Human and Economic Impact of Reproductive Health Supplies Shortage and Stockouts in Bangladesh: Final Report

Publication date: 2009

Dhaka: August 2009 Abul Barkat Murtaza Majid, Azizul Karim Shahadat Hossain Siddiquee, Mir Nahid Mahmud Prepared for Family Planning Association of Bangladesh (FPAB) Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh PDF processed with CutePDF evaluation edition www.CutePDF.com Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh Prepared by Abul Barkat1 Murtaza Majid2, Azizul Karim3, Shahadat Hossain4, Mir Nahid Mahmud5 House 5, Road 8, Mohammadia Housing Society, Mohammadpur, Dhaka–1207, Bangladesh Phone: (8802)8116972, 8157621, Fax: (8802)8157620 E-mail: hdrc@bangla.net, hdrc.bd@gmail.com; Website: www.hdrc-bd.com Prepared for Family Planning Association of Bangladesh Date: August 10, 2009 _______________________________________________ 1 Professor & Chair, Department of Economics, University of Dhaka 2 Director Health, Human Development Research Centre 3 Retd. Division Chief, Planning Commission and Consultant HDRC 4&5 Lecturer Department of Economics, University of Dhaka i Acknowledgement Reproductive Health is one of the crucial parts of the Health and Family Planning Sector of Bangladesh. Under the current Health, Nutrition and Population Sector Program (HNPSP) of Bangladesh, health and population are managed separately. In HPNSP, the services like Family Planning, MR, Emergency Obstetric Care (EOC) and supply of medicines of DDS kits (Kits for MCH services) are also included in RH services and managed through almost the same manpower and facilities of family planning. Although there has been a great achievement in family planning knowledge, attitude and practice– the current population is around 150 million with 56% contraceptive prevalence rate (CPR) and 2.7 TFR. Although CPR was always increasing, this is the first time when there is a decreasing trend in CPR. Incidence of stock-out/shortage/irregular supply, shortage of manpower at field level, irregularities in local level monitoring and reporting, shortage of trained procurement staff, and the World Bank’s procurement and supply process consuming 16-18 months and even more following 19 steps have been identified as major causes behind it. The World Bank consortium supports by providing fund for procurement of various RH commodities. The main problem about RH commodities management is that the procurement system is quite complex and time-consuming. For the last one and half years, condom, oral pill, injectables, implants and IUDs were short in supply for some times - both through the public, as well as private distribution channels. It has caused unintended pregnancy, preventable illness, unnecessary sufferings and death. The discontinuation in supply affecting the contraceptive prevalence rate (CPR), total fertility rate (TFR), increasing the maternal mortality and morbidity, and ultimately bearing on the quality of MCH-FP services in the country. There has been a substantial human impact, affecting national economy and poverty alleviation initiatives. For this purpose, Project Resource Mobilization and Awareness (PRMA) had decided to conduct a study to ascertain the impact of shortage/stock- outs/irregular supply of RH supplies, especially- Contraceptives and DDS kits on human aspect as well as national economy. Another aspect of the study was to examine the sufficiency of allocation/release of funds vis a vis needs of RH supplies for ensuring adequate and need-based service delivery. Project Resource Mobilization and Awareness (PRMA), a project of Family Planning Association of Bangladesh (FPAB), the IPPF member association in Bangladesh is working to narrow the demand-supply gap in RH supplies. It will initiate advocacy program to the government policy level to ensure regular and adequate supply of RH supplies including contraceptives. This study provides an overall scenario of the major contraceptive users (pill, injectables, and condom) and the sufferers of shortage/stock outs/irregular supply; and its impact and cost at personal level, at FWA level and finally at national level. The study also forwards relevant suggestions and ii recommendations for improvement of the situation through different new activities at local and managerial level of government, regularization of monitoring, more involvement of NGOs, and simplification of the procurement mechanism. We, at the Human Development Research Centre (HDRC) are first and foremost thankful to PRMA, FPAB and IPPF for assigning the responsibility to undertake the study. We are grateful to Dr. Jahir Uddin Ahmed, Acting Director General, FPAB for his very timely decision about the urgency to conduct such study to improve the reproductive health situation in the country. We express our deep sense of gratitude to Dr. Ataur Rahman (IPPF/SARO, Delhi, India), Mr. Pradeep Patro (IPPF/SARO, Delhi, India) and Mr. Gias Uddin (Unit Head, PRMA, FPAB) for their heartfelt cooperation and professional support during the study. We are immensely indebted to Mr.Dhiraj Kumar Nath (National Adviser, PRMA, FPAB) and Md. Nurul Hossain (RH Specialist and Consultant, PRMA, FPAB) for being with us throughout the study – always with constructive suggestions towards improving the methodology and analysis of the study findings. Suggestions forwarded by all the stakeholders have been useful in finalizing the study recommendations. We express out debt to concerned officials, especially to Mr. Abdul Quaiyum, Director General, Family Planning (DGFP), Dr. Jafar Ahmed Hakim (Director, MCH-FP), Mr. Abdullah-al-Mohsin Choudhury (Director, Finance, DGFP), Mr. Ganesh Chandra Sarker (Director, IEM, DGFP), and Dr. Taposh (Assistant Director, CCSDP, DGFP). We are thankful to Dr. Mujibul Hoque (Deputy Director, Family Planning, Tangail), Sajida Khatoon ((Deputy Director, Family Planning, Comilla), Bishwanath Bagchi (Deputy Director, Family Planning, Bogra), Mr. Lutfor Rahman (Deputy Director, Family Planning, Barisal), Mr. Saidur Rahman (Deputy Director, Family Planning, Jessore), Mr. Mozammel Hoque (Deputy Director, Family Planning, Sunamgonj) and others who attended the group discussions in districts of Tangail, Comilla, Bogra, Sunamgonj, Barisal, and Jessore. We are indebted to all UFPOs and FWAs who have helped our field team in conducting the study. We are highly indebted to the Female and Male users of contraceptives and the sufferers who have participated in various interviews and FGDs for their critical views and high utility suggestions forwarded to improve upon the relevant situation. We are grateful to Mr. Shankar Lal Baroi, former Consultant of HDRC for his sharing of real field experiences, views, and insights while preparing the data collection tools, training of the field associates, and compilation of qualitative information. iii We are indeed grateful to the dedicated staffs of HDRC and field associates who were involved in the data collection process. We thankfully acknowledge them for their sincerity, hard work and team spirit that helped the study to depict a real picture of the research questions. We are thankful to all the in- house staff of HDRC for their steady and sincere efforts throughout the study. Finally, thanks are due to those female and male users and sufferers whose experiences and suggestions were indeed the basis of the study. All our efforts in the study will be fruitful if the study findings help the concerned authorities in taking appropriate measures to lessen the sufferings of users of contraceptives and MCH services, especially women in reproductive age. Abul Barkat, Ph.D Dhaka: August 10, 2009 Team Leader Abbreviations ADP Annual Development Program BDHS Bangladesh Demographic and Health Survey CIDA Canadian International Development Assistance CPR Contraceptive Prevalence Rate CWH Central Warehouse DDS Drug Dietary Supplement DGFP Directorate General of Family Planning ELCO Eligible Couples EOC Emergency Obstetric Care EPI Expanded Programme on Immunization FGD Focus Group Discussion FPAB Family Planning Association of Bangladesh FWA Family Welfare Assistant GD Group Discussion GDP Gross Domestic Product GOB Government of Bangladesh HDRC Human Development Research Centre HNPSP Health, Nutrition and Population Sector Program ICB International Competitive Bidding IDA International Development Agency IMR Infant Mortality Rate IUD Intrauterine Contraceptive Device KII Key Informant Interview MCH Maternal Child Health MCH-FP Maternal Child Health-Family Planning MCWC Maternal Child Welfare Centre MDG Millennium Development Goal MMR Maternal Mortality Rate MoH&FW Ministry of Health and Family Welfare MR Menstrual Regulation MTBF Medium Term Budgetary Framework MWRA Married Women of Reproductive Age NFR Net Fertility Rate NGO Non-Government Organization NMR Neonatal Mortality Rate PRMA Project Resource Mobilization and Awareness QCO Quality Control Officer RADP Revised Annual Development Program RH Reproductive Health SDP Service Delivery Point TFR Total Fertility Rate TQM Total Quality Management UFPO Upazila Family Planning Officer UFWC Union Family Welfare Centre UHC Upazila Health Complex UNFPA United Nations Population Fund WHO World Health Organization I CONTENTS Sl. No. Title Page # Acknowledgement Abbreviations Executive Summary . i-vii CHAPTER I: BACKGROUND, OBJECTIVES AND METHODOLOGY.1 1.1. Introduction .1 1.2. The RH Drug Availability Scenario in Bangladesh .1 1.3. Objectives of the Study.3 1.4. Methodology .3 1.4.1. The Study Design.3 1.4.2. Methods of Data/Information Collection .3 1.4.3. Sample Design .4 1.4.4. Analysis Plan: Descriptive and Inferential Analyses.5 1.4.5. Study Implementation .6 CHAPTER II: CURRENT SYSTEM OF PROCUREMENT, SUPPLY AND MONITORING OF REPRODUCTIVE HEALTH COMMODITIES .10 2.1. Introduction .10 2.2. System of Procurement of RH Commodities .10 2.3 System of Supply and Distribution .12 2.4. Alternative System of Collection of RH-FP Commodities in the event of Shortage of Supplies .13 2.5. Monitoring System and Forecasting of Stock-out/Shortages .13 2.6. Status of Stock-out/Shortages of RH Commodities during the last one year according to Service Providers and Field Managers .13 2.7 Causes of Stock-out/Shortage of RH Commodities according to Service Providers and Field Managers .14 CHAPTER III: USERS AND SUFFERERS OF ORAL PILL, INJECTABLE AND CONDOM: OFFICIAL DATA VS FIELD REALITY.15 3.1. Discrepancy in Number of Users: Official Data Vs Field Reality.15 3.2. Discrepancy in FWA Registers and Primary Interview Findings .16 CHAPTER IV: DEMOGRAPHIC AND SOCIO-ECONOMIC CHARACTERISTICS OF USERS AND SUFFERERS OF CONTRACEPTIVES.22 4.1. Introduction .22 4.2. Age Distribution of Sample Users and Members of Suffering Households.22 4.2.1 Distribution of the members of the suffering households .23 4.3. Educational Status of Members of Suffering Households.23 4.4. Occupational Status of the Members of Suffering Households .23 4.5. Economic Conditions of the Suffering Households .24 4.6. Income .25 CHAPTER V: IMPACT ON INDIVIDUALS/HOUSEHOLDS DUE TO SHORTAGE/ STOCKOUT/IRREGULAR SUPPLY OF CONTRACEPTIVES .26 5.1. Introduction .26 5.2. Contraceptive Practice of Three Major Contraceptives during Last One Year .26 II 5.3. Sufferer Situation of Shortage/Stock-out/Irregular Supply .26 5.3.1. Percentage of users who didn’t get timely service due to shortage/stock-outs/ irregular supply .26 5.3.2. Number of times suffered from shortage/stock-out/irregular supply .27 5.3.3. Percentages of users who had problems/sufferings due to shortage/stock-out/ irregular supply and Sufferers by methods .27 5.3.4. Pregnancy and related problems (Delivery, Abortion, MR) due to shortage/ stock-out/ irregular supply.28 5.3.5. Method changed and number of times changed due to the problem of shortage/stock-out/irregular supply .29 5.4. Sources of Supply of Contraceptives for Sufferers .30 5.5. Distance of Contraceptive Supply Source, Time and Cost of Transportation.30 5.6. Various problems/sufferings and loss of time due to shortage/stock-out/irregular supply .31 5.6.1. Physical /health sufferings and problems.31 5.6.2. Physical/health sufferings and problems by methods .32 5.6.3. Psychological sufferings and problems .34 5.6.4. Psychological sufferings/ problems by methods .35 5.6.5 Sufferings and problems in income generating activities (IGAs) .36 5.6.6 Sufferings/problems in income generating activities by methods.36 5.6.7 Sufferings and problems of household works and family care .37 5.6.8 Sufferings/problems in household activities by methods.37 5.6.9 Sufferings and problems in social work.38 5.6.10 Sufferings/problems in social activities by methods .39 5.6.11 Alternative practices in users in case of problem in supply .39 5.7. Average hours lost due to shortage/stock-out/irregular supply .40 5.8. Average income lost due to shortage/stock-out/irregular supply.41 CHAPTER VI: IMPACT ON NATIONAL ECONOMY DUE TO SHORTAGE, STOCK- OUT AND IRREGULAR SUPPLY .43 6.1. Introduction .43 6.2 Impact on National Economy due to Shortage/Stock-out/ Irregular Supply of Oral pill, Injectables, and Condom.43 6.2.1 Estimation methodology .43 6.2.2 Direct Loss of Income at the National Level.43 6.2.3 Medical Cost of suffering at the National Level .44 6.2.4 Estimation of loss from physical or health related problems at the national level .45 6.2.5 Loss from psychological health problems at the national level .45 6.2.6. Loss from income generating activities at the national level .46 6.2.7 Loss from household activities at the national level .47 6.2.8 Loss from social activities at the national level .47 6.2.9 Total national loss by broad components.48 6.2.10 Unexpected pregnancy, MR and abortion at the national level due to shortage/stock-outs/irregular supply .48 CHAPTER VII: ADEQUACY OF FINANCIAL SUPPORT FOR AND PRIORITY OF NATIONAL HEALTH NUTRITION AND POPULATION SECTOR.49 7.1 Health Nutrition Population Sector Programme .49 7.2 Trend Analysis of Allocation and Utilization of Fund .49 III 7.3 Trends in Allocation, Expenditure on Contraceptives and DDS kits: FP sub-sector under HNPSP .50 7.4 Adequacy of Fund for National RH-FP Programme: FP sub-sector.53 7.5. Findings and Lessons Learnt.54 CHAPTER VIII: CONCLUSIONS AND RECOMMENDATIONS .55 8.1 Conclusions .55 8.2 Highlights of Some Field Problems Observed During Field Investigation .56 8.3 Recommendations .56 8.3.1 Sufferer’s opinion about shortage/stock-out/irregular supply for improving the present situation .56 8.3.2 Suggestions and Recommendations of the Service Providers and Managers for Improving the Present Situation .57 List of Figures Figure 1.1: Triangulation of findings with the district level managers and others .6 Figure 2.1: Procurement Spiral of Activities .11 Figure 2.2: Flow Chart of FP Contraceptives Commodities Supply .12 Figure 3.1: Discrepancy between FWA reporting and field survey in terms of share of sufferers of three methods.15 Figure 3.2: User-Sufferer Tree (oral pill, injectable, condom) .17 Figure 4.1: Distribution of household members of sample users from FWA register by marital status .23 Figure 4.2: Distribution of household members of sample users by educational status .23 Figure 4.3: Distribution of household members of sample users whether they can sign .23 Figure 5.1: Distribution of actual users by methods .26 Figure 5.2: Status of sufferings and distribution of sufferers by methods.28 Figure 5.3: Unexpected pregnancy and related outcomes of the sufferers .28 Figure 5.4: Distribution of sufferers by changing methods .29 Figure 5.5: Distribution of sufferers by their reported broad type(s) of sufferings (%) .31 Figure 6.1: Percentage distribution of income loss of the sufferers by methods .44 Figure 6.2: Share of medical costs incurred by categories .44 Figure 6.3: Percentage distribution of loss from psychological sufferings/problems .46 Figure 6.4: Share of loss from household activities .47 Figure 6.5: Share of loss by different items .48 Figure 6.6: Share of total loss by broad categories (in million Tk.).48 List of Tables Table 2.1: Month-wise number of Upazilas and Service Delivery Points (SDPs) experienced stock-out of condoms, oral pill and injectables: November 2007 to October 2008 (No monthly report was available for 4 months).14 Table 3.1: Discrepancy in facing stock-out/shortage/irregular supply by methods: FWA record vs field reality .16 Table 3.2: Percentage distribution of real users of 3 contraceptives (pill, injectables and condom) and non-users .16 Table 3.3: Discrepancy in number of users (oral pill, injectable, condom): FWA Register (reporting) vs Field Reality .18 Table 4.1: Percentage distribution of the sample users by age .22 IV Table 4.2: Percentage distribution of the household members of sample users by age .22 Table 4.3: Percentage distribution of the household members of sample users by education by sex .23 Table 4.4: Distribution of the occupational status of the members of suffering households .24 Table 4.5: Status of suffering households by socio-economic condition .24 Table 4.6: Percentage distribution of the household members of sample users from FWA register by income categorization.25 Table 5.1: Distribution of users by status of getting contraceptive supply/service .27 Table 5.2: Distribution of users by methods who did not had the supply/service in time .27 Table 5.3: Distribution of the sufferers by numbers times suffered due to shortage/stock-out/irregular supply.27 Table 5.4: Percentage distribution of sufferers by method change/switch .29 Table 5.5: Method switch matrix associated with shortage/stock-out/irregular supply.29 Table 5.6: Distribution of sufferers by number of times changed method from pill .29 Table 5.7: Distribution of sufferers by number of times changed method from injection .30 Table 5.8: Distribution of sufferers by number of times changed method from condom .30 Table 5.9: Distribution of sufferers by use of health care facilities .30 Table 5.10: Percentage distribution of sufferers by use of health care facilities and distance, time spent and transportation cost .30 Table 5.11: Pattern of physical/health sufferings/problems .32 Table 5.12: Pattern of physical/health sufferings/problems related to shortage/stock-out/ irregular supply of pill .32 Table 5.13: Pattern of physical/health sufferings/problems due to shortage/stock- out/irregular supply of injection .33 Table 5.14: Pattern of physical/health sufferings/problems due to shortage/stock-out/ irregular supply of condom .33 Table 5.15: Pattern of psychological sufferings/problems .34 Table 5.16: Pattern of psychological sufferings/problems due to shortage/stock-out/irregular supply of pill .35 Table 5.17: Pattern of psychological sufferings/problems related to injection shortage/stock-out/irregular supply.35 Table 5.18: Pattern of psychological sufferings/problems related to condom shortage/stock-out/irregular supply .35 Table 5.19: Pattern of sufferings/problems related to income generating activities .36 Table 5.20: Pattern of sufferings/problems related to IGAs due to shortage/stock- out/irregular supply of pill .36 Table 5.21: Pattern of sufferings/problems related to IGAs due to shortage/stock- out/irregular supply of injection .37 Table 5.22: Pattern of sufferings/problems related to IGAs due to shortage/stock-out/ irregular supply of condom .37 Table 5.23: Pattern of sufferings/problems in household activities .37 Table 5.24: Pattern of sufferings/problems related to household activities due to shortage/stock-out/irregular supply of pill .38 Table 5.25: Pattern of sufferings/problems related to household activities due to shortage/stock-out/irregular supply of injection .38 Table 5.26: Pattern of sufferings/problems related to household activities due to shortage/stock-out/irregular supply of condom.38 Table 5.27: Pattern of sufferings/problems regarding social activities .39 Table 5.28: Pattern of sufferings/problems related to social activities due to shortage/stock-out/irregular supply of pill .39 V Table 5.29: Pattern of sufferings/problems related to social activities due to shortage/stock-out/irregular supply of injection.39 Table 5.30: Pattern of sufferings/problems related to social activities due to shortage/stock-out/irregular supply of condom.39 Table 5.31: Alternative ways followed to avoid problems in supply.40 Table 5.32: Pattern of physical sufferings and problems by hours lost per suffering.40 Table 5.33: Pattern of psychological sufferings and hours lost per suffering .40 Table 5.34: Pattern of sufferings related to IGAs and hours lost per response .41 Table 5.35: Pattern of sufferings related to household activities and hours lost per response .41 Table 5.36: Pattern of sufferings related to social activities and hours lost per response.41 Table 5.37: Percentage distribution of sufferers by average loss of income due to problem of shortage/stock-out/irregular supply of FP methods .42 Table 5.38: Percentage distribution of sufferers by loss of their income in absolute value due to problem of shortage/stock-out/irregular supply of FP methods .42 Table 5.39: Percentage distribution of income losers by methods suffering due to problem of shortage/stock-out/irregular supply of FP methods .42 Table 5.40: Average loss in income by methods due to problem of shortage/stock- out/irregular supply of FP methods .42 Table 6.1: Percentage distribution of the net income loss of the sufferers by methods.44 Table 6.2: Pattern of medical costs incurred by items.44 Table 6.3: Pattern of loss from physical or health related sufferings/problems .45 Table 6.4: Pattern of loss from psychological sufferings/problems.46 Table 6.5: Pattern of loss from sufferings/problems related to income generating activities .46 Table 6.6: Loss by components of household activities.47 Table 6.7: Loss from social activities.47 Table 6.8: Pattern and share of loss by different items .48 Table 7.1: Trend in general in ADP allocation for HNPSP.49 Table 7.2: Trends in Allocation and Expenditure for National FP Programme .50 Table 7.3: Trends in allocation and expenditure on contraceptives for national FP programme.51 Table 7.4: Trend in Allocation and Expenditure on DDS kits for last 3 years FY 2005-06 to 2007-08.52 List Boxes Box 1.1: Definition of a “Sufferer”.4 Box 5.1: Reported physical sufferings and problem.31 Box 5.2: Psychological sufferings and problems.34 Box 5.3: Sufferings and problems in income generating activities .36 Box 5.4: Sufferings and problems of household works and family care .37 Box 5.5: Sufferings and problems in social work.38 Annexes Annex 1: Data Collection Instruments.59-76 Annex 2: Members of the Study Team .77-79 EXECUTIVE SUMMARY Background Bangladesh with around 150 million population is one of the largest and most densely populated among the least developed countries. The population of Bangladesh is increasing at the rate of 1.43% (2 million) per year and Contraceptive Prevalence Rate (CPR) has reached 55.8% (BDHS, 2007). To achieve the Total Fertility Rate (TFR) of 2.2 by 2010, CPR should be increased to 72 % coupled with a progressive method mix supported by a robust BCC campaign. In the Health, Nutrition and Population Sector Program (HNPSP), the services like Family Planning, Menstrual Regulation (MR), Emergency Obstetric Care (EOC) and supply of medicines of DDS kits are included in RH services. Incidence of shortage/stock-out/irregular supply of short-term and some long-term FP methods has been noticed occurring at repeated intervals during the last few years. This is a challenge to the national health and population programme having implications for the national economy. Among the supplies, Bangladesh Family Planning Programme procures the contraceptives and other RH commodities with World Bank credit money which is adequately available, but procurement is both time- consuming (18-24 months) and cumbersome. In addition, a number of FWA units have been suffering from inadequate field level manpower. FPAB is implementing Project Resource Mobilization and Awareness (PRMA) in Bangladesh as an important catalyst to increase the financial and political commitment to sustainable RH supplies. The accompanying study has been conducted to understand various human impact of shortage/stock-out/irregular supply of three major contraceptives at the level of household as well as on national economy, and to examine the sufficiency of allocation of funds vis a vis need of GoB financial mechanism for it. Objectives of the Study 1. To assess human impact, i.e., how much will be an increase in population and sufferings of the affected people due to commodity shortage/ stock-outs/irregular supply. 2. To assess impact on national economy because of sufferings in the population due to commodity shortage/stock-outs/irregular supply. 3. To ascertain the trends, sufficiency and priority for allocation of fund for health, RH and commodity, and to assess the trends in utilization of the funds. Methodology The research design has two broad segments - quantitative and qualitative. The core research has been conducted with the contraceptive users (of oral pill, injectables, and condom) at 30 FWA units who have suffered at least once due to shortage/stock-out/irregular supply during one year period preceding the survey (i.e., during March 2008-February 2009). The following data/information collection instruments were administered: • Individual Interviews with 2756 Users (Quantitative) • Individual Interview with 205 Sufferers (Quantitative) • Focus Group Discussion (FGDs) (Qualitative) • Group Discussions (GDs) at District Level (Qualitative) • Group Discussions (GDs) at DGFP level (Qualitative) • Data/Information obtained through Formats (Quantitative) HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh ii The findings were analyzed to prepare the draft report for submission to PRMA, FPAB and SARO/IPPF for their comment. The key finding with associated implications has been presented at a national seminar. After receiving comments on those from the national seminar in presence of Honorable Minister, Ministry of Health and Family welfare, the report has been finalized by the Team Leader and Consultants. Current System of Procurement, Supply, and Monitoring System of Procurement The current procurement activities from the beginning to end have 19 steps. If these steps are complied timely, 18 months are required for completion. Procurement of RH commodities, both off-shore and inland, is bound by rules. Consultation with and concurrence by Funding Partners (World Bank, and donors) are needed to finalize the deal. It is usually time- consuming, and the system allows dual control, delay and inefficiency. Knowledgeable field managers viewed the system of procurement as not free from blemish. System of Supply and Distribution Supply process is initiated from the Central Warehouse (CWH) of FP Directorate at Dhaka, and then to 21 regional warehouses located at District HQs, to all Upazila FP stores (482 upazilas) and from there to the Service Delivery Points (SDPs) consisting of FWCs, MCWCs, FWAs, and NGO clinics. And finally, RH-FP materials (contraceptives, kits, MSR items) are being distributed/administered by FWAs and FWVs and others concerned to clients/users. The clients/users receive the supplies at home, satellite clinics, FWCs, MCWCs, community clinics (where this clinic is functioning) and also at NGO clinics. The main source of supply of RH-FP commodities is FWAs. They are supposed to make home visit to MWRAs once in every two months. In focus group discussions (FGD) with the “Sufferers”, FWAs were also identified as source in nearly 80% supplies to the clients. In case of stock- out/shortages, some field managers address situations through revising their distribution plan for RH commodities to meet the priority needs of users on a selective basis. Switch-over of FP methods is also encouraged by them to meet the crisis. Monitoring System The national monitoring system is based on Form7 and Form7-B submitted to MIS by Warehouses and Upazila FP offices respectively. The Monthly Logistics Report is a monitoring tool which is providing useful “information on monthly distribution and stock balance of all major contraceptives and DDS kits of warehouses/upazila stores”. There is no forecasting mechanism to project commodity requirements for a growing population with diversified needs (of method-mix). The monitoring at the field level is also weak. Status of Stock-out Situation Regarding the status of stock-out/shortages of RH commodities during the last one year (November 07 to October 2008) the “Family Planning Monthly Logistics Report of DGFP” shows that stock-out was experienced by a large number of upazilas (44.58% highest, 24.16% lowest). Field Managers, in their interviews, admitted with hesitation that stock-out situation prevailed during the last one year in one FP method or the other. Causes of Stock-out The causes of stock-out as reported by the Field Managers and other concerned officials of the FP Department include irregular supply, bottlenecks in procurement process, dualism, lack of forecasting mechanism to assess/project needs, and overall management inefficiency. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh iii Discrepancy in Number of Users: Official Data vs. Field Reality The question of discrepancy, and finding out of real number of users and actual number of sufferers aroused when the data collected through a specific format from 437 FWAs didn’t match with that of the data collected through Pre-test and small-scale field survey. As a result the study strategy was changed and data were collected through 2,756 household interviews with the users of 3 major FP methods (pill, injectables, and condom) in 30 FWA units. In this study, the statistical discrepancy found in number of users between FWA register and the actual users of FWA unit was 4.8%, where real users were 95.2% and 132 were non users (out of 2,756 household respondents interviewed) during any time in the last 365 days preceding the survey. Out of the 95.2% real users, 83.5% got regular supply and 11.8% did not receive regular supply. However, according to FWA reporting – stock-out or shortage or irregular supply of these 3 methods is 0.6% as against 11.8% found in the field survey. Of this 11.8%, 7.4% (205 persons) are “sufferers” and 4.3% are “non-sufferers” (managed the method). Lack of effective supervision of field visit of the FWAs and lack of updating of the FWA register book are thought as contributors to this type of statistical discrepancy. At the second stage, Individual level sufferer interview were conducted with 205 sufferers suffering from various problems due to shortage/stock-outs/irregular supply of oral pill, or injectables, or condom during last one year. The 7.4% sufferers (205 persons) include 3.7% sufferers of oral pill, 2.1% sufferers from injectables, and 1.6% sufferers of condom. Demographic and Socio-economic Characteristics of Sufferers The average age of the users in the sample is 32 years. A large part of the users in sample (27.7%) are in the age group of 26-30 yrs. The average household size of ‘suffering household’ is 4.5. More than 98% of the members fall into categories of married and unmarried. Primary level education dominates over other categories of education. About 39% of the members of ‘age 5 or above’ have primary education. About 76% are literate and 24% illiterate. Illiteracy is higher pronounced among female members (56.5%) than that among male members (43.5%). Majority of the members (29.9%) by occupation constitute the student group followed by housewives (23.5%). It was also found that 68.8% of the sample households have their own agricultural land and 99% have their own homestead. A 14.1% are living in the houses which are vulnerable. About 77% of households can meet their educational and 52% can meet their medical expenses. The yearly income per household is Tk. 66,826. For 50.2% of the suffering households the annual income is less than Tk.50,000. Impact on individuals/households Contraceptive practice of three major contraceptives Among the number of actual sample users, majority (56.9%) use pill as their contraceptive method, followed by injectables (27.5%) and condom (15.6%). Sufferer situation of shortage/stock-out/irregular supply Of the users who were facing irregular supply, about 63% suffered from different dimensions of ailments and set-backs like physical, psychological, social, income generating, and household related activities. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh iv Out of 205 sufferers, about 55% suffered physically. Among the physical sufferings, headache has been found as the prime cause of physical sufferings (18.9%), followed by general weakness (15.3%). Each physical sufferer suffered from more than one problem. About 79% suffered psychologically. Anxiety and fear of being pregnant had been found to be the two major causes of psychological sufferings. About 25% faced problems regarding income generating activities (IGA) and 33% suffered from household related activities, and 6% suffered from activities related to family care. In IGA, the most frequent loss happened from the absence to the non-agricultural sector. Each suffered from more than one problem regarding IGAs. On an average, each suffered from more than two problems regarding household related activities and family care. On an average, each social sufferer suffered from more than one problem. About 31% of the total sufferers incurred medical costs due to their physical or health related problems/sufferings. The average annual medical cost per suffering household stood at Tk. 1,286. Medicine was found as the major cost item which is slightly higher than that of the diagnostics costs. Among the total users in the sample, 0.8% suffered from unexpected pregnancy. More than one alternative sources of having FP methods were mentioned by each sufferer where pharmacy topped the list. Income Loss to Sufferers About 64% of the total sufferers lost some portion of their net income. The average net annual income loss per suffering household amounted to Tk. 1,026. Among the income losers, more than 80% lost their portion of net income which is below 2.5%, and 70% of the income losers lost income less than Tk. 1,000. The highest loss incurred is found for the stock-out of oral pill (48.4%), followed by injectables (36%), and condom (15.6%) respectively. As for the loss of hours, the annual mean hours lost per suffering for physical sufferers was 425 hours; 456 hours for psychological sufferers; 91 hours for IGAs; 1662 hours for disruption of household activities; and 21 hours for disruption of social activities. Each sufferer suffered from more than one type of sufferings. Impact of Shortage/Stock-out/Irregular supply on National Economy Estimates show that the annual total number of users suffering from problems due to stock- out/shortage/ irregular supply of three family planning commodities (oral pill, injectables and condom) is 1.54 million in Bangladesh. Nationally, estimates show that the total loss of time of the sufferers (during last year) would be about 4,275 million hours, money value of which amounted to Tk. 60,932 million. Loss of net income at the national level due to shortage/stock-out/ irregular supply amounted to Tk. 1,005 million. Medical cost, at the national level, incurred due to shortage/stock-out/ irregular supply amounted to Tk. 629 million. Loss of time from physical or health related problems was 1,131.4 million hours, money value of which amounted to Tk. 16,123 million for the sample period nationally. Loss of time of the sufferers who suffered psychologically stood at 1,145.3 hours which amounted to Tk. 16,326 million for the sample period nationally. Loss of time of the sufferers those suffered from disruption of income generating activities (IGAs) had been calculated at 46.53 million hours, and its value amounted to Tk. 662 million. Loss of time due to disruption of household related activities at the national level has been calculated at 1,949.7 million hours and amounted to loss of Tk. 27,784 million. Loss of time due to disruption of social activities at the national level due to shortage/stock-out/ irregular supply had been calculated at 2.5 million hours and its money value amounted to Tk. 37 million. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh v Adequacy of Financial Support and Priority of Health, Nutrition and Population Sector Programme It is well-established that Health-Nutrition-Population Sector is priority one and to carry on a major thrust, the government has brought the Ministry of Health and Family Welfare under Medium Term Budgetary Framework (MTBF) from 2006-07. The government has also been increasing allocation (13-15%) in the ADP almost every year. But on close examination of R-ADP allocations and expenditures for last 3 years from FY 2005-06 to FY 2007-08 for the national FP Programme a quite different scenario had been captured. Allocation of fund was erratic with rise and fall – from Tk.9767.10 million in FY 2005-06 to Tk. 12153.94 million in FY 2006-07 (an increase of 24.44%) to Tk. 9,633.62 million in FY 2007-08 (a decline of 21.26%). Even the allocation of FY 2007-08 compared to allocation of FY 2005-06 decreased by 1.36%. Again, allocations/expenditures for contraceptive procurement under non-development budget was ‘Zero’. The pattern of financing for contraceptives procurement was one-sided and single dimensional (development budget only); for DDSkits, allocations under development budget (for last 3 years) fluctuated beyond a reasonable degree – from “0.0” (FY 2005-06) to Tk. 968.90 million (FY 2006-07), to Tk.134.21 million (FY 2007-08) showing dramatic rise and fall. Allocation for DDS Kits under non- development budget was ‘nil’ in FY 2007-08. The scenario in its totality gave an impression of infinite uncertainty in procurement planning. The result was shortage/stock-outs/irregular or delayed supply from time to time as it had been revealed in this study. The government of Bangladesh spends not more than US $ 5 per capita annually for HNPSP services which is meager to the ever growing needs of an expanding population. Although, the issue of how much money is needed for what purpose is debatable, the central point focused was absorption capacity and efficiency of spending the available resources. Pouring in more resources may not be much difficult for Health-Population sector-wide programme, but the real difficulty lies with management efficiency to get the investment hit at the bottom, where it is needed most, to ensure services to the rural poor deprived of most of the basic needs of subsistence living. Key Findings The key concluding findings of this study to ascertain the human impact of stock- out/shortage/irregular supply of three select family planning commodities (oral pill, injectables, and condom), and its impact on national economy during last one year are as follows. • Total number of annual users faced stock-out shortage/irregular supply of three family planning commodities– oral pill, injectables and condom – is 2.43 million in Bangladesh. • During the last year preceding the survey a 7.8% of the users (1.54 million) of oral pill, injectable, and condom faced shortage/stock-out/irregular supply and as a result suffered from various problems (Sufferers). • Nationally, the estimates show that the total loss of time of the sufferers (during last year) would be about 4,275 million hours, money value of which amounted to Tk. 6,0932 million. • Number of unexpected pregnancy due to shortage/stock-out/ irregular supply of these 3 methods have been calculated at 159,800, of which 90,240 (57%) went for MR and 22,560 for abortion. Thus, shortage/stock-out/ irregular supply of these 3 methods are responsible for 47,000 additional child birth due to unexpected pregnancy which had contributed to the incremental population during last year. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh vi • There are 19 steps in the Procurement process which take 18 to 24 months and there is lack of proper forecasting mechanism for projection of procurement needs. • There is acute shortage of field staff for motivation and service-delivery, and they lack in spirit, motivation and skill-based training. The programme requires multiple inputs and safeguards from different authorities to reach a sustainable level. Highlights of Some Field Problems From field Investigators interaction with FP users and sufferers of stock-out/shortages of RH commodities, major problems that could be gleaned on the surface were inefficient management of FWA register, lack of clients care, negligence to ‘cafeteria’ approach to motivate clients, irregular household visits, and inadequate counseling of ELCOs by FWAs. Recommendations Sufferers Opinion about Shortage/Irregular Supply Sufferers expressed that authorities should supply RH-FP commodities in sufficient quantity and on regular basis. FWAs and other field staff should not charge money for providing injectables, oral pill, and condom. Besides, home delivery, depot holder system (nearest to clients housing area) should be established to make RH commodities readily available in times of need. Supervision of field staff by responsible supervisors should be geared up. Service Providers and Managers Service Providers and Managers consider simplification of procurement procedure is critically important to avert stock-out situation. Besides, to appropriate forecasting of actual needs of RH-FP commodities, a mechanism must be evolved and set-up as safeguard against hazards from shortage or stock-out situation. The programme managers also viewed the logistic system as a part of the entire gamut of organization-management services system and suggested a holistic approach to sustainable improvement in the complex sector of Health- Nutrition-Population planning and development. Summary of Recommendations • Streamline procurement system and make the procedure simpler – reduce steps of bureaucratic bottlenecks, cumbersome and time-consuming formalities. • Effect need-based, bottom-up procurement plan. • Like the other issues, ‘Population problem’ should be focused as a major national issue. • Encourage, promote/patronize for local production of quality FP-RH commodities, particularly contraceptives such as pill, condom, injectables etc. in public and private sectors to procure it locally. • Empower District FP Authorities to make local procurement of available RH commodities to meet shortages in the supply line/stocks urgently. • Allocate fund from Revenue Budget of the government for procurement/production of RH commodities to reduce donor-dependence with the objective of achieving self reliance and sustainability. • Establish a sound monitoring system, a forecasting mechanism of procurement and supply. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh vii • Ensure training and re-training of field functionaries to build up their work skill (motivation, service-delivery, record-keeping, reporting, monitoring etc.) and meet the discrepancy of the govt. report and the field reality. • Permanent contraceptive methods should be encouraged. • Undertake basic studies to develop suitable contraceptives suitable for use by the ever growing population of Bangladesh. • Undertake separate study on ‘Reasons of irregular supply of FP items at the service delivery points’. • Expand and equip storage facilities to have a capacity for at least 24 months stocks in stores at different levels (regional/local). • Increase manpower at the field level to regularize home visit and to ensure proper service delivery near the door steps of clientele. Alternatives/options to increase manpower in the field should also be seriously examined, pilot tested and adopted, if found economically-socially suitable/viable. • Utilize the services of NGOs in service delivery and monitoring where there is shortage in manpower to strengthen home visit and service delivery. • Strengthen FP programme by professional people (population-FP) of the Department (cadre) to get the best out of present day bureaucracy, democratic culture and specialization. In view of the findings of the study and recommendations by Programme Managers, Service Providers and Clients, the study team suggest to institute a full-fledged Project Resource Mobilization and Awareness (PRMA) Unit for effective monitoring of procurement and supply activities of RH-FP commodities. PRMA may also be given the responsibility of advocacy at various levels. The study team also suggests a time-bound implementation plan for implementation of all feasible recommendations for the greater interest of the nation. CHAPTER I BACKGROUND, OBJECTIVES AND METHODOLOGY 1.1. Introduction Bangladesh with around 150 million populations is one of the largest and densely populated among the least developed countries. This population is already creating pressure on the resource of Bangladesh. According to Government of Bangladesh, currently the population of Bangladesh is increasing at the rate of 1.43 percent per year and Contraceptive Prevalence Rate (CPR) is 55.8 percent. If we want to achieve the replacement level fertility with Total Fertility Rate (TFR) of 2.2 by 2010, CPR should be increased to 72 percent. However, currently the TFR is 2.7 percent and CPR is 56 percent. With this current rate of TFR and CPR, the population will increase at the rate of 2 million per year. The targeted Net Fertility Rate (NFR) is 1 for 2010. According to a recent publication of GoB on World Population Day, the 2008 population will stabilize at 250 million in the year 2085. In Bangladesh, the Health, Nutrition and Population Sector Program (HNPSP) of 2003-2006 have been extended to 2010, where field activities in health and population are managed separately. In HNPSP, the services like MR, Essential Obstetric Care (EOC) and supply of medicines of DDS kits (Kits for MCH services) are also included in RH services and managed using almost the same manpower and facilities. Although use of contraceptives was increasing, for the first time during the last couple of years it is on decreasing trend (BDHS, 2007). Incidence of shortage/stock-out of short-term re-supply methods as well as some long-term methods has been noticed occurring in repeated intervals in the supply chain during the last few years. It is most likely that the same scenario will be observed certainly for MR kits, DDS kits and EOC drugs and supplies, if not taken care immediately. This is a new challenge to the national health and population programme as well as national economy. While analyzing the causes, it was observed that the knowledge and attitude of various programme and its users were positive and always on increase, but the problem lies with the RH drug availability and accessibility scenario and its continuity of supply through different tiers/channels. 1.2. The RH Drug Availability Scenario in Bangladesh Logistics and supply of RH commodities in Bangladesh is managed by the Ministry of Health and Family Welfare (MoH&FW) through two departments- (i) Central Medical Store department under Directorate of Health and (ii) Central Warehouse under Directorate of Family Planning. The World Bank consortium supports by providing fund for procurement of various contraceptives and RH commodities. UNFPA also directly procures contraceptives (also procures CIDA-funded contraceptives) and provides these to government. However, the main problem about contraceptives and RH commodities procurement system is that, it is quite complex and time-consuming. For the last one and half years, condom, oral pill, injectables, implants and IUDs are short in supply for some times - both through the public, as well as private distribution channels. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 2 Among the supplies, Bangladesh Family Planning Program procures the contraceptives, and other RH commodities are imported (including MR kits) from off-shore sources with World Bank credit money which is adequately available but accessing the money has presented problems. It requires strict observation and compliance with the IDA procurement guidelines, and it is both time consuming (takes about 16-18 months) and cumbersome. Shortage of trained procurement staff is also another problem that has resulted in delayed procurement of contraceptives and other supplies. The World Bank procurement and supply process usually need to follow around 19 steps and takes even more time although it has been normally prescribed as 16-18 months (see Figure 2.1, Procurement Spiral Diagram). Because of the long timeframe and delay in procurement and supply process, it causes shortage, stock- out and a crisis situation for the RH commodities. This is due to the fact that it is very tough for the Bangladesh Family Planning Program to assume how the use rate and method-mix of contraceptive will be after one and half years. These are causing shortage/stock-out in supply and increase in discontinuation rate of some of the short and long-term methods (Pill, Condom, Injectable, IUD, Implant, Emergency Contraception, Sterilization MSR), and DDS kits medicines. If these commodities are not supplied in time (before shortage/ stock-outs) these may cause unintended pregnancy, preventable illness, and unnecessary sufferings. These have a lot of human impact and will affect national economy as well. In addition to this, a number of FWA units are suffering due to lack of field level manpower (FWAs). Since majority of the FWAs has been recruited by 1980, currently their work loads have been increased to more than double in some areas. According to DGFP officials, previously a FWA had to provide service to 500 MWRAs, which currently has increased to around 1200. In some FWA units, they can’t bear this load due to their old age as well. According to some researchers, starting of Community Clinic system is also one of the major obstacles for the reduction in CPR. The CPR is also low in most of the Haor, Hilly and Slum areas, which are hard-to-reach and inaccessible. Whatever the cause is, the discontinuation in supply disrupts the contraceptive use and lowers the contraceptive use rate (CPR), increases the total fertility rate (TFR), increases the maternal mortality and morbidity, and ultimately affects the population and MCH-FP services of the country. Against the abovementioned facts and figures that reiterate the urgent need for interventions that would help narrow the demand-supply gap in RH supplies, FPAB is implementing Project Resource Mobilization and Awareness (PRMA) in Bangladesh as an important catalyst to increase the financial and political commitment to sustainable RH supplies. The Advocacy Team at SARO, comprising the Communication, Advocacy and Resource Mobilization specialists backstop the planning and implementation of PRMA, in Bangladesh. For innovative and effective implementation, SARO and FPAB have proposed to set up a full fledged and dedicated PRMA Unit for effective implementation of project activities. There are National Consultants (PRMA) for advocating with the government, and to reach out and convince the highest officials in the relevant ministries and other government agencies. Project Resource Mobilization and Awareness (PRMA) undertaken by FPAB will initiate advocacy program to the government policy level to ensure regular and adequate supply of RH supplies including contraceptives. This project on cursory review has identified some gaps, especially shortage and stock-outs of contraceptives during the last couple of years. This project will function as an important catalyst to increasing commitment for sustainable RH supplies. The advocacy needs to be evidence based and supported by empirical findings. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 3 For this purpose, HDRC has conducted the accompanying study entitled ‘Human and Economic Impact of RH Supplies Shortage/Stock-outs in Bangladesh’ to ascertain the impact of it, especially- Contraceptives (3 major items) on human aspect as well as on national economy. Another aspect of the study was to examine the sufficiency of allocation/release of funds vis a vis need of RH supplies in the GoB financial mechanism for ensuring proper and need based service delivery. 1.3. Objectives of the Study The objectives of the study were as follows: 1. To assess human impact, i.e., how much will be increase in population and sufferings of the affected people due to RH commodity shortage/ stock-outs. 2. To assess impact on national economy because of RH commodity shortage/stock-outs and sufferings in the population. 3. To ascertain the trends, sufficiency and priority for allocation of fund for health, RH programme and its community through budget analysis of a couple of years and also to assess the trends in utilization of the funds. Further, this study has examined how best we can simplify the fund release mechanism; how far we can meet growing demand for fund, and thus the discontinuation rate of RH supplies can be minimized to zero. All these issues have been examined, analyzed and solutions sought from the field. This study will initiate the national level advocacy for the RH supply initiatives of Project Resource Mobilization Awareness (PRMA) as well. 1.4. Methodology 1.4.1. The Study Design The key purpose of this research was to determine the sufferings on population due to shortage of the contraceptives and other RH commodities, and finally the impact of the same on the National Economy as a whole. It also assessed the sufficiency of allocation/release of funds and suggested the need of a simplified financial mechanism for the same. For this purpose, the users, sufferers, suppliers, service providers, district and central level managers were interviewed and discussed in group; information obtained through data collection formats were analysed, and finally presented at ministry level for their input. 1.4.2. Methods of Data/Information Collection The total research design has two broad segments namely, quantitative and qualitative research. Broadly, two groups of audiences has been targeted – (i) Contraceptive Users and Sufferer Population, and (ii) Key Stakeholders. This section delineates all pertinent methodological issues of the study. The data/information collection instruments along with the relevant respondents/participants are presented below. On Contraceptive Users and Sufferer Population (Pill, Injectables and Condom) – • Individual Interviews with Users • Individual Interview with Sufferers • Focus Group Discussion (FGDs) HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 4 On Key Stakeholders- • Group Discussions (GDs) at District Level • Group Discussion (GDs) at DGFP level • Data/Information obtained through administering Formats. And finally, • Secondary Analysis of Data/Information • Presentation at Ministry level. Quantitative Survey Primarily, Individual user level interviews were conducted at 30 FWA units on contraceptive user population for identification of the sufferer population. Through this user interview, the sufferers were identified. At the second stage, individual level sufferer interviews were conducted with the population who has suffered due to shortage/stock- outs/irregular supply of pill or injectables or condom during last one year (from March 2008 to February 2009). In addition, Secondary Analysis of Data/Information obtained through Formats was conducted at Directorate level. For diagnosing the stock-out situation due to shortage of supplies through GoB channel, Secondary Analysis of Data/Information of Family Planning Monthly Logistics Report of Directorate General of Family Planning (from November 2007 to October, 2008) was also conducted. Qualitative Study FGDs were conducted with some of the sufferers (8 in 6 divisions) on the same population. FGDs were conducted for different methods on the affected population. Group Discussions were also conducted at District level (6 in 6 divisions), and finally at Directorate level (DGFP) for collecting Information from key stakeholders. The managers concerned with finance, MIS, supply and service delivery were present in those meetings. 1.4.3. Sample Design At first, a total of 2756 users of pill, injectables, condom (on average 90/FWA unit) were sampled from the FWA Register from 30 FWA units on random basis. However, Individual user level interview were conducted with 2624 user population (pill, injectables, condom) for identification of the sufferers. Study Areas The study has been conducted in all over Bangladesh in 30 FWAs distributed in 6 divisions. FWA units and its population, users and sufferers have been taken as the basic unit of the study. Box 1.1: Definition of a “Sufferer” ‘Sufferer’ means a person – man or woman – who used either of the three family methods, namely oral pill or injectables or condom but experienced irregular supply or shortage or stock- out any time at least once during the last one year preceding the survey and had suffered from problems due to that. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 5 Study Population, Sample Size and Methods of Data/Information Collection The purpose of such selection was to address the issues in line with the objectives of the study. At first, some basic data with number of contraceptive users and sufferers has been sought from 384 FWAs distributed randomly and distributed more all less homogeneously all over Bangladesh (see Special Note for ‘Rationale of selecting 384 FWA units for Secondary Analysis of Data/Information Obtained through Formats’ in next page). It was presumed that suffering filled-in by the shortage/stock-out/irregular supply of contraceptive will come out from those formatted reports from FWAs. However, number of sufferers didn’t come out through those reports from FWAs, and Pretest in 20 Upazilas contradicted some of the reports from FWAs. After this, the strategy was changed and through the meeting with FPAB and SARO/IPPF it was decided that sufferers will be identified through Individual Interview with contraceptive users of 3 major methods. Group discussion were conducted at district level with Deputy Director of Family Planning and other officials and staff associated with collection, supply and providing service. Individual User Interviews were conducted at 30 FWA units and identify sufferers to find- out human impact for shortage of contraceptive supplies (pill, injectables, and condom) in 17 districts of 6 divisions. In each FWA unit around 90 persons were interviewed primarily on contraceptive supplies to identify the persons suffering from irregular use of contraceptives. Then, Individual Sufferer Interviews were conducted with the sufferers to find-out specific human impact, hours lost/sufferer for shortage/stock-out/ irregular supply of contraceptive supplies (pill, injectables, and condom) in those FWA units. Around 205 sufferers of shortage/stock-out/ irregular supply of contraceptive supplies (pill, injectables, and condom) were interviewed who reported suffering from problems due to irregular supply of contraceptives. Focus Group Discussions (FGDs) were also conducted with some of the sufferer population from commodity shortage in these areas. In each district one FGD i.e., in total 6 FGD in 6 districts were conducted. Secondary Analysis of Data/Information collected from FWA units, District level, Directorate level was done using special tabulation plan. Data was collected from 30 FWAs using specific formats. Data was collected from each of the 6 districts for the supply and stock-outs. All these selection were collaborative endeavor of FPAB, PRMA and study team. For this purpose, 6 districts were selected semi-purposively among the 6 divisions. However this is to note that, for FWA units, data was collected from 384 FWA units through a format. For this purpose, special paper message with format were sent to 384 FWA units. However, this data were not used, as information related to stock-out/shortage and irregular supplies were not reported in those formats. Special collaboration of DGFP and FPAB was required for this purpose. 1.4.4. Analysis Plan: Descriptive and Inferential Analyses Since the study was involved with multiple data collection instruments, development of an analysis plan required substantial time and efforts. Developing this analysis plan was a joint effort of the Team Leader and the Consultants. This was done simultaneously in the course HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 6 of preparation, guidelines and checklists. The findings were analyzed to prepare the draft report for submission to PRMA, FPAB and IPPF/SARO for finalization. On the other hand it the key finding with associated implications has been presented at a national seminar in presence of Honorable Minister, Ministry of Health and Family Welfare. After receiving comments on those from the national seminar the report has been finalized by the Team Leader and Consultants. Through this triangulation process with the users and district level managers the information collected in all the areas were validated in the process of analysis. Broadly six methods of quantitative and qualitative research were implemented to collect all relevant information in line with the objectives of the study (delineated in Section 1.3.2). The analysis was conducted in specific areas by indicators using appropriate information compilation and analysis formats designed by the Team Leader and other core-team members competent in quantitative and qualitative research and subject specialists. Figure 1.1: Triangulation of findings with the district level managers and others All information collected and compiled was triangulated at district level in presence of local health and family planning managers to validate the findings. These activities were conducted by consultants and trained field-workers who were provided with a topic-guide in line with the thematic issues, variables and relevant indicators of the study. A total of 6 triangulations in 6 sample districts were conducted with district level managers and other persons involved with service delivery, distribution and supply. In each district, triangulation was conducted on requirement of – Contraceptives, DDS Kits, and other RH Supplies and their supply position. 1.4.5. Study Implementation Fifteen field teams guided by a most competent team leader and a coordinator were deployed for data collection in 30 FWA units spread over 6 divisions. This section delineates the Study Areas, Study Population and Sample Size and Methods of Data/Information Collection. Finally, one of the crucial components in any research – the Triangulation Plan and its implementation has already been shown as part of Analysis Plan. In order to address the research issues, the quantitative and qualitative methods were implemented in the following way. GD Input Individual User Interview Secondary Analysis of Format Data KII FGD Outcomes • Validation of findings in National Seminar • Inferences and conclusions • Supplement and complement findings • Suggestions and recommendations towards better RH care HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 7 A. Preparation, Pretest and Finalization of Instruments, Guides, and Checklists Instruments, Guides and Checklists for all the above mentioned data collection methods were prepared first. These were then pre-tested in 20 upazilas to assess how relevant items are, how well the respondents understand it, and whether there are problems in administering the instruments. On the basis of the pre-test results, the Strategy of the study, Instruments, Guides and Checklists were modified and the revised ones were sent to PRMA, FPAB for their review and approval. After receiving comments from them, the guidelines and checklists were finalized. The final version was then re-translated in both Bangla and in English. The copies of Bangla version were reproduced for field. The pre-testing team included, among others, the Team Leader, the Team Consultants, and Members and Consultants from PRMA and FPAB. B. Quantitative Interviews An advance team was sent for this purpose. For each FWA unit around 90 persons were listed primarily for interview to identify the persons who have suffered due to irregular use of contraceptives during last year. Since FWA units are more or less homogenous in all over Bangladesh, user’s interview was conducted in around 30 FWA units distributed randomly and distributed more all less homogeneously all over Bangladesh. At first, 2756 users of pill, injectables, and condom were selected from FWA Register at 30 FWA units for Individual User Interview. However, due to irregularities in FWA Register, 132 users could not be identified as users (during any time in the last year), who have been denoted as non-users in our study. For this purpose, Individual user level interview were conducted with 2624 user population (oral pill, injectables, and condom) for identification of the sufferers. Through this user interview, 324 users were identified who didn’t get their contraceptive supply regularly due to shortage/stock-out/irregular supply. Out of these 324 users, 205 sufferers were identified who suffered from various problems and illness due to shortage/stock-out/irregular supply of these 3 contraceptives. Secondly, Individual Sufferer Interviews were conducted with these 205 sufferers of shortage/stock-out/ irregular supply of contraceptive supplies (pill, injectables, and condom) to find-out specific human impact, hours lost/suffered due to this irregular use of contraceptives. In this process, data were collected on health perspective, psychological perspective as well as productivity losing perspective. Alternative source of supply (if any) was explored as well. Thus, quantitative analysis of health, psychological and economic impacts due to shortage/stock-out/irregular supply of contraceptives was ascertained. C. Focus Group Discussion (FGD) FGDs were conducted with 8 groups in 6 districts with sufferers of RH supplies, especially- Contraceptives (condom, oral pill, injectables). FGDs were conducted with users who suffered from shortage of supply of the abovementioned items. Both male and female in groups of discussants were conducted FGDs in groups of 7-9. FGDs were conducted with one group in each district i.e., a total of 6 FGDs in 6 districts. Separate groups by sufferer of contraceptive method user were organized. Individual group discussion by item and guide were organized. These FGDs were conducted by facilitator and documentation assistant (male or female, according to FGD participant’s gender). D. Group Discussion (GD) Group discussions (GDs) and Key Informant Interviews (KIIs) were carried out with the administrators, store keepers and in-charge of the FP suppliers at Ministerial level of HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 8 MOHFW, Directorate General of Family Planning, and District Family Planning Office. These GDs & KIIs were moderated by Consultants with a topic guide emanating from the objectives of the study. Bearing in mind the objectives of the study, GDs & KIIs were carried out with the following groups of stakeholders. At Directorate level Director General, Directorate General of Family Planning; Director, Finance and Planning; Director, IEM; Additional Director, Clinical Contraception Service Delivery Program; Director General, FPAB, Md. Nur Hossain, Consultant, PRMA, FPAB; Md. Gias Uddin, Project Manager, PRMA, FPAB; and Dr. S.M.Nijamul Hoque, Senior Program Officer, EngenderHealth. District level Deputy Director, FP, District FP office; MO (Clinic), MCWC; AD (Clinical Contraception); UFPO, Supply Officer, and Store Keeper, RWH of District. E. Quality Control Production of high quality output in the research depends much on the quality assurance system followed in the endeavor. A system of TQM (Total Quality Management) was instituted which took care of all systematic arrangements and activities directed towards safeguarding, maintenance and promotion of quality throughout the research period. The TQM framework involved, among others, the following: 1. Ensuring full and effective coordination among the key personnel. 2. Instituting division of labor by assigning specific and time-bound job responsibility to each member of the key personnel. 3. Recruiting support staff having appropriate qualification, skill and motivation. 4. Working out well-defined job responsibilities for each member of the support team and implement those. 5. Imparting adequate appropriate training to the support staff. 6. Instituting timely reporting and efficient communication mechanism with FPAB 7. Deploying mechanisms for appropriate selection of study area. 8. Field checking to validate and monitor the process of collection of information 9. Quality control checking of information management 10. Devising all necessary management arrangements for timely coping with unforeseen situations. 11. Instituting time and cost optimization mechanisms in the study. A sound quality control system was instituted to adequately monitor the quality of data collection. For this purpose, fifteen Quality Control Officers (QCOs) were deployed – one in each team. They constantly moved around the sample spots; and ensured quality through: (i) field checking, and (ii) monitoring. Field checking was undertaken in both `presence' and `absence' of the field teams. ‘Checking in presence’ means verification of the work of a field team in a sample area during the time of information collection. ‘Checking in absence’ means verification of the work of a field team in a sample area after the team had left the site, after completing its assigned work in the area. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 9 During their field checking, the Quality Control Officers performed checking the data accuracy. Some of the reported non-response items were also checked to ensure that they were all due to valid reasons. `Field checking in presence' was conducted for all field members, while `field checking in absence' were done over randomly selected sites. The Quality Control Officers verified/cross-checked the papers/checklists were completed by them with the corresponding field team. Discrepancies, if any, were corrected, per instructions recorded in the field manual. Data monitoring was done by comparing results of some key variables in completed papers/checklists tabulating the variables by field teams, sample sites and enumerators. The comparisons showed, if any field team in filling in papers/checklists were re-interviewed. In addition, the Team Leader, and other members of the core-team also maintained constant touch with the field operations. The core-team members undertook field trips as per the need of the study. F. Secondary Analysis of Data/Information and Preparation of Draft Report The study was conducted primarily on 437 FWA units (in place of 384 FWA units), 45 UFWCs, 14 MCWCs and 20 UFPO’s office from 23,500 FWA units of Bangladesh, and then actual sufferer level data were collected from 30 FWAs. It is to be mentioned that, FWA units were selected as basic units for analysis of data for this study. After data collection, development of an analysis plan required substantial time and efforts. It was a joint effort of Team Leader and the Consultants. After data collection, this was done in the course of the preparation of tables and report. The findings were analyzed to prepare the draft report for submission to PRMA, FPAB and SARO/IPPF for their comments and suggestions. G. Presentation of Report at Ministry level The Report has been presented at a national dissemination seminar by Prof. Abul Barkat, Team Leader of the study and Chief Adviser (Hon.), HDRC. The following high level officials were present in the dissemination seminar: 1. Prof. A.F.M. Ruhal Haque, Honorable Minister, Ministry of Health and Family Welfare, Government of the People’s Republic of Bangladesh, as Chief Guest 2. Prof. Dr. M.S. Akbar, MP, FRCP, DCH, FIAP, Chairman, Bangladesh Red Crescent Society 3. Mr. Mohammad Abdul Qayyum, Director General, Directorate General of Family Planning 4. Ms. Anjali Sen, Regional Director, IPPF/SARO 5. Mr. Steve Kinzett, Senior Technical Officer, Reproductive Health Supplies Coalition 6. Ms. Sarah Shaw, Resource Mobilization and Awareness Officer, IPPF 7. Mr. Dhiraj Kumar Nath, Former Advisor to Non-Party Caretaker Government of the People’s Republic of Bangladesh 8. Dr. Jahiruddin Ahmed, Director General (In-charge), FPAB 9. District level managers of Health and Family Planning of Government of Bangladesh. 10. Participants from FPAB, DGFP, SMC, USAID and other NGOs and media Finally, the Chairperson of the dissemination seminar Mrs. Meher Afroze Chumki, MP and Chairman, Parliamentary Standing Committee, Ministry of Women and Children Affairs and President, FPAB delivered her concluding speech. Invaluable suggestions were forwarded by the participants. CHAPTER II CURRENT SYSTEM OF PROCUREMENT, SUPPLY AND MONITORING OF REPRODUCTIVE HEALTH COMMODITIES 2.1. Introduction In almost all sectors of activities, one major component is procurement and supply of commodities, services, hardware and software etc. The procurement and supply management is contained in system called logistics system. In the social service sector, particularly in health-population sector, a sound logistics system is sine qua non for its successful operation. The Directorate of Family Planning has a Logistics Management System which has been strengthened over the years. The logistics system with well-established procurement procedure and nation-wide net work of supplies of RH-FP commodities, MSR, kits etc. providing service to the people and eligible couples, at large. 2.2. System of Procurement of RH Commodities The present system of procurement is fastened by rules and formalities deemed to be necessary to ensure fair deal. In fulfilling the rules of procurement and necessary formalities it takes nearly 18 months if all activities are processed and completed on time; any exception to this due to avoidable/unavoidable reasons might prolong the procurement time, as evident from experiences, beyond 18 months by 6 to 8 months or even more. The ‘Procurement Spiral of Activities’ from start to end entail 19 steps before having the possession of commodities (See Figure 2.1). It is assumed that there is a forward procurement plan, and a time-bound projected RH-FP commodity requirements in place, which is reviewed periodically to be compatible with present stock and emerging needs of future. The procurement spiral shows activities/steps taken to secure supplies at hand mainly from off- shore sources. The procurement is based on International Competitive Bidding (ICB). Again, in utilizing project aid (grant, loan etc) views/consent/approval of concerned agency, be it bank (World Bank/Asian Development Bank) or development partner/donor, is needed. Usually, in matters of procurement packages and plans – specification, bidding document, evaluation of bids, and the funding agency is consulted for their views and consent. In the procurement process the game is played by both government agencies as well as funding partner agency(ies). Knowledgeable Field Managers viewed the present procurement process subjected to dualism, delay and that often without good understanding between partners (GOB and donors/Bank), is also vulnerable to inefficiency. Although World Bank funded procurements follow World Bank Guidelines, some of the provisions of Public Procurement Act 2006 and Rules 2008 mentioned about procurement process that are also considered while executing procurement. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 11 Figure 2.1: Procurement Spiral of Activities *Assumes procurement activity, review and approvals are processed in a timely manner. Source: Based on Procurement Premier for Health and Family Planning Programs in Bangladesh, DELIVER John Snow, Inc. USA (Page 12) HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 12 2.3 System of Supply and Distribution The Directorate General of Family Planning under the Ministry of Health and Family Welfare (MOHFW) is the lead agency responsible for implementation of National Family Planning & MCH Programme and it has a vast network of supply and distribution system of RH-FP commodities all over the country. With the procurement cycle (ref: Procurement Spiral) completed, supply process is initiated – the Central Warehouse (CWH) of FP Directorate at Dhaka which provides facilities for safe storage is also central to supply life line of RH-FP commodities. From central warehouse to 21 regional warehouses located at District HQs, to all upazilas (sub-district) FP stores (480 upazilas) and from there to about 30,000 Service Delivery Points (SDPs) consisting of FWCs, FWAs and NGO clinics. And finally, RH-FP materials (contraceptives, kits, MSR items) are distributed/administered by FWAs and FWVs and other concerned to the clients/users. The clients/users receive the needed supplies at home, satellite clinics, FWCs, MCWCs, community clinics (where this clinic is functioning) and also at NGO clinics. FWAs are supposed to make home visit of an eligible couple (ELCO) once in every two months. The main source of supply of RH-FP commodities is FWAs. In focus group discussions (FGD) with the “Sufferers”, FWAs were identified as source in nearly 80% supplies to the clients. A Flow Chart (Figure 2.2) about channels of supply of RH-FP commodities is below. Figure 2.2: Flow Chart of FP Contraceptives Commodities Supply SMT w Chittagong Port Dhaka Airport Kamalapur Container Deport Dhaka Clients/Users Central Warehouse (Dhaka) Regional Warehouse (21 district HQs) Upazila FP Stores (All upazilas) Service Delivery Points (SDPs) (FWCs /FWAs /NGO clinics) HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 13 2.4. Alternative System of Collection of RH-FP Commodities in the event of Shortage of Supplies The scope of an effective alternative system of collection by or delivery of RH commodities to FWAs/ SDPs is quite limited. There is no recognized source of supply as an alternative to the established network of supply has been stated earlier (Figure 2.2). The usual practice is temporary loan taken from neighboring upazila/SDPs where stocks are available beyond their own needs. In addressing situations arising out of shortage/irregular supply, some Field Managers (District and Upazila level) chalked out a distribution plan of RH commodities with preference to users who need them most. Temporary rationing of commodities is also done to offset a crisis situation. In an emergency situation, MSR shortage is met by local purchase utilizing “Impressed Fund” at the disposal of Deputy Director, FP. Field managers also reported that switch-over of methods is encouraged to encounter shortages of one, or the other method of contraception. 2.5. Monitoring System and Forecasting of Stock-out/Shortages The National Monitoring of Logistics for Bangladesh Family Planning Programme is largely dependent upon Form 7 filled up and submitted by warehouses and Form 7B submitted by Upazila Family Planning Offices to MIS unit of the Directorate General of Family Planning. In Family Planning Monthly Logistics Report, a monitoring tool of the Directorate, it is stated that – “It provides useful information on monthly distribution and stock balance of all the major contraceptives and DDS kits of warehouses/upazila stores”. (Ref: Family Planning Monthly Logistics Report, September 2008 of MIS, Directorate General of FP). In addition, at upazila and district levels monthly review meetings, telephonic report, indent for and appraisal of supply position to the higher authorities is regularly done for performance monitoring. Field managers in almost all group meetings opined that there is no forecasting mechanism to project commodity needs of ever increasing population/ELCOs of the country. Admittedly, expertise is lacking in this area of activity. 2.6. Status of Stock-out/Shortages of RH Commodities during the last one year according to Service Providers and Field Managers During the course of literature review, Monthly Report titled “Family Planning Monthly Logistics Report” compiled and circulated by MIS unit of the Directorate General of Family Planning for the last one year from November 2007 to October 2008 (12 months) was sought for review and analysis. Reports for 4 months (November 2007 to February 2008) were not available. Remaining monthly reports for eight months from March 2008 to October 2008 were available and each one was examined. Table 2.1 provides the number of Upazilas and SDPs by month where there was stock-out of condoms, oral pill, and injectables during last 8 months. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 14 Table 2.1: Month-wise number of Upazilas and Service Delivery Points (SDPs) experienced stock-out of condoms, oral pill and injectables: November 2007 to October 2008 (No monthly report was available for 4 months). Number of Upazilas* (SDPs) Experienced Stock-out all over the Country Months Condom Oral Pill (Sukhi) Injectables (Depo Provera) Total number of Upazila (SDPs) March’ 08 161 (5023) 24 (99) 29 (161) 214 (5283) April’ 08 160 (4071) 21 (96) 24 (77) 205 (4244) May’ 08 118 (1859) 25 (69) 26 (104) 169 (2032) June’ 08 88 (719) 26 (102) 24 (76) 138 (897) July’ 08 114 (912) 37 (89) 39 (70) 190 (1071) August’ 08 68 (437) 22 (55) 26 (167) 116 (659) September’ 08 65 (390) 26 (59) 27 (273) 118 (722) October’ 08 65 (263) 25 (69) 34 (297) 124 (629) * Figures in Parenthesis stand for SDPs experienced stock-out Source: Family Planning Monthly Logistics Report, March 2008 to October 2008 of the Directorate General of Family Planning, Govt. of Bangladesh, 6 Karwanbazar, Dhaka 1215 The data in Table 2.1 revealed that the first-half of the year 2008 the stock-out situation as experienced by a large number of Upazilas and Service Delivery Points was acute, critical and alarming, too. Overall, the highest with 44.58% and the lowest with 24.16% Upazilas (out of 480 Upazilas) experienced stock-out of 3 FP methods (condom, oral pill, injectables) during March-October 2008 period. Field Managers and Functionaries at District and Upazila levels in general, admitted stock-out situation in group discussions, but the tendency was, as it was noticed, defensive and to shy away from field reality. 2.7 Causes of Stock-out/Shortage of RH Commodities according to Service Providers and Field Managers Before digging out the causes of stock-out/shortages, it will be useful to mention the system of supply of RH commodities to District/Regional warehouse/Upazila stores, FWAs, MCWC, SDPs and others. Supply and distribution guidelines of the Directorate General of FP provide the basis of supply to the field. In general, it is designed on “Push” methodology (applicable in over 90% cases); if supplies received are found short of needs, or validity date expired, ‘indent’ for specific items are given to the concerned authority. In fact, following 7B Form report, all supplies are received at Upazila level. Some field managers, however, reported that they give indent for ‘Implant’. In all Group Discussions, and during ‘FGDs with sufferers’ it was mentioned that ‘irregular supply’ (not on time supply) of RH commodities was the major cause of shortage at the end point – the users. The users suffer because they do not get supplies as per their need, in time. On the other hand, as opined by the Field Managers, stock-out occurs because of weaknesses in procurement planning (through projecting the need after 18 months), bureaucratic bottlenecks – too much of formalities which is time consuming (16-18 months), and lack of a forecasting mechanism which could project the needs – how much, what is needed, when, where and how to ensure delivery/supply of RH commodities in time, for a growing population of eligible couples. It was also opined that management inefficiency was partly responsible for stock-out, delay, shortage and disruption of supplies to the users. Unless the users at the end of the channel (of supplies) get the needed RH commodities in time, there will be no light lit at the end of the tunnel. CHAPTER III USERS AND SUFFERERS OF ORAL PILL, INJECTABLE AND CONDOM: OFFICIAL DATA VS FIELD REALITY 3.1. Discrepancy in Number of Users: Official Data Vs Field Reality This section focuses on specific issue that has been found in the sampling selection from the FWA register book. Finding out of real number of users and real number of sufferers was a big challenge in this study. The question of discrepancy aroused when the primary data collected through a specific format from 437 FWAs didn’t match with that of the data collected through small scale sample survey as well as through pre-test. FWAs were not able to provide the data of the sufferers who were suffering due to shortage/stock-out/irregular supply of pill, injectables and condom. For this reason, the total strategy of the study had to be changed and sampling was done from the FWA register book. In order to identify the gaps between official data and real life situation, two-step procedure was followed. In step 1, data were collected from FWAs using a Format containing most up to date information about number of ELCOs, number of users of modern methods, number of users of oral pill, condom and injectables, number of suffers (due to stock- out/shortage/irregular supply) of these 3 FP methods during last one year, and number of users of those methods who switched to other method(s) during the reference period. Based on the initial field visits it was found that the above data supplied by FWAs are not free from discrepancy. For example, it was observed that the number of users and number of sufferers reported by FWAs do not comply with the real field situation; it was also observed that although FWA reported certain number of clients as `sufferers’ they were unable to provide names/addresses of those sufferers. Therefore, in step 2, an attempt has been made using a simple interview format to identify actual users of above 3 FP methods as well as to identify the sufferers. This exercise generated information which is adequate enough to show huge discrepancy between the reporting by FWAs and our actual field data collection result. It is worth here to mention two broad groups of discrepancies. First, as shown in Table 3.1, only 6 out of 30 FWA units (i.e., 20%) reported irregular supply from oral pill, but from field survey the proportion of pill users irregular supply found 76.7% (in 23 out of 30 FWA units). Similarly, only 6 out of 30 FWA units (i.e., 20%) reported irregular supply of injectables, but from field survey the proportion of injectables irregular supply found 66.7% (in 20 out of 30 FWA units), and Only 4 out of 30 FWA units (i.e., 13.3%) reported sufferings from condom, but from field survey the proportion of condom users reported irregular supply found 83.3% (in 25 out of 30 FWA units). Second, while for the three FP methods (oral pill, injectables, and condom) estimation based on FWA reporting shows only 0.61% faced irregular supply, but in reality it is 12.3% (estimation based on information in Table 3.3). The method wise discrepancy between FWA reporting and actual field survey was as follows (shown in Figure 3.1). HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 16 • For oral pill, 0.6% (FWA reporting) Vs 9.6% (field survey) • For injectables, 0.3% (FWA reporting) Vs 10.7% (field survey) • For condom, 1.9% (FWA reporting) Vs 25.4% (field survey) Table 3.1: Discrepancy in facing stock-out/shortage/irregular supply by methods: FWA record vs field reality Method (s) % FWA units reported “stock- out/shortage/irregular supply” % FWA units in which “stock-out/ shortage/ irregular supply” found through field survey Oral pill 20.0 76.7 Injectables 20.0 66.7 Condom 13.3 83.3 Source: Estimated by the authors based on data in Table 3.3 Data was collected through 2756 household interview of the users of 3 major FP methods (pill, injectables and condom) from FWA Registers in 30 FWA units. After this change in strategy, the next challenge was to find out the real number of users, real number of users faced irregular supply, and real number of sufferers out of it. The real number of users found was 2624 (95.2%) out of 2756 interviewees (who are shown as users in the FWA register) and the rest 132 (4.8%) were non-users. This gave rise to statistical discrepancy in number of users between FWA register and the actual users of FWA unit (95.2%), which we call “field reality”. Thus, the rate of statistical discrepancy was found 4.8% of the total sample users (Table 3.2). Table 3.2: Percentage distribution of real users of 3 contraceptives (pill, injectables and condom) and non-users Status of FP Commodities Frequency Percent Users 2624 95.2 Non-users 132 4.8 Total Sample 2756 100 Lack of proper supervision of field visit of the FWAs and updating of the FWA Register are most likely factors contributed to this discrepancy. Discrepancy in number of users, FWA Register vs. Field reality has been presented in Table 3.3 where the discrepancy has been shown by FWA units. 3.2. Discrepancy in FWA Registers and Primary Interview Findings Through the user interview of 2624 actual users, 324 users faced irregular supply was detected who didn’t get timely supply of these 3 major contraceptives (pill, injectables and condom) due to stock-out/shortage/irregular supply. From these 324 persons getting irregular supply, 205 sufferers were identified. At the second stage Individual level sufferer interview were conducted with 205 sufferer populations due to shortage/stock-outs/irregular supply of pill, injectables, or condom who have suffered during last one year (Figure 3.2). It is evident from the field based findings pertaining to the user-suffer of oral pill, injectables and condom that using FWA registers a total of 2756 users (of above three methods) have been sampled. Assuming this sample as 100%, the user-sufferer proportion would be as follows: • 95.2% are actual users and 4.8% are non-users • 83.5% got regular supply and 11.8% did not receive regular supply in the last year • 7.4% are sufferers and 4.3% are non-sufferers (switched and/or managed the method) • 3.7% suffered from oral pill, 2.1% suffered from injectables, and 1.6% suffered from condom. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 17 Figure 3.2: User-Sufferer Tree (oral pill, injectable, condom) Sample Users From FWA Registers 2756 (100% Users found in Survey 2624 (95.2%) Non-users found in Survey 132 (4.8%) Regularly Supplied 2300 (83.5%) Irregular supply/ Stock-out/Shortage 324 (11.8%) Non-sufferer 119 (4.3%) Sufferer 205 (7.4%) Condom 45 (1.6%) Injectables 58 (2.1%) Pill 102 (3.7%) HDRC Human and Economic Impact of RH Commodity Shortage/Stock-outs in Bangladesh 18 Table 3.3: Discrepancy in number of users (oral pill, injectable, condom): FWA Register (reporting) vs Field Reality FWA register Pill Injectable Condom All (pill + injectable+ condom) FWA register (reporting) Field survey FWA register (reporting) Field survey FWA register (reporting) Field survey FWA register (reporting) Field survey Sl. # Unit address (FWA Unit) # ELCO/ MWRA # Users: modern method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock-out/ shortage # switched to other method 1 FWA Unit # : 1Ka Union: Charghat Upazila: Charghat District: Rajshahi 1089 875 510 4 56 1 - 149 - 19 2 2 112 3 12 3 - 771 7 87 6 2 2 FWA Unit # : 3 Ka Union: Charghat Upazila: Charghat District: Rajshahi 1551 1343 811 16 52 2 1 214 2 19 - - 133 6 8 - - 1158 24 79 2 1 3 FWA Unit # :3 Ka Union: Mirzapur Upazila: Sherpur District:Bogra 1873 1302 800 - 47 6 - 250 - 24 1 - 143 - 17 7 - 1193 - 88 14 - 4 FWA Unit # : 2 Ka Union: Sughat Upazila: Sherpur District:Bogra 1157 825 485 - 53 2 1 161 - 23 1 - 17 1 15 2 - 663 1 91 5 1 5 FWA Unit # : 1 Ka Union: Garidha Upazila: Sherpur District:Bogra 3398 2545 433 - 57 41 1 369 - 34 15 1 35 - 13 8 2 837 - 104 64 4 6 FWA Unit # : 1 Ka Union: Kushumbi Upazila: Shaerpur District:Bogra 1139 827 262 - 55 2 1 94 - 30 1 - 11 - 11 2 2 367 - 96 5 3 7 FWA Unit # : 2 Ka Union: Saikola Upazila: Chatmohar District:Pabna 1577 1276 484 - 60 4 3 41 - 25 3 2 20 - 10 3 - 545 - 95 10 5 HDRC Human and Economic Impact of RH Commodity Shortage/Stock-outs in Bangladesh 19 FWA register Pill Injectable Condom All (pill + injectable+ condom) FWA register (reporting) Field survey FWA register (reporting) Field survey FWA register (reporting) Field survey FWA register (reporting) Field survey Sl. # Unit address (FWA Unit) # ELCO/ MWRA # Users: modern method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock-out/ shortage # switched to other method 8 FWA Unit # : 1 Kha Union: Janipur Upazila: Khoksha District:Kushtia 952 686 275 - 62 4 - 66 - 16 3 - 193 - 30 3 - 534 - 108 10 - 9 FWA Unit # : 2 Ka Union: Kolora Upazila: Narail Sadar District: Narail 690 544 346 - 35 2 - 56 2 21 - - 65 - 21 6 1 467 2 77 8 1 10 FWA Unit # : 2 Kha Union: Kolora Upazila: Narail Sadar District: Narail 839 618 382 4 50 2 1 86 1 10 - - 29 - 13 8 4 497 5 73 10 5 11 FWA Unit # :2 Kha Union: Navaron Upazila: Jhikargacha District: Jessore 1076 855 440 - 58 2 1 139 - 21 - - 72 - 17 15 4 651 - 96 17 5 12 FWA Unit # : 3 Ka Union: Magura Upazila: Jhikargacha District: Jessore 1086 772 311 - 56 - - 220 - 20 1 2 102 - 15 10 1 633 - 91 11 3 13 FWA Unit # : 1Kha Union: Zahapur Upazila:Murad-nagar District: Comilla 693 458 108 - 25 3 3 85 - 17 6 6 13 - 12 2 1 206 - 54 11 10 14 FWA Unit # : 2 Kha Union: Jattrapur Upazila:Muradnagar District:Comilla 770 576 289 - 45 4 4 139 3 30 6 6 28 3 15 5 2 456 6 90 15 12 HDRC Human and Economic Impact of RH Commodity Shortage/Stock-outs in Bangladesh 20 FWA register Pill Injectable Condom All (pill + injectable+ condom) FWA register (reporting) Field survey FWA register (reporting) Field survey FWA register (reporting) Field survey FWA register (reporting) Field survey Sl. # Unit address (FWA Unit) # ELCO/ MWRA # Users: modern method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock-out/ shortage # switched to other method 15 FWA Unit # : 2 Ga Union: Hathazari Upazila:Hathazari District:Chittagong 949 592 389 - 65 6 2 20 - 19 3 2 27 - 7 - - 679 - 91 9 4 16 FWA Unit # :3 Ka Union: Kaptai Upazila: Kaptai District:Rangamati 273 173 86 - 35 - - 42 - 16 3 2 67 - 24 5 1 502 - 75 8 3 17 FWA Unit # : 2 Union: Pashim Birgaon Upazila: Sadar District:Sunamgonj 609 373 145 - 44 - - 105 - 48 - - 32 - 15 4 1 282 - 107 4 1 18 FWA Unit # : 1 Kha Union: 3 no Dakkhin Purba Baniachong Upazila:Baniachong District: Hobigonj 770 485 224 - 33 - - 125 - 25 5 4 60 - 22 - - 409 - 80 5 -4 19 FWA Unit # : 2 Kha Union: Taral Upazila:Derai District:Sunamganj 543 326 137 - 57 7 3 41 - 22 2 - 11 - 10 3 1 189 - 89 12 4 20 FWA Unit # : 2 Ka Union: Taral Upazila:Derai District:Sumanganj 495 273 144 - 66 2 - 105 - 23 - - 32 3 8 - - 181 3 97 2 - 21 FWA Unit # : 3 Ka Union: Madhabpasha Upazila:Babuganj District: Barisal 1185 724 257 - 64 2 2 103 - 29 2 3 63 - 14 5 5 381 - 107 9 10 22 FWA Unit # :2 Kha Union: Kalaskathi Upazila:Bakerganj District: Barisal 843 533 316 - 57 2 - 77 - 27 1 - 20 - 8 2 - 413 - 92 5 - HDRC Human and Economic Impact of RH Commodity Shortage/Stock-outs in Bangladesh 21 FWA register Pill Injectable Condom All (pill + injectable+ condom) FWA register (reporting) Field survey FWA register (reporting) Field survey FWA register (reporting) Field survey FWA register (reporting) Field survey Sl. # Unit address (FWA Unit) # ELCO/ MWRA # Users: modern method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock- out/ shortage # switched to other method # users # faced irregular supply/ stock- out/ shortage # users visited # faced irregular supply/ stock-out/ shortage # switched to other method 23 FWA Unit # : 2 Kha Union: Chandpasha Upazila: Babuganj District:Barisal 523 353 212 - 40 1 - 168 - 34 2 1 30 - 12 2 2 510 - 86 5 3 24 FWA Unit # : 3Ka Union: Madobpara Upazila: Babuganj District: Barisal 977 694 246 - 30 2 - 228 - 28 - - 22 - 10 2 - 496 - 68 4 - 25 FWA Unit # : 3Ka Union: Ghatail Upazila: Ghatail District: Tangail 1092 723 222 9 42 - - 64 2 31 - - 120 7 8 2 - 406 - 81 2 - 26 FWA Unit #: 2 Kha Union: Ghatail Upazila: Ghatail District: Tangail 1633 1025 348 16 41 - - 42 1 20 - - 47 8 14 - - 437 18 75 - - 27 FWA Unit # : 3 Kha Union: Kamrabad Upazila:Sharisha-bari District: Jamalpur 984 662 319 - 62 18 1 100 - 20 7 2 34 - 13 1 - 453 25 95 28 3 28 FWA Unit # : 2 Ka Union: Motbari Upazila: Trishal District: Mymenshing 1189 966 620 - 57 22 1 102 - 20 11 - 55 - 13 1 - 77 - 90 34 1 29 FWA Unit # : 3 ka Union: Shakua Upazila: Trishal District:Mymenshing 959 600 516 4 47 - - 138 - 21 - - 10 - 10 2 - 664 - 78 2 - 30 FWA Unit # : 3 Ka Union: Horiampur Upazila: Trishal District:Mymenshing 1152 766 509 - 42 6 1 46 - 29 2 - 15 - 13 1 - 570 4 84 9 1 All 32066 22770 10626 53 1493 143 26 3647 11 721 77 33 1618 31 410 104 27 15627 95 2624 324 86 *Faced stockout or shortage or irregular supply of the method means those who did not had the supply in time at the time of his/her usual use during last one year preceding the survey CHAPTER IV DEMOGRAPHIC AND SOCIO-ECONOMIC CHARACTERISTICS OF USERS AND SUFFERERS OF CONTRACEPTIVES 4.1. Introduction This chapter focuses on demographic and socio-economic characteristics of the sample users and the sufferers of oral pill, injectable, and condom contraceptive methods. Overall 7.4% of the sample users suffered due to irregular supply/service for the above mentioned methods. As the sufferings could vary by the demographic and socio-economic characteristics, so this could be the rational for this chapter. 4.2. Age Distribution of Sample Users and Members of Suffering Households While the sample users were distributed in broad age group, it has been observed that, the largest part of the sample users, i.e., 27.7% were in the age group of 26-30 followed by 24.5%, 18.3% and 16% in age groups of 31-35 yrs., 36-40 yrs., and 21-25 yrs. respectively. Only 2.9% of the users were in the range of 15-20 yrs (Table 4.1). Table 4.1: Percentage distribution of the sample users by age Age group Percentage 15-20 2.9 21-25 16.0 26-30 27.7 31-35 24.5 36-40 18.3 41-45 7.2 46-50 2.4 51-55 0.8 56-60 0.3 61-65 0.1 Total 100 The average household size is 4.5. Table 4.2 shows the distribution of the household members who belongs to the households suffered from the usage of contraceptive methods. By the age group category, majority of the members of sufferings households, i.e., 31.4% are in the age group of 0-10 followed by 20%, 19.4% and 15.8% in the age groups of 11-20, 31- 40 and 21-30 respectively. Table 4.2: Percentage distribution of the household members of sample users by age Age in years Percentage 0-10 31.4 11-20 20.0 21-30 15.8 31-40 19.4 41-50 9.2 51-60 2.0 61-90 2.1 Total 100 HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 23 4.2.1 Distribution of the members of the suffering households Distribution of the members of the suffering households shows that 48.1% of the members fall into categories of married and 50.6% belongs to unmarried category. Only a small fraction either falls into category of widowed or divorced/separated (Figure 4.1). 4.3. Educational Status of Members of Suffering Households Findings about education status implies that 39.1% of the members who age 5 or above have the primary education, followed by 29.4% with secondary education, and 23.9% with no education. Other type of education include Madrasah, old age education etc. Figure 4.2 give the clear picture about the educational status of the members of suffering households. About 76% were literate and 24% illiterate (Figure 4.3). Education by sex indicates a much higher illiteracy among the female members (56.5%) as compared to that among the male members (43.5%). A reverse situation is found for the secondary education where higher percentage of female students has the secondary education. This is most likely due to the existence of governments countrywide Female Secondary School Stipend Programme. On the whole, a trivial fractional gap exists between the male and female education. Among the male students a high proportion (41.5%) and among female students a lower proportion (36.5) have completed the primary education (Table 4.3). Table 4.3: Percentage distribution of the household members of sample users by education and sex Education Sex No education Primary Secondary Higher education Others Total Male 20.4 41.5 28.2 6.8 3.2 50.9 Female 27.5 36.5 30.7 2.0 3.3 49.1 Total 23.9 39.1 29.4 4.4 3.2 100 4.4. Occupational Status of the Members of Suffering Households In terms of occupation, a large part of the household members (29.9%) belong to “student” group followed by 23.5% housewives. The occupational distribution of the rest of the members are child less than 6 years (15.3%), household help (1.1%), farmer (8.5%), petty 50.6%48.1% 1% 0.3% Figure 4.1: Distribution of household members of sample users from FWA register by marital status Unmarried Married Widowed Divorced/Separated HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 24 trader (3.5%), salaried (3%), agricultural labor (2.6%), and non-agricultural labor (2.8%). Main occupations of the suffering households are summarized in table 4.4. Table 4.4: Distribution of the occupational status of the members of suffering households Main occupation Frequency Percent Farmer 80 8.5 Housewife 220 23.5 Agricultural labor 24 2.6 Non-agricultural labor 26 2.8 Salaried 28 3.0 Mason 4 0.4 Carpenter 4 0.4 Auto rickshaw/Van driver 13 1.4 Fisherman 2 0.2 Boatman 1 0.1 Shopkeeper 8 0.9 Petty trader 33 3.5 Business 13 1.4 Tailor 2 0.2 Driver 2 0.2 Cottage 4 0.4 Village doctor /Quack 1 0.1 Mechanics 2 0.2 Teaching 1 0.1 Imam/moajjin/priest 8 0.9 Retired service holder/aged 13 1.4 Student 280 29.9 Unemployed 14 1.5 Child less than 6 years 143 15.3 Household help 10 1.1 Total 936 100.0 4.5. Economic Conditions of the Suffering Households Table 4.5 depicts economic conditions of the suffering households in terms of owning agricultural land, homestead, housing condition, food security and the ability of the household to meet educational and medical expenses. About 69% of the households have their own agricultural land and 99% have their own homestead. 14.1% are living in the houses which are vulnerable. Findings also indicate that 76.6% of the households are economically able to send their children to school, which is 52.2% when it course to the question of ability to meet necessary health expenses (Table 4.5). Table 4.5: Status of suffering households by socio-economic condition Status Number of households Percentage Having agricultural land 141 68.8 Having homestead 203 99.0 Vulnerable housing condition 29 14.1 Safe food consumption 162 79.0 Economically able to send their children to school 157 76.6 Able to meet health expenditure 107 52.2 N 205 - HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 25 4.6. Income Data on income has been collected on yearly basis. The yearly income per sample household is Tk. 66,826. The majority of the suffering households (50.2%) fall in the range of up to Tk.50,000, followed by 38% and 7.8% in the income ranges of Tk. 50,001-100,000 and Tk. 100,001-150,000 respectively. The rest constitute the upper ranges which covers only 4% of the suffering households (Table 4.6). Table 4.6: Percentage distribution of the household members of sample users from FWA register by income categorization Income (in Tk.) Frequency Percent Up to Tk. 50,000 103 50.2 50,001-100,000 78 38.0 100,001-150,000 16 7.8 150,001-200,000 2 1.0 200,001-250,000 2 1.0 250,001-350,000 2 1.0 350,001-400,000 1 0.5 400,001and above 1 0.5 Total 205 100 CHAPTER V IMPACT ON INDIVIDUALS/HOUSEHOLDS DUE TO SHORTAGE/ STOCK-OUT/ IRREGULAR SUPPLY OF CONTRACEPTIVES 5.1. Introduction One of the key objectives of the study was to assess human impact of population and sufferings of the affected people due to shortage/ stock-outs/irregular supply of RH commodities. “Human impact” in this study means impact on individual as well as on household. Since a lot of commodities are there in the list of RH commodities, it was impossible to find out the affected people or population suffered due to shortage/stock-outs of RH commodities, for this purpose sufferer of three major contraceptives–pills, injectables and condom – has been selected for individual household interview and FGD. The primary work was Individual user level interview at 30 FWA units on 2756 contraceptive users (of above 3 FP methods) population listed from the FWA Registers. However, in the real field situation we got 2624 users and the rest 4.8% were non-users. Then the next level was identification of the users who didn’t get timely service i.e., the population from where sufferers were identified for in-depth interview. After this identification, interview was conducted with sufferers to assess the impact of population and sufferings of the affected people due to shortage/ stock-outs/irregular supply of the 3 commodities. During FGD with the sufferers and GD with program managers and service providers, impact of shortage/stock-outs/ irregular supply of other RH commodities were also discussed. The findings have been presented below. 5.2. Contraceptive Practice of Three Major Contraceptives during Last One Year Among the sample users (according to FWA register), 95.2% was found as actual users and 4.8% was found as non-users. The concept of non-users could be contributed to the fact of non availability of the user or not continuing the methods or migration, or lack of up-to-date data in the FWA register etc. Among the actual sample users majority 56% use pill as their contraceptive method followed by 28% and 16% for injection and condom respectively (Figure 5.1). 5.3. Sufferer Situation of Shortage/Stock-out/Irregular Supply 5.3.1. Percentage of users who didn’t get timely service due to shortage/stock-outs/ irregular supply Among the total interviewees 11.8% reported that they did not get timely service/supply of the 3 contraceptives due to shortage/stock-outs/irregular supply, this 12.3% of the 2624 users. Distribution of the users by status of getting contraceptive supply/service has been shown in Table 5.1. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 27 Table 5.1: Distribution of users by status of getting contraceptive supply/service Status Frequency Percent Got regular supply/service 2300 87.7 Irregular supply/ shortage/ stock-outs 324 12.3 Total 2624 100 The highest percentage of users faced irregular supply of pill (44%), followed by condom (32%) (Table 5.2). Table 5.2: Distribution of users by methods who did not had the supply/service in time Irregular supply/ shortage/ stock-outs Methods Frequency Percent Pill 143 44.1 Injection 77 23.8 Condom 104 32.1 Total 324 100 5.3.2. Number of times suffered from shortage/stock-out/irregular supply The following table shows to what extent the users faced difficulties for not having the service timely. Average number of times suffered due to shortage/stock-out/irregular supply during one year preceding survey is 2.01. In this case it is found that two times facing difficulties is the major findings. So what this finding implies is that if a user face difficulty once, then the users try for this once again. If users face the same difficulties at the second time, the user may feel bored. So, it is observed that at the third stage, it starts declining (Table 5.3). Table 5.3: Distribution of the sufferers by numbers times suffered due to shortage/stock- out/irregular supply Times service not found Frequency Percent Once 98 30.2 Twice 126 38.9 Thrice 100 30.9 Total 324 100 5.3.3. Percentages of users who had problems/sufferings due to shortage/stock-out/ irregular supply and Sufferers by methods It is to note that, this is not necessarily true that all those faced shortage/stock-out/irregular supply suffered due to that. Though 11.8% of the total sample faced shortage/stock- out/irregular supply, 7.4% suffered from problems (Sufferers) due to that. Of the users who were confronted with the shortage/stock-out/irregular supply, about 63% (205 out of 324 cases) suffered from different ailments like physical, psychological, social, and a fall in income generating, and household related activities (Figure 5.2). Among the sufferers, majorities suffered from the stock-out/irregular supply of pill (49.8%) and this was followed by 28.3% and 21.9% for injection and condom respectively. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 28 Non-sufferer 36.7% Sufferer 63.3% Pill 49.8% Injection 28.3% Condom 21.9% Figure 5.2: Status of sufferings and distribution of sufferers by methods 5.3.4. Pregnancy and related problems (Delivery, Abortion, MR) due to shortage/ stock-out/ irregular supply Among the total sample users, 0.8% (21 out of 205) suffered from unexpected pregnancy. Though at a first glance, this rate seems to be negligible, it would turn to an alarmingly high figure if the data are extrapolated to the national level. This rate would be significantly higher if the sufferers of other different methods are included. Figure 5.3 below shows that, 10.2% of the sufferers suffered from unexpected pregnancy. Among the sufferers of unexpected pregnancy, 28.6% gave birth and the remaining did not give birth. Live birth was found for 23.8% of the unexpected pregnancy cases. Out of the sufferers of unexpected pregnancy 71.4% did not want to give birth and went to undertake different strategies: MR was done by 57% and the remaining 14% went for abortion (Figure 5.3). Figure 5.3: Unexpected pregnancy and related outcomes of the sufferers HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 29 5.3.5. Method changed and number of times changed due to the problem of shortage/ stock-out/irregular supply Among the sufferers due to shortage/stock-out/irregular supply, 39% had changed the methods, which is 3.1% of the total sample users (Figure 5.4). The following table 5.4 has been constructed on the basis of idea that changing method could have a relation with scarcity. The table shows the distribution of those who had changed the methods as a percentage of total sufferers by methods. The findings indicate that, 24.5% of pill sufferers, 53.4% of the injection sufferers, and 53.3% of condom sufferers changed their methods. Table 5.4: Percentage distribution of sufferers by method change/switch Methods Sufferers Methods changed Methods change as a % of sufferers Pill 102 25 24.5 Injection 58 31 53.4 Condom 45 24 53.3 Total 205 80 39.0 The table 5.5 below shows the method switch matrix from which we can have the ideas about the pattern of switching. The matrix implies that 92% of the pill method changers switched to injection, rest of them switched to traditional method (8%). For the injection methods, it was found that almost all the method changers were switched to pill. However, those switched from condom were using either pill (41.7%) or switched to traditional method (58.3%), which is very serious as this could lead to the unexpected pregnancy, MR, or abortion. Table 5.5: Method switch matrix associated with shortage/stock-out/irregular supply Methods switched to Methods switched from (used preceding the survey) Pill Injection Condom Traditional Pill 23(92.0%) - 2(8.0%) Injection 30 (96.8%) - 1 (3.2%) Condom 10 (41.7%) - 14 (58.3%) Number of Switching by Methods A total of 25 pill users changed their methods and switched to other methods. Among them, majority (88%) changed their method once (Table 5.6). Table 5.6: Distribution of sufferers by number of times changed method from pill No. of times changed by pill users Frequency Percent One time 22 88.0 Two times 3 12.0 Total 25 100 A total of 31 injection users changed their methods and switched to other methods. Among them, majority (87%) changed the method just for one time (Table 5.7). Unchanged 61% HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 30 Table 5.7: Distribution of sufferers by number of times changed method from injection No. of times changed by injection users Frequency Percent One time 27 87.1 Two times 4 12.9 Total 31 100 A total 24 of the condom users changed their methods and switched to other methods. Among them, majority (45.8%) changed the method once (Table 5.8). Table 5.8: Distribution of sufferers by number of times changed method from condom Times service not found Frequency Percent Once 11 45.8 Two 2 8.3 Thrice 4 16.7 Four 4 16.7 Five 1 4.2 Ten times above 2 8.3 Total 24 100 Overall, in all three cases, we see that the majority of the switchers changed their methods for once. 5.4. Sources of Supply of Contraceptives for Sufferers The sufferers were interviewed regarding source of supply of the three contraceptives (pill, injectables, and condom). It was revealed that, 86% of them receive their supply/service from the FWAs. The next was UHFWC (7.3%), followed by Satellite Clinic (3.4%). Only 2% received their supply/service from UHCs (Table 5.9). Table 5.9: Distribution of sufferers by use of health care facilities Health care received from Frequency Percent FWA 177 86.3 UHFWC 15 7.3 UHC 4 2.0 MCWC 2 1.0 Satellite Clinic 7 3.4 Total 205 100 5.5. Distance of Contraceptive Supply Source, Time and Cost of Transportation The average distance of all health care facilities reported in this study is slightly higher than 2 km. The average time spent on both way (go and back) is about 35 minutes and average cost incurred was approximately Tk.18. The following table shows that MCWC is far away from the household as compared to other health care facilities (Table 5.10). Table 5.10: Percentage distribution of sufferers by use of health care facilities and distance, time spent and transportation cost Health care received from Distance (in km.) Time spent both way (in minutes) Transportation costs (in Tk.) FWA 2.05 35.19 17.73 UHFWC 2.13 35.93 23.33 UHC 1.25 37.50 22.50 MCWC 3.50 33.00 13.00 Satellite Clinic 1.14 22.71 8.57 Total 2.02 34.84 17.87 HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 31 5.6 Various Problems/Sufferings and Loss of Time due to Shortage/Stock-out/ Irregular Supply The sufferers were interviewed regarding various problems/sufferings and loss of time due to shortage/stock-out/irregular supply. Their responses were categorized in 5 broad groups/ dimensions, namely, (1) Physical/health related sufferings/ problems; (2) Psychological sufferings/ problems; (3) Income generating activities related problems; (4) Problems related to household works; and (5) Problems related to social works/gatherings. An overall pattern of sufferings by five broad groups is shown in figure 5.5. The figure is drawn for individual categories as the same sufferer suffered from more than one category. The prevalence of psychological sufferings was found as extreme, followed by physical/health related sufferings. 5.6.1. Physical /health sufferings and problems The irregular users of the 3 methods (pill, injectables and condom) were interviewed regarding their physical sufferings and problems. All physical sufferings and related problems reported by the sufferers can be seen in Box 5.1. About 55% of the sufferers (112 out of 205) reported physical/health related sufferings due to shortage/stock-out/ irregular supply. It was found that dizziness and vertigo was the most common physical suffering and was reported by 19% of them. It was followed by general weakness (15.3%), vomiting and nausea (15%), anorexia (11%), burning sensation of the body (7.8%). Around 4.5% of the sufferers reported of unexpected pregnancy. (See, Table 5.11 for details). Box 5.1: Reported physical sufferings and problem • Vomiting/Nausea • Dizziness/Vertigo • Only few drops of blood during menstruation/ Bleeding in between two periods • Menorrhegia • Lower abdominal pain in between two periods • Dysmenorrhea • Hypertension • Mastalgia/ Feeling heaviness of breasts • Unexpected pregnancy • Burning sensation of the body • Amenorrhea for 3 months • Unexpected weight gain/loss • Anorexia • Facial pigmentation • Acne • Lower abdominal pain/uterine pain • General weakness • Waist pain and others HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 32 Table 5.11: Pattern of physical/health sufferings/problems Physical/health sufferings/ problems Number of responses Percentage of responses Vomiting/Nausea 53 15.0 Dizziness/Vertigo 67 18.9 Only few drops of blood during menstruation/ Bleeding in between two periods 12 3.4 Menorrhegia 12 3.4 Lower abdominal pain in between two periods 12 3.4 Dysmenorrhea 10 2.8 Hypertension 5 1.4 Mastalgia/feeling heaviness of breasts 10 2.8 Unexpected pregnancy 16 4.5 Burning sensation of the body 26 7.3 Amenorrhea for 3 months 12 3.4 Unexpected weight gain/loss 5 1.4 Anorexia 39 11.0 Facial pigmentation 1 0.3 Acne 3 0.8 Lower abdominal pain/uterine pain 14 4.0 General weakness 54 15.3 Waist pain and others 3 0.9 Total 354 100 5.6.2. Physical/health sufferings and problems by methods Sufferings that arose from the shortage/stock-out/irregular supply of pill, injection and condom are summarized in Tables 5.12, 5.13 and 5.14 respectively. From the findings, it is clear that the greater extent of sufferings arose from the shortage/stock-out/irregular supply of injection. Dizziness/vertigo was found as the major physical/health related sufferings arising from the shortage/stock-out/irregular supply of pill (17.3%), which was followed by general weaknesses (16.5%), and vomiting/nausea (10.8%) (Table 5.12). Table 5.12: Pattern of physical/health sufferings/problems related to shortage/stock-out/ irregular supply of pill Physical/health sufferings/ problems Number of responses Percentage of responses Vomiting/Nausea 15 10.8 Dizziness/Vertigo 24 17.3 Blood during menstruation 8 5.8 Menorrhegia 7 5.0 Lower abdominal pain between two periods 3 2.2 Dysmenorrheal 6 4.3 Hypertension 1 0.7 Mastalgia/feeling heaviness of breast 5 3.6 Unexpected pregnancy 7 5.0 Burning sensation of the body 7 5.0 Amenorrhea for 3 month 8 5.8 Unexpected weight gain/loss 1 0.7 Anorexia 11 7.9 Facial pigmentation 1 0.7 Acne 2 1.4 Lower abdominal pain/uterine pain 7 5.0 General weakness 23 16.5 Waist pain and others 3 2.2 Total 139 100 HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 33 Dizziness/vertigo was found as the major physical/health related sufferings arising from the shortage/stock-out/irregular supply of injection (18.6), which was followed by vomiting/ nausea (17.4%) and general weaknesses (16.2%) (Table 5.13). Table 5.13: Pattern of physical/health sufferings/problems due to shortage/stock- out/irregular supply of injection Physical/health sufferings/ problems Number of responses Percentage of responses Vomiting/Nausea 29 17.4 Dizziness/Vertigo 31 18.6 Blood during menstruation 4 2.4 Menorrhegia 5 3.0 Lower abdominal pain between two periods 7 4.2 Dysmenorrheal 4 2.4 Hypertension 2 1.2 Mastalgia/feeling heaviness of breast 5 3.0 Unexpected pregnancy 7 4.2 Burning sensation of the body 13 7.8 Amenorrhea for 3 month 4 2.4 Unexpected weight gain/loss 2 1.2 Anorexia 19 11.4 Acne 1 0.6 Lower abdominal pain/uterine pain 7 4.2 General weakness 27 16.2 Total 167 100 Dizziness/vertigo was found as the major physical/health related sufferings arising from the shortage/stock-out/irregular supply of condom (25%), which was followed by Vomiting/ Nausea (18.8 %), and Anorexia (18.8%) (Table 5.14). Table 5.14: Pattern of physical/health sufferings/problems due to shortage/stock-out/ irregular supply of condom Physical/health sufferings/ problems Number of responses Percentage of responses Vomiting/Nausea 9 18.8 Dizziness/Vertigo 12 25.0 Lower abdominal pain between two periods 2 4.2 Hypertension 2 4.2 Unexpected pregnancy 2 4.2 Burning sensation of the body 6 12.5 Unexpected weight gain/loss 2 4.2 Anorexia 9 18.8 General weakness 4 8.3 Total 48 100 The findings related to physical/health related sufferings/problems were also supported by FGDs and case studies. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 34 Case Studies Case Study on Coercive Motivation Arifa-18 years, from Village- Chandreshar, Union – Kusmbi, FWA unit-1 ka reported that she has a child aged one and half years. She has been inserted Copper T on 27th January, 2009 through aggressive motivation. She was using pill which was not supplied to her regularly before inserting Copper T. Now, the Copper T is not suiting her, and she is suffering from vertigo, nausea, anorexia, general weakness and menorrhegia (excessive bleeding). Her husband is also objecting to it, and she has not yet been provided any follow-up care/support. She is unable to work with full strength. Another woman of this unit was using pill, which not supplied to her on regular basis. Due to this, she becomes pregnant and has given birth to third child which was an unwanted pregnancy. Case Study on Unwanted Pregnancy Mr. Nazir Ahmed from Barisal reported that, due to irregular supply of condom her wife became pregnant which was unwanted. His wife had to do MR for this unintended pregnancy. For this they had to suffer a lot both physically and psychologically. He had to spend a lot visiting doctor, buying medicines, and pathological check-ups. Case Study on Welcoming the MR clients and Misbehave with others In Jamalpur, the sufferers reported in FGD that the FWA doesn’t want to supply Injectables to them and inform them that it is out of stock now in govt. sources. She coercively asks them to go for tubectomy, vasectomy and copper T. She doesn’t behave properly with the injectables users. She welcomes the MR clients. 5.6.3. Psychological sufferings and problems The irregular users of the 3 methods (pill, injectables and condom) were interviewed regarding their psychological sufferings and problems. It was reported by more than one-third (35.6%) that they suffer from ‘anxiety/ suspense’. It was followed by ‘fear of being pregnant’ (29.6%). The rest one-third suffered from despondency, insomnia, lassitude, etc. They also fear of ‘Socially being embarrassed due to pregnancy’, especially those who are elderly. Table 5.15: Pattern of psychological sufferings/problems Psychological sufferings /problems Number of responses Percent of responses Anxiety/Suspense 119 35.6 Lassitude 33 9.9 Fear of being pregnant 99 29.6 Socially embarrassed due to pregnancy 8 2.4 Insomnia 35 10.5 Despondency 40 12.0 Total 334 100 During FGDs, the sufferer of injectables reported that they have suffered from stock-out (as reported by FWAs) 1 to 3 times during last year and each time they suffered for 1 to 2 months. Box: 5.2: Psychological sufferings and problems • Anxiety/Suspense • Lassitude • Fear of being pregnant • Socially embarrassed due to pregnancy • Insomnia • Despondency HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 35 5.6.4. Psychological sufferings/ problems by methods The findings about psychological sufferings/problems by methods imply that the greater extent of sufferings arose from the shortage/stock-out/irregular supply of injection. Anxiety/suspense was found as the major psychological sufferings/problems arising from the shortage/stock-out/irregular supply of pill (35.5%), which was followed by fear of being pregnant (34.2%), and despondency (11.6%) (Table 5.16). Table 5.16: Pattern of psychological sufferings/problems due to shortage/stock-out/irregular supply of pill Psychological sufferings /problems Number of responses Percent of responses Anxiety/Suspense 55 35.5 Lassitude 13 8.4 Fear of being pregnant 53 34.2 Social embarrassment due to pregnancy 3 1.9 Insomnia 13 8.4 Despondency 18 11.6 Total 155 100 Anxiety/suspense was also found as the major psychological suffering/problem arising from the shortage/stock-out/irregular supply of injection (33.0%), which was followed by fear of being pregnant (25.8%), insomnia (16.5%) and despondency (13.4%) (Table 5.17). Table 5.17: Pattern of psychological sufferings/problems related to injection shortage/stock- out/irregular supply Psychological sufferings /problems Number of responses Percent of responses Anxiety/Suspense 32 33.0 Lassitude 7 7.2 Fear of being pregnant 25 25.8 Social embarrassment due to pregnancy 4 4.1 Insomnia 16 16.5 Despondency 13 13.4 Total 97 100 Anxiety/suspense was also found here as the major psychological suffering/problem arising from the shortage/stock-out/irregular supply of condom (39.0%), which was followed by fear of being pregnant (25.6%), lassitude (15.9%), despondency (11.0%) (Table 5.18). Table 5.18: Pattern of psychological sufferings/problems related to condom shortage/stock- out/irregular supply Psychological sufferings /problems Number of responses Percent of responses Anxiety/Suspense 32 39.0 Lassitude 13 15.9 Fear of being pregnant 21 25.6 Social embarrassment due to pregnancy 1 1.2 Insomnia 6 7.3 Despondency 9 11.0 Total 82 100 HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 36 5.6.5 Sufferings and problems in income generating activities (IGAs) Out of 205 sufferers, about 25% faced sufferings/problems regarding their income generating activities (IGAs). On an average, each sufferer suffered from more than one problem (Table 5.19). Table 5.19: Pattern of sufferings/problems related to income generating activities Problems related to income generating activities Number of responses Percent of responses Preparing crop land 2 2.9 Plantation 1 1.5 Nursing 3 4.4 Cutting/boiling 4 5.9 Vegetables garden 1 1.5 Poultry rearing 18 26.5 Cow/goat rearing 8 11.8 Buying & Selling goods to the market 2 2.9 Agricultural labor 7 10.3 Labor to non-agricultural sector 22 32.4 Total 68 100 5.6.6 Sufferings/problems in income generating activities by methods The findings about sufferings/problems regarding IGAs imply that the greater extent of sufferings arose from the shortage/stock-out/irregular supply of condom. ‘Problem regarding labor to non-agricultural sector’ was found as the major sufferings/problems arising from the shortage/stock-out/irregular supply of pill (28.6%), which was followed by ‘poultry rearing’ (23.8%), and ‘labor to agricultural sector’ (19%) (Table 5.20). Table 5.20: Pattern of sufferings/problems related to IGAs due to shortage/stock-out/ irregular supply of pill Problems related to income generating activities Number of responses Percent of responses Preparing crop land 1 4.8 Nursing 1 4.8 Poultry rearing 5 23.8 Cow/goat rearing 3 14.3 Buying & Selling goods to the market 1 4.8 Agricultural labor 4 19.0 Labor to non-agricultural sector 6 28.6 Total 21 100 ‘Problem regarding poultry rearing’ was found as the major sufferings/problems arising from the shortage/stock-out/irregular supply of injection (52.6%), which was followed by ‘labor to non-agricultural sector’ (15.8%), ‘cow/goat rearing’ (15.8%) (Table 5.21). Box: 5.3: Sufferings and problems in income generating activities • Preparing crop land • Plantation • Nursing • Cutting/boiling • Vegetables garden • Poultry rearing • Cow/goat rearing • Buying & Selling goods to the market • Agricultural labor • Labor to non-agricultural sector HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 37 Table 5.21: Pattern of sufferings/problems related to IGAs due to shortage/stock out/irregular supply of injection Problems related to income generating activities Number of responses Percent of responses Cutting/boiling 1 5.3 Vegetables garden 1 5.3 Poultry rearing 10 52.6 Cow/goat rearing 3 15.8 Buying & Selling goods to the market 1 5.3 Labor to non-agricultural sector 3 15.8 Total 19 100 Here labor to non-agricultural sector was also found as the major sufferings/problems arising from the shortage/stock-out/irregular supply of condom (46.4%), which was followed by agricultural labour (10.7%), poultry rearing (10.7%) and cutting/boiling (10.7) (Table 5.22). Table 5.22: Pattern of sufferings/problems related to IGAs due to shortage/stock-out/ irregular supply of condom Problems related to income generating activities Number of responses Percent of responses Preparing crop land 1 3.6 Plantation 1 3.6 Nursing 2 7.1 Cutting/boiling 3 10.7 Poultry rearing 3 10.7 Cow/goat rearing 2 7.1 Agricultural labor 3 10.7 Labor to non-agricultural sector 13 46.4 Total 28 100 5.6.7 Sufferings and problems of household works and family care Out of 205 sufferers, about 31% suffered from household related activities and family care (Box 5.4). On an average each sufferer suffered from more than two problems (Table 5.23). Table 5.23: Pattern of sufferings/problems in household activities Household activities Number of responses % of responses Cleaning houses 49 31.4 Cleaning utensils 37 23.7 Cooking 41 26.3 Hosting guests 5 3.2 Collecting firewood 9 5.8 Nursing child 15 9.6 Total 156 100 5.6.8 Sufferings/problems in household activities by methods The findings about sufferings/problems related to household activities by methods imply that the greater extent of sufferings arose from the shortage/stock-out/irregular supply of injection. Box: 5.4: Sufferings and problems of household works and family care • Cleaning houses • Cleaning utensils • Cooking • Hosting guests • Collecting firewood • Nursing child HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 38 ‘Problems in cleaning houses and cooking’ was found as the major sufferings/problems arising from the shortage/stock-out/irregular supply of pill (30.2%), which was followed by ‘cleaning utensils’ (28.3%) (Table 5.24). Table 5.24: Pattern of sufferings/problems related to household activities due to shortage/ stock-out/irregular supply of pill Household activities Number of responses % of responses Cleaning houses 16 30.2 Cleaning utensils 12 22.6 Cooking 15 28.3 Hosting guests 2 3.8 Collecting firewood 4 7.5 Nursing child 4 7.5 Total 53 100 Again ‘Problem regarding cleaning houses’ was found as the major suffering/problem arising from the shortage/stock-out/irregular supply of injection (32.1%), which was followed by ‘cooking’ (25.6%) and ‘cleaning utensils’ (23.1%). For clarity, you are referred to Table 5.25. Table 5.25: Pattern of sufferings/problems related to household activities due to shortage/ stock out/irregular supply of injection Household activities Number of responses % of responses Cleaning houses 25 32.1 Cleaning utensils 18 23.1 Cooking 20 25.6 Hosting guest 2 2.6 Collecting firewood 5 6.4 Nursing child 8 10.3 Total 78 100 ‘Problem regarding cleaning houses’ was also found as the major suffering/problem arising from the shortage/stock-out/irregular supply of injection (32%). This was followed by ‘cleaning utensils’ (28%) and ‘cooking’ (24%) (see Table 5.26). Table 5.26: Pattern of sufferings/problems related to household activities due to shortage/ stock-out/irregular supply of condom Household activities Number of responses % of responses Cleaning houses 8 32.0 Cleaning utensils 7 28.0 Cooking 6 24.0 Hosting guest 1 4.0 Nursing child 3 12.0 Total 25 100 5.6.9 Sufferings and problems in social work Out of 205 sufferers, about 6% suffered from activities related to performing and participating in social work. Three-fourths of them suffered from ‘Attending different social clubs/gatherings’ and one-fourth suffered from problem like ‘Participation in salish’ (Table 5.27). Box: 5.5: Sufferings and problems in social work • Attending different social clubs/ gatherings • Participation in salish HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 39 Table 5.27: Pattern of sufferings/problems regarding social activities Social problems and sufferings No. of responses % of responses Attending different social clubs/gatherings 12 75.0 Participation in salish 4 25 Total 16 100 5.6.10 Sufferings/problems in social activities by methods The findings about sufferings/problems related to social activities by methods imply that the greater extent of sufferings arose from the shortage/stock-out/irregular supply of condom. Problem regarding attending different social clubs/gathering was found as the major sufferings/problems arising from the shortage/stock-out/irregular supply of pill (100%). Table 5.28: Pattern of sufferings/problems related to social activities due to shortage/stock- out/irregular supply of pill Social problems and sufferings No of responses % of responses Attending different social clubs/gatherings 2 100.0 Problem regarding attending different social clubs/gathering was found as the major suffering/problem arising from the shortage/stock-out/irregular supply of injection (60%), which was followed by participation in salish (40%). For clarity, you are referred to Table 5.29. Table 5.29: Pattern of sufferings/problems related to social activities due to shortage/stock- out/irregular supply of injection Social problems and sufferings No of responses % of responses Attending different social clubs/gatherings 3 60.0 Participation in salish 2 40.0 Total 5 100.0 Problem regarding attending different social clubs/gathering was found as the major suffering/problem arising from the shortage/stock-out/irregular supply of condom (77.8%), which was followed by participation in salish (22.2%). For clarity, you are referred to Table 5.30. Table 5.30: Pattern of sufferings/problems related to social activities due to shortage/stock- out/irregular supply of condom Social problems and sufferings No of responses % of responses Attending different social clubs/gatherings 7 77.8 Participation in salish 2 22.2 Total 9 100.0 5.6.11. Alternative practices in users in case of problem in supply On an average, more than one alternative sources of having FP methods were found for each sufferer. This is summarized in the table below. Majority goes to pharmacy for purchasing the required FP product. Second most important alternative followed was switching to other methods (Table 5.31). However, due to non-availability of methods about 14% reported that they have stopped using any method (5.31). HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 40 Table 5.31: Alternative ways followed to avoid problems in supply Alternative ways No. of responses Percent of responses Pharmacy 141 61.6 NGOs 6 2.6 Other methods 48 21.0 No methods 28 12.2 No financial ability to take measure 6 2.6 Total 229 100 5.7. Average Hours Lost due to Shortage/Stock-out/Irregular Supply As 55% of the total sufferers suffered physically, so on an average each sufferer suffered from more than three cases. Thus the following table calculates the hours lost per suffering. It has been found that the highest hours lost per suffering have occurred for Amenorrhea (Table 5.32). Table 5.32: Pattern of physical sufferings and problems by hours lost per suffering Physical/health problems Number of responses Hours lost per case Vomiting 53 320 Headache 67 399 Bleeding during menstruation 12 871 Menorrhegia 12 695 Pain in abdomen during menstruation 12 204 Pain during menstruation 10 75 High blood pressure 5 107 Mastalgia/Feeling heaviness of breast 10 516 Unexpected pregnancy 16 640 Burning sensation of the body 26 260 Amenorrhea for 3 months 12 1427 Unexpected weight gain/loss 5 862 Anorexia 39 223 Facial pigmentation 1 1 Acne 3 9 Lower abdominal pain/uterine pain 14 282 General weakness 54 485 Waist pain 3 594 Total 354 425 Out of total sufferers, about 79% suffered psychologically. On an average each psychological sufferer suffered from more than two problems (Table 5.33). Table 5.33: Pattern of psychological sufferings and hours lost per suffering Psychological problems/sufferings No of responses Hours lost per case Anxiety/ Suspense 119 360 Lassitude 33 352 Fear of being pregnant 99 319 Socially embarrassed due to pregnancy 8 365 Insomnia 35 1220 Despondency 40 516 Total 334 456 HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 41 Out of 205 sufferers, about 25% faced problems regarding income generating activities (IGAs). On an average, each sufferer suffered from more than one problem. The most frequent loss happens from the absent to the non-agricultural sector. However, the highest average loss in hours per case is found for cow/goat rearing. The lowest hours lost was found for vegetable gardening (Table 5.34). Table 5.34: Pattern of sufferings related to IGAs and hours lost per response Problems related to income generating activities No of responses Hours lost per case Preparing crop land 2 15 Plantation 1 24 Nursing 3 9 Cutting/boiling 4 21 Vegetables gardening 1 1 Poultry rearing 18 155 Cow/goat rearing 8 257 Buying & Selling goods to the market 2 24 Agricultural labor 7 49 Labor to non-agricultural sector 22 36 Total 68 91 Out of the 205 sufferers, about 31% suffered from household related activities and family care. On an average each sufferer suffered from more than two problems. In terms of hours lost per case highest loss occured for ‘hosting guest’ and the lowest for ‘nursing child’(Table 5.35). Table 5.35: Pattern of sufferings related to household activities and hours lost per response Household activities No of responses Hours lost per case Cleaning houses 49 1436 Cleaning utensils 37 1463 Cooking 41 1682 Hosting guests 5 6208 Collecting firewood 9 1711 Nursing child 15 1292 Total 156 1662 Out of all sufferers, about 6% suffered from household related activities and family care. On an average each sufferer sufferings from problems related to social activities suffered from more than one problem. The following table shows that the highest loss per case of suffering for this is found on account of ‘not attending different social clubs/gatherings’ (Table 5.36). Table 5.36: Pattern of sufferings related to social activities and hours lost per response Social problems No of responses Hours lost per case Attending different social clubs/gatherings 12 21 Participation in salish 4 23 Total 16 21 5.8. Average income lost due to shortage/stock-out/irregular supply This sub-section focuses on the income loss due to the stock-out, shortage or irregular supply of the three major family planning methods. Average income per household per year was calculated to Tk. 66,826. About 64% of the households reported that they have lost some portion of their income. Among the income losers, more than 80% lost their portion of net income which ranging between Tk.1 and Tk. 2.5 (Table 5.37). HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 42 Table 5.37: Percentage distribution of sufferers by average loss of income due to problem of shortage/stock-out/irregular supply of FP methods Loss interval (in Tk.) Frequency Percent <2.50 108 82.4 2.51-5.00 13 9.9 5.01-7.50 6 4.6 7.51-10.00 2 1.5 10.01-12.50 2 1.5 Total 131 100 In terms of the range of loss of their income in absolute value, it is observed from the following table that about 70% of the income losers lost income in absolute value ranging between Tk. 2 and Tk. 1000 (Table 5.38). Table 5.38: Percentage distribution of sufferers by loss of their income in absolute value due to problem of shortage/stock-out/irregular supply of FP methods Loss amount range (in Tk.) Frequency Valid Percent < 1000 91.0 69.5 1001-2000 14.0 10.7 2001-3000 13.0 9.9 3001-4000 5.0 3.8 4001-5000 3.0 2.3 5001-6000 5.0 3.8 Total 131 100 In terms of method wise income loss, the Table indicates the income losers are symmetrically distributed. However, it was found that the income loss of injection sufferers are the highest at Tk.1,050 per sufferer and for condom sufferers it is the lowest at Tk. 774 (Tables 5.39 and Table 5.40). Table 5.39: Percentage distribution of income losers by methods suffering due to problem of shortage/stock-out/irregular supply of FP methods Methods Income losers % Pill 66 50.4 Injection 41 31.3 Condom 24 18.3 Total 131 100 Table 5.40: Average loss in income by methods due to problem of shortage/stock- out/irregular supply of FP methods Methods Average loss in income (in Tk.) Income loss of Pill sufferers 874 Income loss of Injection sufferers 1050 Income loss of Condom sufferers 774 CHAPTER VI IMPACT ON NATIONAL ECONOMY DUE TO SHORTAGE, STOCK-OUT AND IRREGULAR SUPPLY 6.1. Introduction This chapter will focus on the impact on the national economy in terms of income loss, medical costs incurred, and costs of time loss from sufferings due to stock- out/shortage/irregular supply of oral pill, injectables, and condom to the users. It will also focus on the methodology on which these parameters have been estimated. Besides, time lost due to sufferings has been converted to money value taking into account the opportunity cost of the sufferers. For this purpose, total lost of time from the sufferings are assumed to be productive time lost. Cost of sufferings of both male and female has been taken into account. 6.2 Impact on National Economy due to Shortage/Stock-Out/ Irregular Supply of Oral pill, Injectables, and Condom 6.2.1 Estimation methodology For the purpose of the estimation of income loss and the total medical cost due to shortage/stock-out/ irregular supply, 30 out of 23,500 FWA units were selected which comprises approximately 0.13% of the total. The total number of oral pill, injectables, and condom users in FWA registers of these 30 units was 26,445. Total sample of this study was 2,756, which is 9.6 times less than the total number of users of three methods in the sample area. This could be treated as highly representative sample. So, for the estimation purpose at the national level, the findings from the sample were extrapolated at the national level. First of all, income loss and medical costs incurred due to the shortage/stock-out/ irregular supply were calculated per FWA unit basis and this was taken as the cost/ FWA unit and income loss/FWA unit. These findings were counted only for the sample. As the sample was 9.6 times less than the relevant population of the sample area, so those figures were multiplied by 9.6 in order to have the findings for the population of that sample area. Dividing that figure by 30, we estimated the medical cost and income loss per FWA unit. Multiplying that figure by 23,500 FWA units, total medical costs and income loss was estimated to represent the national level. Besides the loss of net income and the medical costs incurred, many types of sufferings borne by the sufferers have been estimated which included physical sufferings/loss, psychological sufferings/loss, loss from income generating activities, loss from households activities, and loss from social activities. For those causes, sufferers lost their time and it is well-known that time is money. So, all the times lost by the sufferers were counted as loss of productive time. The same process was applied for counting the cost from loss of their time at the national level. 6.2.2 Direct Loss of Income at the National Level About 64% of the total sufferers lost some portion of their net income. The estimated annual (for the last one year preceding the survey) average net income loss per suffering household amounted to Tk. 912. Of the methods considered in this study, pill sufferers reported the highest net income loss (434.25 million Tk.). This was followed by injection (323.82 million Tk.). Condom sufferers contributed to the least income loss which is Tk. 139.86 million. By Estimation Formula: National Counts = (Events within sample * Multiplier)/Sample FWA units * Total FWA units in Bangladesh HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 45 using the methodology to estimate the income loss by methods, it was found that the national annual loss of income amounts to Tk. 897.93 million. This was the direct loss of their income due to shortage/stock- out/irregular supply of three FP methods: Oral pill, Injectables, and Condom. Now, we will focus on the distribution of the net income loss of the sufferers by methods. The highest loss incurred is found for the stock-out of pill (48.4%), followed by injection (36.1%) and condom (15.6%) respectively (Table 6.1 and Figure 6.1). Table 6.1: Percentage distribution of the net income loss of the sufferers by methods Methods Taka (in million) Share of Income Loss (%) Pill 434.25 48.4 Injection 323.82 36.1 Condom 139.86 15.6 Total 897.93 100 6.2.3 Medical Cost of suffering at the National Level About 31% of the total sufferers incurred medical costs due to their physical or health related problems/sufferings. The medical costs comprised of fees, medicine, diagnostics, transportation, and food related costs. By using the methodology to estimate the income loss by methods, it was found that the medical costs nationally amount to Tk. 629 million due to the stock-out/irregular supply of the considered methods in this study. This was the direct medical cost incurred for the households suffered physically. The table and the graph shows the distribution of the total medical costs incurred due to the stock-out/shortage/ irregular supply of pill, injection and condom. Medicine was found as the major cost item which is slightly higher than that of the transportation costs. It was also observed from the findings that the least cost incurred for diagnostics as few of the sufferers went for diagnostics (Table 6.2 and Figure 6.2). Table 6.2: Pattern of medical costs incurred by items Cost Items Cost (in million Tk.) Share of Total Cost (%) Visit 122.6 19.5 Medicine 214.4 34.1 Diagnostics 129.1 20.5 Transportation 51.3 8.2 Food 112.4 17.8 Total 629 100 Figure 6.1: Percentage distribution of income loss of the sufferers by methods 16% 36% 48% Pill Injection Condom HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 46 6.2.4 Estimation of loss from physical or health related problems at the national level About 55% of the total sufferers suffered physically. From each sufferer, we had more than 3 responses. In this section, time lost was calculated due to physical sufferings. The total loss of those suffered physically in terms of time stood at 150,450 hours. This was multiplied by 9.6, which gave us the figure for the total population in 30 FWA units. This amount rose to 1.44 million hours. So, per FWA unit, this gave us the amount of 48,144 hours. For the national level, this figure stood at 1,131.3 million hours. Average wage rate per hour was calculated at Tk. 14.25. Assuming that all the time lost for these sufferings was productive, the estimated loss from sufferings/problems at the national level in terms of money value due to shortage/stock-out/ irregular supply amounts to Tk. 16,122 million. This was the indirect loss of income at the national level that arose from physical or health related sufferings/problems. The distribution of loss from physical suffering arising from the stock-out is summarized in the following table. The highest cost is found for “headache” response as this was the most frequent response. The second major category is “general weaknesses” (Table 6.3). Table 6.3: Pattern of loss from physical or health related sufferings/problems Physical/health problems Loss (in million Tk.) Share of loss (%) Vomiting 1817 11.3 Headache 2865 17.8 Bleeding during menstruation 1119 6.9 Menorrhegia 894 5.5 Pain in abdomen during menstruation 261 1.6 Pain during menstruation 78 0.5 High blood pressure 57 0.4 Mastalgia/Feeling heaviness of breast 553 3.4 Unexpected pregnancy 1097 6.8 Burning sensation of the body 724 4.5 Amenorrhea for 3 months 1834 11.4 Unexpected weight gain/loss 462 2.9 Anorexia 932 5.8 Facial pigmentation 0.1 0.0 Acne 3 0.0 Lower abdominal pain/uterine pain 423 2.6 General weakness 2807 17.4 Waist pain 191 1.2 Total 16122 100.0 6.2.5 Loss from psychological health problems at the national level In this section, time lost was calculated for psychological sufferings. The prevalence of psychological sufferings was higher than that of other types of sufferings. About 79% of the total sufferers suffered psychologically. From each psychological sufferer, we had more than 3 responses. Here per FWA unit, the amount of time lost is 48,737.5 hours. For the national level, this figure stood at 1,145.3 million hours. Average wage rate per hour was calculated at Tk. 14.25. Assuming that all the time lost for these sufferings was productive, the estimation of loss from psychological problems at the national level in terms of money value due to shortage/stock-out/ irregular supply amounts Tk. 16,321 million. This was the indirect loss of income that arose from psychological problems at the national level. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 47 Anxiety and insomnia have been found as the two major cost components from psychological sufferings. The following table and the graph will provide the clear conception of the disaggregated data. The graph is used to know about the proportional distribution of loss by components (Table 6.4 and Figure 6.3). Table 6.4: Pattern of loss from psychological sufferings/problems Psychological problems Loss (in million Tk.) Share (%) Anxiety/Suspense 4591 28.1 Lassitude 1245 7.6 Fear of being Pregnant 3384 20.7 Embarrassment 313 1.9 Insomnia 4576 28.0 Despondency 2212 13.6 Total 16321 100.0 6.2.6. Loss from income generating activities at the national level About 25% of the total sufferers suffered from time loss related to income generating activities. From each sufferer, we had more than 3 responses. In this section, time lost from income generating activities was calculated. The total time loss from income generating activities stood to 6,187.5 hours. This loss multiplied by 9.6, gives the figure for the total population for 30 FWA units, 59,472 hours. So, per FWA unit, this gave us the amount of 1980 hours. For the national level, this figure stood at 46.53 million hours. Average wage rate per hour was calculated at Tk. 14.25. Assuming that all the time lost for these sufferings was productive, the estimation of loss from disruption of incoming generating activities at the national level due to shortage/stock-out/ irregular supply amounts Tk. 663.1 million. This was the indirect loss of income that arose from the disruption of income generating activities at the national level. The distribution of loss from income generating activities at the disaggregated level is shown in the following table. The table indicates that poultry rearing sector has the largest share of the total loss incurred from the time loss from their income generating activities (Table 6.5). Table 6.5: Pattern of loss from sufferings/problems related to income generating activities Problems related to income generating activities Loss (in million Tk.) Share of Loss (%) Preparing crop land 3.2 0.5 Plantation 2.6 0.4 Nursing 2.9 0.4 Cutting/boiling 9.0 1.4 Vegetables garden 0.1 0.0 Poultry rearing 299.0 45.1 Cow/goat rearing 220.3 33.2 Buying and selling goods to the market 5.1 0.7 Agricultural labor 36.8 5.5 Labor to non-agricultural sector 84.9 12.8 Total 663.1 100.0 Anxiety/ Suspense 28% Lassitude 7%Fear of being Pregnant 21% Embarrass -ment 2% Insomnia 28% Despon- dency 14% Figure 6.3: Percentage distribution of loss from psychological sufferings/problems HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 48 6.2.7 Loss from household activities at the national level About 31% of the total sufferers suffered from time loss related to household activities. From each sufferer, we had more than 3 responses. In this section, time lost from household related activities has been calculated. The total time loss attributed to household activities stood at 259,275.8 hours. If this is multiplied by 9.6, this would give us the figure of 2.48 million hours for the total population in 30 FWA units. So, per FWA unit, this gave us a figure of 82,968.2 hours. For the national level, this figure stood at 1949.7 million hours. Assuming that all the time lost for these sufferings was productive and the average wage rate per hour is Tk. 14.25, the estimated loss attributed to household activities at the national level due to shortage/stock-out/ irregular supply amounts to Tk. 27784 million. This was the indirect loss of income that arose from the disruption of household related activities at the national level. The share and the amount of loss by the components are shown in the following table and the pie chart (Table 6.6 and Figure 6.4). Table 6.6: Loss by components of household activities Household activities Loss (in million Tk.) Share of Loss (%) Cleaning houses 7540 27.1 Cleaning utensils 5801 20.9 Cooking 7390 26.6 Hosting guests 3326 12.0 Collecting firewood 1649 5.9 Nursing child 2077 7.5 Total 27784 100.0 6.2.8 Loss from social activities at the national level About 6% of the total sufferers suffered from time loss related to social activities. This was the lowest prevalence rate among the activities considered in this study. From each sufferer, we had more than 3 responses. For this section, time lost from social activities was calculated. The total time loss from social activities stood at 345.2 hours. This multiplied by 9.6 gives us the figure for the total population. So, per FWA unit, this gave us the figure of 110.4 hours. For the national level, this figure stood at 2.6 million hours. Assuming that all the time lost for these sufferings was productive and the average wage rate per hour is Tk. 14.25, the estimated loss attributed to social activities at the national level due to shortage/stock-out/irregular supply amounts to Tk. 37 million. This was the indirect loss that arose from the disruption of social activities at the national level. The loss categories and the amount of loss and their share are shown in the following table (Table 6.7). Table 6.7: Loss from social activities Social problems Loss (in million Tk.) Share of Loss (%) Attending different social clubs 27 73 Participation in salish 10 27 Total 37 100 Cleaning houses 27% Cleaning utensils 21% Cooking 27% Hosting guests 12% Collecting firewood 6% Nursing child 7% Figure 6.4: Share of loss from household activities HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 49 6.2.9 Total national loss by broad components The following table is the summary table that shows the distribution of the losses which were incurred from sufferings attributable to different activities. As the total time was lost from the household activities, so the highest bar in the following diagram (Figure 6.6.) shows the total loss from the loss of household activities in terms of money cost. The second highest cost was incurred for psychological cause. The following table and the graph summarize the total amount of loss by different categories. It is found that households has the largest share of the cost (45.3%) followed by psychological (26.8%) and health related problems (26.3%) respectively (Table 6.8, Figure 6.5 and Figure 6.6). Table 6.8: Pattern and share of loss by different items Loss Items Amount (in million Tk.) Share Physical 16123 26.5 Psychological 16326 26.8 IGAs 662 1.1 Household Activities 27784 45.6 Social Activities 37 0.1 Total 60932 100.0 6.2.10 Unexpected pregnancy, MR and abortion at the national level due to shortage/ stock-outs/irregular supply About 10.2% of the total sufferers reported unexpected/ unwanted pregnancy. Total unexpected pregnancy for the population was calculated based on the sample. The number stood at 202 for 30 FWA units. So, unexpected pregnancy per FWA unit was 6.8. The national estimated figure is 159,800. Of the unexpected pregnant mothers, 57% went for MR. So, the MR per FWA unit was 3.84 and the national figure stood at 90,240. The national figure for abortion was 22,560. Unexpected/unintended pregnancy as a result of shortage/stock-out/ irregular supply stands at 159,800 which are terminated by 90,240 MR cases and 22,560 abortions. The net addition to the growing population is 47000 babies born per year. This unintended/unexpected number of birth will impact on national economy. Unexpected pregnancy and additional child birth could be considered as the ‘additional child birth due to unexpected pregnancy’ which contributed to higher rate of population growth. MR and abortion could contribute to the extra burden on their family budget and sometimes it also contributed to maternal mortality and morbidity. CHAPTER VII ADEQUACY OF FINANCIAL SUPPORT FOR AND PRIORITY OF NATIONAL HEALTH NUTRITION AND POPULATION SECTOR 7.1 Health Nutrition Population Sector Programme The National Health Nutrition Population Sector Programme (HNPSP) was designed at an estimated cost of Tk. 324,503 million for a period from July 2003 to June 2011. The implementation status – both physical and financial – is reviewed annually, jointly by Development Partners (bank and other donors) and the Government of Bangladesh. The Health Nutrition Population Sector Programme is one of the priority sectors for both development and alleviation of poverty. The HNPSP aims at reducing: • NMR per 1000 live birth from 32 to 21. • IMR per 1000 live birth from 48 to 37. • MMR per 1000 live birth from 2.75 to 2.40 by 2015. • Total Fertility Rate (TFR) from 2.8% to 2.2%. • Increase CPR from 58% to 72%. • Malnutrition of under-five children from 42% to 30%. • Anemia of pregnant women from 45% to 30%. • Increase vaccination coverage with full series of routine EPI vaccine to 90% by 2010. In order to give a major thrust to HNPSP, the government has brought the Ministry of Health and Family Welfare under Medium Term Budgetary Framework (MTBF) from 2006-07. 7.2 Trend Analysis of Allocation and Utilization of Fund An analysis of last 3 years ADP allocations of 2005-06, 2006-07, 2007-08 for HNPSP revealed an increasing trend. Table 7.1 below shows the trend in allocation in ADP for HNPSP. Table 7.1: Trend in general in ADP allocation for HNPSP ADP financial year (FY) Total allocation in million taka Increment 2005-06 (year 1) 22693.50 Base year 2006-07 (year 2) 24241.60 6.82 % 2007-08 (year 3) 27287.50 20.24 % As compared to the base year (FY 2005-06), there has been an increase of Tk. 1548.10 million in year 2006-07 which was about 7% higher, and in FY 2007-08 the increment was Tk. 4594.0 million which was more than 20% (over the base year 2005-06). Regarding rising trend, the government document – Annual Development Programme FY 2007-2008 – stated that, “Considering health sector as the priority one, adequate allocation has been given in ADP 2007-08 for successful implementation of programmes related to Health, Nutrition and Family Welfare” (see page 281 of ADP 2007-08). The ADP 2007-08 allocated Tk. 27287.5 million, and “in comparison with the allocation of RADP 2006-07, the ADP allocation of 2007-08 increased by Tk. 3045.9 million (GOB Tk. 1903.3 million and Project aid Tk. 1142.6 million) which was 13% higher” (page 282 of ADP 2007-08). HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 50 The overall utilization status of ADP allocations for HNPSP, on average, was between 79% and 86% annually. It was neither dismal, nor promising. Despite availability of funds, utilization could not reach the expected level. The plausible reasons as reported by knowledgeable persons include political instability, bureaucratic bottlenecks, indecision, and inefficiency. The general scenario is that the government of Bangladesh spends an estimated “US $ 5 per capita on HNPSP services, private out of pocket expenditure is about US $ 7 per capita. This level of spending falls far short of the level required for providing a basic service package. According to WHO, the optimum suggested expenditure for the least developed countries is US$ 34 per capita per year”. (Ref: Unlocking the potential – National Strategy for Accelerated Poverty Reduction, Page 142, Planning Commission, October-2005). There is no study conducted so far, about the entire Health Nutrition and Population Programme (a sector-wide programme for the entire country) specific to ascertaining trends, sufficiency/adequacy of allocation of fund (need-based), utilization, capturing priority and capacity of absorption. There are various other facets of such a study requiring an in-depth examination of financing, resource management system, and disbursement mechanism. The present study can not/did not address all these issues. The issues are broad, complex, interwoven, overlapping, cross-cutting, and multi-dimensional. The ‘objective-3’ of the present study has been addressed within a limited scope, time and cost. To address pertinent issues fully – an independent study with more time and resource would be a bare necessity. 7.3 Trends in Allocation, Expenditure on Contraceptives and DDS kits: FP sub- sector under HNPSP Within the limited scope/objective of the present study (titled: Human and Economic Impact of RH supplies shortage and stock-outs in Bangladesh), it was possible to dig out some facts and figures about the trends in allocation, utilization/expenditure of fund for RH supplies particularly contraceptives and DDS kits. An analysis of development as well as non- development/revenue budget allocation revealed an erratic pattern in allocation with fluctuating expenditure for last 3 (three) financial years. Table 7.2 below shows the trend. Table 7.2: Trends in Allocation and Expenditure for National FP Programme (in million taka) Total Allocation for FP Programme Total Expenditure FP Programme and % of allocation Financial years (FY) Development Non-development Total Development Non- development Total Expenditure (% of allocation) 2005-06 4510.10 5257.0 9767.1 2971.55 4635.55 7607.10 (77.88%) 2006-07 5648.73 6505.21 12153.94 4763.65 5733.02 10496.67 (86.36%) 2007-08 3300.89 6332.73 9633.62 2716.46 5524.94 8241.40 (85.55%) 3 years 13459.72 18095.03 31554.67 10451.66 15893.51 26345.17 (83.49%) In FP sub-sector of HNPSP, for FY 2005-06, the total allocation was Tk. 9767.10 million and expenditure was Tk. 7607.10 million which was 77.88% of allocation; in FY 2006-07, total allocation was Tk. 12153.94 million and total expenditure being Tk. 10496.67 million, percentage was 86.36. In terms of total allocation in FY 2006-07, it was 24.43% rise over FY 2005-06, and as regards expenditure it was 37.98% rise. Allocation in non-development vs HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 51 development budget, if compared between 2005-06 and 2006-07, had also registered a rise of 23.74%, and in expenditure (non-development) there was 23.67% rise. This shows a rising trend both in allocation and expenditure during FY 2005-06 and FY 2006-07. During FY 2007-08, an amount of Tk. 9633.62 million was allocated to FP Programme and Tk. 8241.40 was expended which was 85.55% of total allocation. Compared to FY 2006-07, the total allocation of FY 2007-08 declined by Tk. 2520.32 million which recorded 20.74% decline and in expenditure almost same scenario of decline – 21.49% was observed. Evidently, position in FY 2006-07 in allocation/expenditure was higher than in FY 2005-06 and FY 2007-08. Apparently, a bulk of allocation/expenditure for contraceptives and DDS kits took place in the FY 2006-07 causing a bump up of about 21.49% over FY 2007-08. Rise of allocation in FY 2006-07 was phenomenal. But between FY 2005-06 and FY 2007-08 the difference was marginal in allocation (Tk. 133.49 million less in FY 2007-08), but in expenditure it was more by Tk. 634.30 million (8.33%) in FY 2007-08. The comparison between FY 2005-06 and FY 2007-08 with a gap of one year in-between might give a signal of weak resource-planning, utilization of resources, and poor management capacity. Regarding allocation of fund for contraceptives procurement and expenditure during last 3 years from 2005-06 to 2007-08, table 7.3 below speaks for itself. Table 7.3: Trends in allocation and expenditure on contraceptives for national FP programme (in million taka) Allocation for contraceptives Expenditure for contraceptives & % of allocation Financial years (FY) Development Non-development Total Development Non- development Total (% of allocation) 2005-06 951.54 0.0 951.54 281.53 0.0 281.53 (29.59%) 2006-07 3406.45 0.0 3406.45 2964.37 0.0 2964.37 (87.02%) 2007-08 1470.20 0.0 1470.20 1360.20 0.0 1360.20 (92.52%) 3 years 5828.19 0.0 5828.19 4606.10 0.0 4606.10 (79.03%) Among the last 3 years period (FY 2005-06 to FY 2007-08), both allocation and expenditure for contraceptives was highest in FY 2006-07 (Tk. 3406.45 million Vs Tk. 2964.37 million). Lowest allocation and expenditure was during FY 2005-06, when expenditure was only Tk. 281.53 million against an allocation of Tk. 951.54 million, which meant that 29.58% of fund was expended. Again, in FY 2007-08 allocations for contraceptives was Tk. 1470.20 million and expenditure was Tk. 1360.20 million, the percentage of utilization was Tk. 92.52%. Overall (for 3 years), 79.03% of allocated fund (Tk. 5828.19 million) could be expended (Tk. 4606.10 million) entirely from development budget, and no allocation/expenditure was made from non-development/revenue budget of the government. This is symptomatic of a disappointing trend. Compared to the total expenditure for RH-FP Programme the procurement cost (expenditure) of contraceptives was 3.70% in FY 2005-06, 24.24% in FY 2006-07, and 16.50% in FY 2007-08. Overall, for the last 3 years the percentage of contraceptives procurement costs/ expenditure was 17.48% of total expenditure for RH-FP Programme. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 52 According to some programme-managers and warehouse managers, 20-22% of total allocation of fund for FP programme, or Tk. 1660-1760 million would be barely necessary for contraceptives procurement annually, and local procurement of quality contraceptives should be encouraged by the government to avert shortage/stock-out/delayed supply etc. with a strong system of procurement-supply-distribution monitoring. Trends in allocation and expenditure on DDS kits The DDS kit is indeed an essential service sub-component for the well-being, particularly of the deprived mothers and children. It also provides coverage to all needing medical care and support at the level of FWC, MCWC, Upazila Health Complex, Satellite Clinic, etc. Allocation of fund for DDS kits is of high importance. Table 7.4 below shows allocation and expenditure trend for procurement of DDS kits. Table 7.4: Trend in Allocation and Expenditure on DDS kits for last 3 years FY 2005-06 to 2007-08 (in million taka) Allocation for DDS kits Expenditure for DDS kits & % of allocation Financial years (FY) Development Non-development Total Development Non- development Total (% of allocation) 2005-06 0.0 150.0 150.0 0.0 150.0 150.00 (100%) 2006-07 968.90 116.23 1085.13 868.90 67.10 936.00 (86.26%) 2007-08 134.21 0.0 134.21 134.21 0.0 134.21 (100%) 3 years 1103.11 266.23 1369.34 1003.11 217.10 1220.21 (89.11%) Sources: ADP/R-ADP, Planning Commission M/O Planning, Govt. of Bangladesh: for Development budget allocation, • M/O Finance, Govt. of Bangladesh, Annual Budget: Non-development Budget Allocations. • Director Finance, DGFP and Director MFSTC: Non-development budget Expenditure. • Line Directors DGFP: Development Budget Expenditure DDS kits procurement was made by Tk. 150 million from non-development/revenue budget allocation of FY 2005-06, there being no allocation from development budget and reasons for this could not be figured out. In FY 2006-07, development budget allocation for DDS kits was Tk. 968.90 million and revenue budget provided Tk. 116.23 million, highest allocation, with expenditure incurred to the extent of Tk. 936.00 million (86.26% of allocation). Again in FY 2007-08, there was no allocation for DDS kits from the revenue budget. As it appeared from table above, the trend in the allocation of fund from both development and non- development/revenue, for DDS kits had been oscillating for reasons not known. No specific justification was available. The question of sufficiency – whether the allocation from both development and non- development budgets was/is sufficient, when addressed to programme-managers, field staff and other respondents, the answer was indirect, and they reported that there was/is huge demand for DDS kits and an increased number of kits should be procured preferably from local market to sustain uninterrupted service delivery. This has given an impression that more funds (higher allocation) would be necessary to meet the ever growing need of the vast number of clientele. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 53 7.4 Adequacy of Fund for National RH-FP Programme: FP sub-sector Although, the objectivity of the ‘Study Objective 3’ about ‘sufficiency of fund’ – an issue of highest consideration – is indeed dubious and complicated, yet the following questions must be investigated in order to assess/ascertain ‘sufficiency’ criterion. Sufficiency is a relative term and the questions are: • How much is – (a) sufficient, (b) more than sufficient, and (c) less than sufficient? • How much (money) is needed to accomplish a purpose: how to assess actual needs, how to ascertain desired need (wish list etc.)? • How much (money) is allocated/received on time/timely, how much is available beyond the expected time? • How much is expended/utilized – and the capacity to absorb resources – to meet specific purpose for which allocation was/is given; or otherwise, how much was/is spent for fulfilling desired need/wish list items to show bulk of expenditure? While investigating some of the questions as noted above it was found that, without carrying out a well-designed need-assessment study/exercise well ahead of time, need-based allocation of fund to any programme(s) is not feasible. Those who ask for allocation and those who provide allocation of fund, both do hardly care for need-assessment. Allocations are asked for and provided on the basis of availability of resources and discretion of the concerned individuals. However, pruning exercises during the middle of the financial year were always done through discussions with concerned persons. Again, a need-based allocation would call for bottom-up planning exercises. It was found that, with the question of allocation of fund, its justification has always been linked to actual utilization status and capacity for absorption of fund fruitfully, in other words, responsibly to derive the expected benefit or outcome. The study team (HDRC) has not done in-depth study of these interlinked issues. Even then, based on – • Trends in allocation of funds (FY-2005-06 to 2007-08) as in ADPs. • Trends in utilization of allocated funds by the Directorate General, FP (DGFP)/ Directors, Finance/MFSTC/Logistics and other professionals; • Discussions with informed/knowledgeable persons and Field Programme-Managers (Deputy Directors, Upazila FP Officers, Medical Officers, Warehouse Managers and others), the study team addressed the issue of ‘sufficiency’ to fulfill ‘Study Objective 3’ to the extent possible. In general, the allocations for HNPSP or particularly for FP sub-sector/RH-FP commodities were viewed as "not sufficient”; and that allocations have to be raised to improve services both quantitatively and qualitatively to reach the poor and poorest of the poor/hardcore poor. Most of the respondents also opined that, an essential condition is the necessity for changing attitude of service providers who must have commitment to the clientele. This was lacking in their opinion. Regarding the capacity for utilization of fund, they reported that delayed release of fund, delay in administrative approval, and delay in financial sanction-orders, and overall, the cumbersome procurement process are the debilitating factors for paralyzing the ability of the Programme/Project Directors in utilizing funds fully. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 54 7.5. Findings and Lessons Learnt Findings • In financing the future Bangladesh must go ahead with huge investment in human resource development and prioritize health, nutrition, and population sector for resource allocation. Currently, Government’s allocation to health, nutrition and population sector in terms of percentage of GDP is 1% or a little more, against WHO estimation of 5% of GDP. This is not at all sufficient. • It is well-established that Health-RH is a factor in ‘investing in people’. Timely need- assessment, resource mobilization, management, and utilization/absorption capacity of the organization (Health, Nutrition and FW) for implementing a robust Health and Family Planning Programme is absolutely necessary. • Evidently, Government’s allocation and public spending is low and barely adequate to meet the demands of an ever expanding health sector programme. But, the real problem is rooted in the inability/inefficiency of the functionaries, and in the system involved in the process of spending public money efficiently. Absorption of allocated fund for specific purpose is an acute problem. This problem is diluted with the blame- game played by key-players in the system of spending public money. • Field managers and knowledgeable persons hardly think that shortage of money is a problem for the sector-wide programme, rather they think that spending money is the problem. Side-by-side, the organizational/structural capacity with available human resources of government, the system of spending money (allocation) within a time- bound planning framework in the backdrop of MDG and HNPSP objectives calls for a serious review/evaluation. This is a challenging task ahead for the nation. Lessons learnt Precisely – • Need-based allocation and auto-release of fund for 3 quarters of the financial year for essential programme components, such as RH commodity procurement must be considered. • At the same time, a hassle-free procurement procedure should be developed ensuring due accountability and transparency. • Gradual absorption of essential RH-commodity costs in the revenue budget, reducing dependency on loan/grant money (of donors) with sting attached, should be planned and acted upon. CHAPTER VIII CONCLUSIONS AND RECOMMENDATIONS 8.1 Conclusions In spite of all the problems and bottlenecks Bangladesh Family Planning Programme has been proceeding well and contributing to the decline in fertility and population growth rate. However, this is the first time when CPR has fallen from 58% to 56% during last 3 years (BDHS, 2007). Some of the major concluding findings of this study to ascertain the human impact of stock-out, shortage and irregular supply of three selected family planning commodities (oral pill, injectables, and condom), and its impact on national economy during last one year are as follows. • There is a discrepancy between the FWA registers and the actual number of users (4.8%). • There is a huge gap between official reporting and that of the actual stock-out, shortage and irregular supply (official reporting 0.6% and HDRC findings 12%) • Total number of users suffering from stock-out, shortage and irregular supply of family planning commodities (oral pill, injectables and condom) was 1.54 in Bangladesh during last one year (sample period). • During the last year preceding the survey, a 7.4% of the users of oral pill, injectable, and condom faced shortage/stock-out/irregular supply and thereby suffered from multidimensional problems including those related to physical and health, psychological, income generating activities, household activities, and social activities. Nationally, estimates show that the total loss of the sufferers (during last year) would be about 4,275 million hours, and money value of that amounts to Tk. 60,932 million. • Loss (annual) of net income at the national level due to shortage/stock-out/ irregular supply amounted to Tk. 1,005million. • Medical cost (annual) at the national level incurred due to shortage/stock-out/ irregular supply amounted to Tk. 629 million. • Loss of time due to physical or health related problems was 1,131.4 million hours which amounted to Tk. 16,123 million for the sample period, nationally. • Loss of time of the sufferers those suffered psychologically stood at 1,145.3 million hours which amounted to Tk. 16,326 million for the sample period, nationally. • Loss of time of the sufferers those suffered from income generating activities has been calculated at 46.53 million hours, which in terms of money value amounted to Tk. 662 million. • Loss of time due to disruption of household related activities at the national level has been calculated at 1,949.7 million hours and amounted to Tk. 27,784 million, nationally. • Loss of time due to disruption of social activities at the national level due to shortage/ stock-out/irregular supply has been calculated at 2.5 million hours and the cost amounted to Tk. 37 million. • In addition, nationally the unexpected pregnancy due to shortage/stock-out/irregular supply of these 3 methods have been calculated to 159,800, out of which 90,240 HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 56 (57%) had gone for MR and 22,560 for abortion. Thus, shortage/stock-out/ irregular supply of these 3 methods are responsible for a total of 47,000 additional child birth due to unexpected pregnancy, which has contributed to unintended increment in population during last year. • There are 19 steps in the Procurement process which takes 18 to 24 months or even more. • There is lack of proper Forecasting mechanism for Projection of procurement needs. • There is lack of coordination among the departments and also with the donor agencies. In terms of economic loss, the estimated total loss in taka arising from loss of time due to sufferings was Tk. 60,932 million during last one year. It is both unacceptable and alarming for RH sector. The programme requires multiple inputs and safeguards from different authorities to reach a sustainable level. The following sections provide some recommendations regarding effective implementation of procurement, supply and distribution of commodities, which deserve merit towards bringing some positive changes in the national FP Programme. 8.2 Highlights of Some Field Problems Observed During Field Investigation HDRC field investigators in post-field discussions found out numerous problems during their stay in the areas under study. These are: • Household visits and counseling of ELCOs by FWAs are not regular and the frequency of visits by them is also very low. • In a good number of cases, couples on record in the FWA Register were not found in the given address. FWA Register entry was questionable. • In some places, against the spirit of “cafeteria approach”, coercive motivation by field staff for using some specific contraceptives by couples was found. • Married women of reproductive age-bracket crossing the menopause age was found in the FWA Register, and more than one Register was found; the Register was not updated, had no serial number for the registered users. • Method switch-over by users was not recorded in the Register. • FWAs were found lacking in knowledge and motivation for better service delivery and record-keeping. 8.3 Recommendations 8.3.1 Sufferer’s opinion about shortage/stock-out/irregular supply for improving the present situation Focus Group Discussions (FGD) were held at FWA unit level, in a good number of places. Some FP users who had experienced stock-out/shortage/irregular supply of RH commodities at least once during last one year and reported their sufferings at the time of interview, participated in Focus Group Discussion and offered their views on a number of issues. Their views were consolidated and are mentioned below: HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 57 • Supply FP-RH commodities in sufficient quantities to meet users needs for at least every 3 months at a time, in a continuous process. • FWAs should make home-visits regularly; and for ensuring regular visits (at home) their (FWAs) number may be increased; users prefer home delivery of contraceptives. • FWAs and other staff should behave well with the clients (users of RH methods) • FWAs and other field staff/clinic staff should not charge money for providing injectables, oral pill and condom (for example, per case of injection Tk. 10-30 is charged). • Follow up service by field staff/FWAs/FWVs should be strengthened so that side- effects of FP methods can be tackled with confidence. • Service centre/depot-holder nearest to client’s household can also be established to ensure needed supply in the event of supply by FWA disrupted, for reasons beyond her (FWA’s) control. • Training to the field workers should be regularly imparted to ensure their skills and commitment to the clientele. • Supervision of field worker’s performance should be done by responsible supervisors so that negligence and inefficiency of these field staff do not kill the desire of the users (clients) for Planned Parenthood, pushing them to unwanted poverty, suffering, and misery. • Low dose oral pill should be made available in greater quantity. For example – Pill users said that they preferred “ Femicon,” against “ Shuki Pill”, since it adjust well with their body chemistry. 8.3.2 Suggestions and Recommendations of the Service Providers and Managers for Improving the Present Situation Six group discussions were held with district and upazila level officials of FP-MCH programme at district HQs. The participants viewed that problems and issues are linked with one-another, and opined that because of inter linkages, a holistic approach to present-day problems should be adopted. Most of them do not think stock-out/shortages/irregular supply as an isolated issue. Procurement-supply-distribution, follow-up, and monitoring are integrated as a system, the success of which depends on – planning, financial, managerial, professional-technical knowledge, skill, and efficiency. They need to grow as a professional cadre and should be given due opportunity, support and guidance in the interest of public service. Summary of recommendations scanned from Interviews, FGDs, Group Discussions, and participants of National Dissemination Seminar are as follows: • Streamline procurement system and make the procedure simpler – reduce steps of bureaucratic bottlenecks, cumbersome and time-consuming formalities. • Effect need-based, bottom-up procurement plan. • Like the other issues, ‘Population problem’ should be focused as a major national issue. • Encourage, promote/patronize for local production of quality FP-RH commodities, particularly contraceptives such as pill, condom, injectables etc. in public and private sectors to procure it locally. HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 58 • Empower District FP Authorities to make local procurement of available RH commodities to meet shortages in the supply line/stocks urgently. • Allocate fund from Revenue Budget of the government for procurement/production of RH commodities to reduce donor-dependence with the objective of achieving self reliance and sustainability. • Establish a sound monitoring system, a forecasting mechanism of procurement and supply. • Ensure training and re-training of field functionaries to build up their work skill (motivation, service-delivery, record-keeping, reporting, monitoring etc.) and meet the discrepancy of the govt. report and the field reality. • Permanent contraceptives methods should be encouraged to get rid of irregular supply system. • Undertake basic studies to develop contraceptives suitable for use by the ever growing population of Bangladesh. • Carry out separate study on ‘Reasons of irregular supply of FP items at the service delivery points’. • Expand and equip storage facilities to have a capacity for at least 24 months stocks in stores at different levels (regional/local). • Increase manpower at the field level to regularize home visit and proper service delivery near the door steps of clientele. • Alternatives/options to increase manpower in the field should be seriously examined, pilot tested and adopted, if found economically-socially suitable/viable. • Utilize the services of NGOs in service delivery and monitoring where there is shortage in manpower to strengthen home visit and service delivery. • Strengthen FP programme by professional people (population-FP) of the Department (cadre) to get the best out of present day bureaucracy, democratic culture and specialization. In view of the findings of the study and recommendations by Programme Managers, Service Providers and Clients, the study team suggest to institute a full-fledged Project Resource Mobilization and Awareness (PRMA) Unit for effective monitoring of procurement and supply activities of RH-FP commodities. PRMA may also be given the responsibility of advocacy at various levels. The study team also suggests a time-bound implementation plan for implementation of all feasible recommendations for the greater interest of the nation. Annex 1: Data Collection Instruments HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 60 Sample ID No. Study on Human and National Impact of RH Commodity Shortage/ Stock-outs in Bangladesh Short Profile of User of Contraceptives Directives to the interviewer: Tell the objectives of interview to the respondent /interviewee. Tell him/her that, the main subject of the study is to know about the problems faced due to non-availability of the family planning supplies. Tell him/her about the other issues that could come and the time needed for this. Assure him/her that their name and address will not be disclosed. Tell him/her that, all information provided will be kept confidential, and shall not be used for any purpose other than this research study. 1. Name of user 2. Age 3. Mobile number 4. Name of Husband/Father/Wife 5. Address of user FWA Unit No.: Ward No. : Village : Union : Upazilla : District: 6 Are you using contraceptive for last one year ? Yes = 1, No = 2 [Answer is no Finish interview Thanks] 7 If yes, what is the name of contraceptive Pill =1, Injection =2, Condom =3 8 Have you received the contraceptive in proper time regularly? Yes = 1, No = 2 [Answer is Yes Finish interview Thanks] Dis Upa FWA Method Un DCI - 1A HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 61 9 If not received regularly for how many times ? 1 time=1, 2 time =2, 3 time =3 10 Have you suffered from any problem due to this irregularity in receiving contraceptive? Yes = 1, No = 2 11 Had you any pregnancy due to this irregularity in receiving contraceptive ? Yes = 1, No = 2 12 Have you changed method due this problem Yes = 1, No = 2 13 If you have changed method, what is the method you are using now ? Pill =1, Injection =2, Condom =3, Copper T= 4, Implant=5, Vasectomy= 6, Tubectomy =7, Withdrawal=8, Kabiraji=9, Safe Period Method=10 Name of the Interview: Date . /03/ 2009 HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 62 Sample ID No.: Study on Human and National Impact of RH Commodity Shortage/ Stock-outs in Bangladesh Interview with Sufferer of Contraceptive Shortage Directives to the interviewers: Tell the objectives of interview to the respondent/ interviewee. Tell him/her that, the main subject of the study is to know about the problems faced due to non-availability of the family planning supplies. Tell him/her about the other issues that could come and the time needed for this. Assure him/her that their name and address will not be disclosed. Tell him/her that, all information provided will be kept confidential and shall not be used for any purpose other than this research study. Sufferer of Contraceptive Shortage: Pill= 1 Injection= 2 Condom= 3 Personal Information of Interviewee Name of user Age Mobile number Name of Husband/Father/Wife Address of user FWA Unit No.: Ward No.: Village : Union : Upazilla: District: Division: Study Conducted for IPPF/FPAB Study Conducted by: Human Development Research Centre (HDRC) Dhaka: March 2009 DCI - 1B Dist Upa FWA Method Un HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 63 Section 1: Information Related to Household 101 Please help us telling details about the following information about your household member Occupation 4 Name of the household members (First write the name of the household head and then others’ name) Age Sex Male =1 Female=2 Marital Status1 Education (highest class pass) Literate=1, Illiterate =2 3 Main Others Kind of disability 1 2 3 4 5 6 7 8 9 * Household members are those who take food together and slept together at least once under the same roof during the last 6 months; exclude the guests. 1 Marital status: Single=01, Married=02, = 03, Widow= 04, Divorced=05 2 Quomi/Hafej Madrasa= 30, NGO school= 31, Maktab education= 32, Elderly education =33; No education=00 3 Literate means a person who can read, write and count 4 Profession code: Farmer=01, Housewife=02, Labor (agriculture)=03, Labor (non-farmer)=04, Employee=05, Mason=06, Carpenter=07, Rickshaw puller=08, Fisherman= 09, Boatman=10, Blacksmith=11, Potter=12, Cobbler=13, Shop owner=14, Small trader=15, Business=16, Tailor=17, Umbrella repairer=18, Driver=19, Cottage industry=20, Quack=21, Traditional Healer=22, Mechanic=23, Barber=24, Hired labor=25, TBA=26, Butcher=27, Teacher=28, Court assistant=29, Poet=30, Imam/Preacher/Bishop/Pastor=31, Retired person=32, Student=33, Unemployed=34, Child (0-6 years)=35, Disabled person=36, Expatriate=37, Household assistant=38, Other= 5 � If there is no other profession then write (–). � If the main profession is student then write 33. 6 Disability code: Blind=1, Deaf=2, Dumb=3, Physically disables=4, Mentally disabled=5, Multiple disability=6, No disability= (-). 102 Socio-economic status of the household: Main indicator 1 Who is household head? Male =1, Female =2 2 Ownership of the land: a b Do you have house? 3 Status of the house? Ruined = 1, Not ruined = 2 4 Status of the food? Safe = 1, Not safe = 2 5 Financial condition regarding sending children to primary school? Completely able = 1, Not able = 2 6 Ability to meet expenditure on health? Completely able = 1, Not able all the time = 2 Note : Safe food means taking 3 meals/day all the year HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 64 Section 2: Various problems regarding untimely supply of RH commodity Where do you get your RH commodity that you currently use? 201 FWA = 1, UHFWC = 2, UHC = 3, MCWC = 4, Satellite Clinic = 5 How far is the RH supply center from your home, how long will it take? 1. How far the RH supply center from home? (km) . 2. How long will it take? (Total trip) (Minute) . 202 3. Transportation cost (up and down) (Tk.) …. 203 How many times did you not get your RH commodity in time last year? 1. How many times did you not get your RH commodity in time last year? . 2. No. of visits (more than 1) for getting the RH commodity. . Did you change your current RH commodity due to untimely supply of RH commodity? Yes = 1, No = 2 1. Name of the changed method Pill =1, Injection =2, Condom =3, Copper T= 4, Implant=5, Vasectomy= 6, Tubectomy =7, Withdrawal=8, Kabiraji=9, Safe Period Method=10 204 2. How many times did you change your RH commodity during the last 1 year? . Due to non-availability/stock-out of the Family Planning method which problems/loss did you face, and which works couldn’t you do/faced problem in work. And for this purpose how many hours did you loss and how many times suffered due to this physical/health/psychological/social/economic sufferings? 205 Problem/Loss/Sufferings Whether suffered? Yes =1, No =2 How many hours suffered each time? How many times suffered A Physical/health problems/loss 1 Vomiting/Nausea 1 2 2 Dizziness/Vertigo 1 2 3 Only few drops of blood during menstruation/ Bleeding in between two periods 1 2 4 Menorrhegia 1 2 5 Lower abdominal pain in between two periods 1 2 6 Dysmenorrhea 1 2 HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 65 7 Hypertension 1 2 8 Mastalgia/ Feeling heaviness of breasts 1 2 9 Cancer/Tumor in ovary 1 2 10 Cancer/Tumor in uterus 11 Unexpected pregnancy 1 2 12 Burning sensation of the body 1 2 13 Amenorrhea for 3 months 1 2 14 Unexpected weight gain/loss 1 2 15 Anorexia 1 2 16 Facial pigmentation 1 2 17 Acne 1 2 18 Lower abdominal pain/uterine pain 1 2 19 General weakness 1 2 B Psychological sufferings /problems/loss 1 Anxiety/ Suspense 1 2 2 Lassitude 1 2 3 Fear of being pregnant 1 2 4 Socially embarrassed due to pregnancy 1 2 5 Insomnia 1 2 6 Despondency 1 2 1 2 1 2 C Problems related to income generating activities 1 Preparing crop field 1 2 2 Preparing seed bed 1 2 3 Taking care of crop 1 2 4 Crop harvesting and processing 1 2 5 Vegetables garden 1 2 6 Raising poultry 1 2 7 Raising livestock 1 2 8 Selling goods in the market 1 2 9 Working in the farm 1 2 10 Non-farm activities (Rickshaw, shop, employment, Handicrafts) 1 2 1 2 1 2 1 2 1 2 HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 66 d. Problems/loss in taking care of family members 1 Cleaning home/surroundings/bed 1 2 2 Washing dishes/clothes/invoking cloths 1 2 3 Cooking 1 2 4 Serving food/Entertaining guest 1 2 6 Fetching water/collecting wood/fuel/ cleaning lamp 1 2 7 Taking care of children (bathing/wearing clothes 1 2 8 Treat the ill person 1 2 1 2 1 2 e. Social problem/Loss 1 Participate in social activities/Club/ Seminar/Samity/participate in organization 1 2 2 Take party in social justice 1 2 1 2 1 2 1 2 Note: * Handicrafts: Bamboo/Cain work/weaving/making net/reticulate bag/rope/ making/repairing items of clothing/embroidery 206 Pregnancy due to unavailability of RH commodity? (If not pregnant skip to Q. 210) Yes= 1, No= 2 207 Giving birth to child due to pregnancy from unavailability of RH commodity? Yes= 1, No= 2 208 Giving birth to dead baby due to pregnancy from unavailability of RH commodity? Alive=1, Dead =2 209 Abortion/MR? Yes= 1, No= 2 210 Did you consult with any doctor when you faced health related problems? Yes= 1, No= 2 211 Total cost on treatment Taka 1 Doctor’s Fee 2 Medicine 3 Diagnostic test 4 Transportation cost 5 Food 212 What is the annual average (net) income of your household? . 213 Did you face any income loss due to untimely supply of RH commodity? Yes= 1, No= 2 214 If yes, what is percentage of the loss of total income? (./.) .% HDRC Human and Economic Impact of RH Supplies Shortage & Stock-outs in Bangladesh 67 What are alternative measures when there is no supply of RH commodity? (multiple responses) (Don’t prompt) Code Buy it from pharmacy 1 Buy it from another NGO 2 Switch to other RH commodity 3 Take no steps 4 215 I have no financial ability to take measures 5 Recommendations Yes= 1, No= 2 216 Recommendations about resolving RH commodity problem (Do not prompt) 1 Regular visit of FWA 1 2 2 Supply adequate RH commodity 1 2 3 Assign depot holder to store condom and pill 1 2 4 Train the employee 1 2 5 Organize regular BCC session 1 2 6 Increase the no. of field workers 1 2 7 Free distribution of RH commodity 1 2 8 Increase pill supply 1 2 9 Make some availability of injection 1 2 10 Provide injection without purchasing change 1 2 11 Supply pill checking expiry date 1 2 12 Supply condom checking expiry date 1 2 13 Make sure timely supply 1 2 14 Make sure whether FWA supplying the RH commo

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