provide SRH information are inadequate. There needs to be capacity building and training on adolescent and youth SRH within the organisation to make the programme more effective. The FPAB IEC materials are simple and easy to understand but there is an inadequate supply of these materials to the community.