88234 BANGLADESH: GOVERNANCE IN SECTORS Working Paper Bangladesh Governance in the Health Sector: A Systematic Literature Review i :RUOG%DQN2I¿FH'KDND Plot - E-32, Agargaon, Sher-e-Bangla Nagar, Dhaka- 1207, Bangladesh Tel: 880-2-8159001-28 Fax: 880-2-8159029-30 www.worldbank.org.bd World Bank 1818 H Street, N.W. Washington DC 20433, USA Tel: 1-202-4731000 Fax: 1-202-477-66391 www.worldbank.org All Bangladesh Development Series (BDS) publications are downloadable at: www.worldbank.org.bd/bds Standard Disclaimer: This volume is a product of the staff of the International Bank for Reconstruction and Development/ 7KH :RUOG %DQN7KH ¿QGLQJV LQWHUSUHWDWLRQV DQG FRQFOXVLRQV H[SUHVVHG LQ WKLV SDSHU GR QRW QHFHVVDULO\UHÀHFWWKHYLHZVRIWKH([HFXWLYH'LUHFWRUVRIWKH:RUOG%DQNRUWKHJRYHUQPHQWVWKH\ represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Copyright Statement: The material in this publication is copyrighted. The World Bank encourages dissemination of this work and will normally grant permission to reproduce portion of the work promptly. Cover Photo: Ismail Ferdous Printed in Bangladesh ii BANGLADESH: GOVERNANCE IN SECTORS Working Paper Bangladesh Governance in the Health Sector: A Systematic Literature Review September 2014 Jonathan Rose, Tracey M. Lane and Tashmina Rahman1 1 Tracey Lane is a senior economist at the World Bank. Jonathan Rose and Tashmina Rahman are consultants at the :RUOG%DQN7KH¿QGLQJVDQGFRQFOXVLRQVRIWKHSDSHUDUHHQWLUHO\WKRVHRIWKHDXWKRUVDQGVKRXOGQRWEHDWWULEXWHG WRWKH:RUOG%DQNLWVDI¿OLDWHGRUJDQL]DWLRQVRUWRPHPEHUVRILWV%RDUGRI([HFXWLYH'LUHFWRUVRUWKHFRXQWULHVWKH\ represent. iii Abstract This working paper provides a systematic review of the literature on governance issues in the %DQJODGHVKKHDOWKVHFWRU2QHRIWKHPDLQ¿QGLQJVLVWKHJHQHUDOODFNRIUHFHQWTXDQWLWDWLYHDQDO\VLV and published, peer-reviewed literature on governance in the health sector, the review additionally draws upon more informal and anecdotal reports. What information is available indicates several governance concerns arising from a lack of control of corruption and inventory management; high medical staff absenteeism especially in rural areas, which is further exacerbated by a human UHVRXUFHV PDQDJHPHQW SUREOHP UHVXOWLQJ LQ ODUJH VWDI¿QJ YDFDQFLHV 2YHUDOO WKH JRYHUQPHQW¶V budget resources to the sector are considerable, over a billion US dollars, and improving the transparency and effectiveness of the management of these resources could have considerable gains in health sector outcomes. iv Table of Contents Executive Summary............................................................................................................... ix Structure and Methods for the Systematic Review......................................................... ix Some Important Observations from the Systematic Review ........................................... x The Main Points Emerging from Literature.................................................................. xiii Other Observations regarding the Literature ................................................................. xv 1. Introduction ............................................................................................................................ 1 Structure and Methods for the Systematic Review.......................................................... 1 Background to the Public Health Sector of Bangladesh.................................................. 3 2. Government Effectiveness in the Health Sector..................................................................... 6 The Literature on Public Financial Management............................................................. 6 Gaps in the Literature on the Public Financial Management......................................... 10 The Literature on Human Resource Management ..........................................................11 Gaps in the Literature on Human Resource Management ............................................. 14 7KH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV ............................................................ 15 *DSVLQWKH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV ................................................ 16 3. Control of Corruption in the Health Sector .......................................................................... 18 The Literature on Corruption & Control Measures ....................................................... 18 Gaps in the Literature on the Control of Corruption...................................................... 22 4. Voice and Accountability in the Health Sector .................................................................... 25 The Literature on Voice and Accountability ................................................................. 25 Gaps in the Literature on Voice and Accountability ..................................................... 27 5. Regulatory Quality in the Health Sector............................................................................... 29 The Literature on Regulatory Quality............................................................................ 29 Gaps in the Literature on Regulatory Quality................................................................ 31 6. Conclusion ............................................................................................................................ 33 Other Observations regarding the Literature ................................................................. 35 List of Tables Table-1: A Description of the Categories of Issues for the Systematic Review............................ ix Table-2: Number of Health Studies across the Governance Areas................................................. x v Table-1.1: A Description of the Categories of Issues for the Systematic Review.......................... 2 Table-1.2: Outpatient Experiences with Public Health Services (in %)......................................... 4 Table-1.3: Budget of MoHFW........................................................................................................ 5 Table-2.1: Summary of the Literature on Public Financial Management ...................................... 6 Table-2.2: Ministry of Health and Family Welfare Budget Execution .......................................... 8 Table-2.3: Gaps in the Literature on Public Financial Management ............................................ 10 Table-2.4: Summary of the Literature on Human Resource Management....................................11 Table-2.5: Vacancy Rate for Public Health Staff by District, 2011 (%) ...................................... 12 Table-2.6: Process of Filling Vacancies among Health Facilities ................................................ 13 Table-2.7: Gaps in the Literature on Human Resource Management .......................................... 14 Table- 6XPPDU\RIWKH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV ..................................... 15 Table- *DSVLQWKH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV .............................................. 16 Table-3.1: Summary of the Literature on Corruption & Control Measures ................................. 18 Table-3.2: Accountants Reporting Informal Payments (%) ......................................................... 21 Table-3.3: Absenteeism Various Studies (%)............................................................................... 22 Table-3.4: Gaps in the Literature on Corruption & Control Measures......................................... 23 Table-4.1: Summary of Voice and Accountability in the Literature ............................................ 25 Table-4.2: Gaps in the Literature on Voice and Accountability................................................... 27 Table-5.1: Summary of the Literature on Regulatory Quality...................................................... 29 Table-5.2: Gaps in the Literature on Regulatory Quality ............................................................. 31 List of Figures Figure-1.1: Density of Different Types of Healthcare Providers ................................................... 5 Figure-2.1: Public Health Expenditure as a Percentage of GDP, 2011 .......................................... 7 Figure-2.2: Map of Human Resource Vacancy Rate at District Level (in Percent) ..................... 12 Figure-2.3: Number of Public and Private Medical Training Facilities ....................................... 14 Figure-2.4: Main Government Entities in the Public Health Sector in Bangladesh ..................... 15 Figure-4.1: Distribution of the Different Types of Complaints Received .................................... 26 Figure-4.2: Complaint Outcomes across Different Complaint Types .......................................... 27 Annexes Annex-1: Satisfaction of Patients with Different Aspects of Inpatient Stay ................................ 36 Annex- 6XPPDU\RIWKH2I¿FLDO%XGJHW&\FOH3URFHVV ........................................................... 38 Annex-3: Summary of the Planning and Monitoring Cycle ......................................................... 40 Annex- 2I¿FLDO)XQG5HOHDVH3URFHVV ...................................................................................... 42 Annex-5: Maps of Physician and Nurse Vacancy rates................................................................ 43 Bibliography ................................................................................................................................. 45 vi Acknowledgements This report was written by a World Bank team comprised of Jonathan Rose, (Governance Researcher consultant and lead author, SASGP), Tracey M. Lane (Senior Economist, Task Team Leader, SASGP) and Tashmina Rahman (Consultant Research Analyst, SASGP). Mariha Khalid 5HVHDUFK $QDO\VW 6$6*3 SURYLGHG UHVHDUFK VXSSRUW ,W ZDV ¿QDQFHG E\ WKH 'HSDUWPHQW IRU International Development (DFID) via the Joint Technical Assistance Program for Bangladesh. Kamrun Nahar Chowdhury (Team Assistant, SASEP) provided support in formatting the report DQGDLGLQJLQWKHSURFHVV7KHDXWKRUVWKDQN-DFTXHOLQH0DKRQLQSDUWLFXODUIRUKHUVXEVWDQWLDO input and support, as well as peer reviewers comments from Yasuhiko Matsuda (Senior Public Sector Specialist, SASHD), Bénèdictede la Briere (Senior Economist, HDNCE), and Richard Butterworth (Governance Advisor, DFID). The team is grateful to Ernesto May (Sector Director, PREM South Asia), Tony Verheijen (former Sector Manager, SASGP), Salman Zaidi and Zahid Hussain (Lead Economists, SASEP), Roland Lomme (Governance Adviser, SASGP) and Andras Horvai (former Country Program Coordinator, Bangladesh) for their guidance, and to Khaled Ahsan (SASGP) for his comments on earlier drafts. vii Government Fiscal Year July 1 – June 30 CURRENCY EQUIVALENTS Currency Unit = Bangladesh Taka (BDT) US$ 1.00 = BDT 77.77 List of Abbreviations ACC Anti-Corruption Commission AG Accountant General BHW Bangladesh Health Watch BMA Bangladesh Medical Association BMDC Bangladesh Medical and Dental Council CAG Comptroller and Auditor General CS Civil Surgeon DDA Directorate of Drug Administration ''2 'UDZLQJDQG'LVEXUVHPHQW2I¿FHU DGDA Directorate General of Drug Administration DGHS Directorate General of Health Services DGFP Directorate General of Family Planning DH District Hospital DP Development Partner ESP Essential Service Package FMRP Financial Management Reform Program HPSP Health and Population Sector Program HPNSDP Health, Population and Nutrition Sector Development Program HRM Human Resource Management IGS Institute of Governance Studies LD Line Directors MCWC Maternal and Child Welfare Center 02 0HGLFDO2I¿FHUV MoHFW Ministry of Health and Family Welfare MoLGRDC Ministry of Local Government, Rural Development and Cooperatives 065 0HGLFDODQGVXUJLFDOUHTXLVLWHV MTBF Medium Term Budget Framework 1*2 1RQJRYHUQPHQW2UJDQL]DWLRQ 2&$* 2I¿FHRIWKH&RPSWUROOHUDQG$XGLWRU*HQHUDO PEIR Public Expenditure and Institutional Review PFM Public Financial Management RTI Right to Information TIB Transparency International Bangladesh UHC Union Health Complex USC Union Sub Centers WGI World Governance Indicators viii Executive Summary 1. The purpose of this systematic review is to inform the World Bank, development partners and other stakeholders on the state of governance in the health sector of Bangladesh. 7KURXJKDV\VWHPDWLFUHYLHZRIWKHOLWHUDWXUHRYHUWKHODVWWHQ\HDUVWKHUHYLHZVXPPDUL]HVWKH extent of the literature on governance of the sector, and brings together disparate pieces to provide VXPPDULHVRIWKHPDLQ¿QGLQJVLQSXEOLF¿QDQFLDOPDQDJHPHQW 3)0 SUDFWLFHVKXPDQUHVRXUFHV management, public procurement, corruption, transparency and accountability. One of the main ¿QGLQJVRIWKLVUHYLHZLVWKHODFNRISXEOLVKHGSHHUUHYLHZHGOLWHUDWXUHRQJRYHUQDQFHDQGWKH review therefore also draws upon informal and anecdotal reports. Furthermore, many of the documents cited in the review are now dated. Structure and Methods for the Systematic Review 2. The review disaggregates the term governance using the categories of the Worldwide Governance Indicators. 7KH WHUP JRYHUQDQFH LV RIWHQ RYHUO\ VLPSOL¿HG DQG QDUURZO\ GH¿QHG The Worldwide Governance Indicators (WGI) allow for a broad inclusion of governance issues and distinguish between characteristics of government effectiveness, control of corruption, voice and DFFRXQWDELOLW\DQGUHJXODWRU\TXDOLW\DVSUHVHQWHGLQ7DEOH:HXVHWKLVUXEULFWRJURXSWKHDVSHFWV of governance discussed in the systematic review within each category in an approach similar to Lewis 7KH*RYHUQPHQWRI%DQJODGHVKKDVVWURQJO\HPSKDVL]HGJRYHUQDQFHFRQFHUQVDQGHDFKRI the governance issues reviewed here is related to actions in the sixth 5 Year Plan and the Strategic Plan for Health, Population and Nutrition Sector Development Program (HPNSDP) of 2011-2016. The categories are not perfect, but offer a comprehensive view into numerous governance dimensions. Table-1: A Description of the Categories of Issues for the Systematic Review Governance Governance Issues Category x 3XEOLF¿QDQFLDOPDQDJHPHQW SODQEXGJHWDQGEXGJHWH[HFXWLRQ Government x +XPDQUHVRXUFHPDQDJHPHQW VWDI¿QJSXEOLFVHFWRUPDQDJHPHQWFDSDFLW\ Effectiveness x 2UJDQL]DWLRQDOHIIHFWLYHQHVV Political Economy – x Cross cutting Integrity in procurement processes x Financial and facility management, including management oversight Control of x Integrity in human resource management Corruption x Integrity in the regulation of the private sector x Transparency x 2SSRUWXQLWLHVIRUFLWL]HQVWRSURYLGHLQSXWWRGHFLVLRQPDNLQJ Voice and x Oversight of service delivery Accountability x 2WKHUPHDQVIRUFLWL]HQVWRKROGJRYHUQPHQWVHUYLFHSURYLGHUVDFFRXQWDEOH Regulatory x 5HJXODWLRQRIWKHTXDOLW\DQGDFFHVVLELOLW\RIVHUYLFHSURYLVLRQLQWKH Quality private sector, with appropriate standards and enforcement ix 3. :LWKLQHDFKFDWHJRU\WKHUHYLHZGRFXPHQWVWKH¿QGLQJVIURPWKHOLWHUDWXUHDFFRUGLQJWR x What evidence is available in the literature in terms of governance outcomes? x What analysis is available regarding the main government systems to achieve these outcomes? In other words, how does government work in practice? 4. This review brings together research to date on governance, pulling together published material as well as selected grey literature. The source of literature includes publicly available articles, books, and reports covering the Bangladesh health sector since 2000; it also includes an analysis of the grey literature, especially the main program documents (program plans, evaluations and other reviews), as well as a selection of the most recent technical documents such as annual SURJUDP UHYLHZVDXGLWDQG¿QDQFLDOUHSRUWV$VXPPDU\RIWKHGLVWULEXWLRQRIWKHOLWHUDWXUHLV SURYLGHGLQ7DEOH:KLOHWKHUHYLHZZDQWHGWRH[SORUHRWKHUTXHVWLRQVDQGLQLWLDWLYHVLWZDV limited by the research and documentation available. Also, though potentially fruitful this report GRHVQRWJREH\RQG%DQJODGHVKWRFRPSDUH¿QGLQJVZLWKVLPLODUUHVHDUFKLQRWKHU6RXWK$VLDQ countries on common issues such as absenteeism, corruption and informal payments for services. Table-2: Number of Health Studies across the Governance Areas Governance Area Number of Studies Government Effectiveness 21 Control of Corruption 14 Voice and Accountability 6 Regulatory Quality 9 Total 50 Note: Other research cited relates to the political economy section, adding up to over 60 studies. Some Important Observations from the Systematic Review 5. 6HYHUDO LQWHUHVWLQJ ¿QGLQJV RQ WKH OLWHUDWXUH HPHUJH UHJDUGLQJ WKH JRYHUQDQFH RI health in Bangladesh: x )LUVWWKHOLWHUDWXUHRQWKHFRQWURORIFRUUXSWLRQLGHQWL¿HVQXPHURXVLVVXHVLQWKHKHDOWKVHFWRU both at the national and local level. These include losses in drug stocks, illegal fees, incorrect GUXJSUHVFULSWLRQVSULYDWHUHIHUUDOVE\GRFWRUVKLJKUDWHVRIXQRI¿FLDODEVHQWHHLVPDQG LQIRUPDOSD\PHQWVE\ORZHUOHYHO0LQLVWU\RI+HDOWKDQG:HOIDUH 0R+): RI¿FLDOVWR KLJKHUOHYHORQHV QRWDEOHZDVWKH¿QGLQJRIDKLJKSURSRUWLRQRIJRYHUQPHQWDFFRXQWDQWV taking informal payments to process bills. Control of corruption measures, such as improved national procurement processes, MoHFW audits and managerial oversight, do not appear to have had the desired impact. On the plus side, evidence suggests that the incidence and amount of illegal fees being paid at public hospitals has declined. x Second, the literature on voice and accountability, while limited, provides a primarily negative account of initiatives so far. These initiatives face impediments such as lack RI ¿QDQFLDO VXSSRUW JHQGHU ELDV DQG HOLWH FDSWXUH 5HVHDUFK DOVR LGHQWL¿HV OLPLWHG GHFHQWUDOL]DWLRQ DV DQ LPSHGLPHQW EXW WKHUH KDV QRW EHHQ D FRPSUHKHQVLYH VWXG\ RQ GHFHQWUDOL]DWLRQWRGDWH x x 7KLUG WKH OLWHUDWXUH RQ KHDOWK VWDII YDFDQFLHV LGHQWL¿HV VHULRXV SUREOHPV RYHUDOO DQG particularly in remote areas. We present original data on such vacancies, including by district, showing variation in physician vacancy rates ranging from 0 to 80.5 percent. At the same time, there are an increasing number of graduates from public and private medical schools and institutes. Several factors may explain these contradictory trends, including WKH FRPSUHVVHG GRFWRUV¶ ZDJH VFDOH D ORZ OHYHO RI MRE VDWLVIDFWLRQ DQG WKH LQWHQVLYH UHFUXLWPHQWSURFHVV)RUWKHVHUHDVRQVZHLGHQWLI\WKLVDUHDDVUHTXLULQJIXUWKHUUHVHDUFK 6. 7KH UHYLHZ LGHQWL¿HV D ODUJH QXPEHU RI JDSV LQ WKH OLWHUDWXUH EXW WKLV VHFWLRQ highlights the main gaps according to two criteria. These gaps provide options for future topics to be researched further. First, we identify the main areas for that represent government priorities and for which there is little information available. Second, we exclude areas of research that are GLI¿FXOWWRPHDVXUHVXFKDVRXWFRPHVRIYRLFHDQGDFFRXQWDELOLW\PHDVXUHVRUWKHTXDOLW\RIQRQ government health provision. 7. According to government priorities in the health sector, there are several areas that represent gaps in current research. The main government documents include the Sixth Five Year Plan of Bangladesh, the Health Policy and the HPNSDP Program Implementation Plan. Through assessing the priorities in these documents, and checking them against the available literature, the following topics emerge as major gaps. These gaps provide options for future topics to be researched further. 8. Very little research has focused on the role of government to oversee and support the private health sector. The private sector features prominently in the Sixth Five Year Plan of Bangladesh, as well as other relevant plans. This sector is large and diverse: private providers range from commercial hospitals to neighborhood drug stores and village doctors; it also encompasses pharmaceutical companies, which make up one of the largest industrial sectors in Bangladesh. )XUWKHUUHVHDUFKPXVWQRWRQO\VHHNWRV\VWHPDWLFDOO\JDWKHUTXDOLW\PHDVXUHVEXWDOVRFULWLFDOO\ DQDO\]HWKHUROHRIJRYHUQPHQWWRVXSHUYLVHDQGVXSSRUWWKHSULYDWHKHDOWKVHFWRU6XFKREVHUYDWLRQV were made in recent Lancet articles (Adams et al., 2013; Ahmed et al., 2013). 9. &XUUHQW UHVHDUFK KDV QRW H[DPLQHG VXI¿FLHQWO\ WKH SUDFWLFH DQG HIIHFWLYHQHVV RI public urban health care, as well as detailed the effects of the institutional arrangement given the assignment of coordination responsibilities to the MoLGRDC.2 The current HPNSDP HPSKDVL]HVWKHLPSRUWDQFHRIXUEDQKHDOWKDQGWKHQHHGIRUDFOHDURUJDQL]DWLRQIRUKHDOWKVHUYLFH delivery in urban areas. Further research should examine the current state of affairs and necessary reforms, due to the rapidly expanding urban population of Bangladesh and need for health services, particularly in informal settlements. 10. Vacancies of critical health staff, especially remote area, as well as larger HR issues is an issue that represents another gap in the literature. The need for smart human resource PDQDJHPHQWDQGGLVWULEXWLRQLVHPSKDVL]HGLQWKHVL[WK)LYH<HDU3ODQRI%DQJODGHVKDVZHOODV the HPNSDP. Some research has documented the disinterest from doctors and nurses in working in remote areas. Meanwhile, government has instituted measures such as fast track promotion in 2 A related overview study was completed in preparing the national urban health strategy, available on the health FRQVRUWLXPZHEVLWHEXWWKHDXWKRUVDUHQRWGHWDLOHG0RUHRYHUWKHWRSLFLVPHQWLRQHGLQ2VPDQ ZKREULHÀ\ GHVFULEHVWKHRUJDQL]DWLRQRIXUEDQKHDOWKFDUHDQGDFFHVVE\WKHSRRU xi order to address this, but the impact of these measures is unclear. A more comprehensive study is needed, including the relative market wages for doctors, as well as the formal and informal HR processes related to transfers and promotions, and the effect of current initiatives, in order WRLGHQWLI\IXUWKHULQWHUYHQWLRQVWRDGGUHVVWKLVSUHVVLQJVWDI¿QJQHHG0RUHRYHUHTXDODWWHQWLRQ VKRXOGEHSDLGWRHIIRUWVWRSUHYHQWXQRI¿FLDODEVHQWHHLVPJLYHQWKDWLWZLOOXQGHUPLQHUHGXFWLRQV in the vacancy rate. 11. The distribution and management of drug supplies also requires further research. 7KH+316'3SODQHPSKDVL]HVWKHQHHGWRLPSURYHGUXJPDQDJHPHQWDQGSURYLVLRQZLWKWDUJHWV tracked that show under 20 percent of facilities with over 75 percent of 37 basic drugs available in 2012, though the ministry is taking initiatives in this regard. The precise cause of these stock outs has not been detailed. As such, further research is needed regarding the drug distribution and management system, and a Public Expenditure Tracking Survey that focuses on this issue would be particularly useful. 12. From government priorities, other potential topics of research include: particular details on facility management practices that may contribute to absenteeism and other forms of corruption, budgetary decisions to increase the budget allocation for health, and the means to HQVXUHWKHTXDOLW\RIGRFWRUHGXFDWLRQDQGWUDLQLQJ 13. In-depth political economy research may also explain persistent problems in the sector. One particular topic that has been studied, but which continually impedes service delivery is the failure to dramatically increase the development budget execution rate. Other useful areas for such UHVHDUFKWRXFKRQDZLGHUDQJHRIWRSLFVWKDWLQFOXGHWKHVWURQJLQÀXHQFHRIGRFWRURUJDQL]DWLRQV WKHQXPHURXVLQWHUHVWVWKDWLQÀXHQFHWKHEXGJHWSURFHVVWKHUHQWVGHULYHGIURPSURFXUHPHQWDQG ORFDOKHDOWKH[SHQGLWXUHVDQGFRQWLQXHGUHVLVWDQFHWRGHFHQWUDOL]DWLRQ 14. Through the systematic review, several other conclusions emerged regarding the literature: x The review included research since 2000, but much of the data is out of date. We therefore hold many of the following conclusions from the literature to be tentative, and recommend updates to the existing studies. x Knowledge management is necessary so that governance research may have an impact. $FRQVLGHUDEOHDPRXQWRIHIIRUWZDVUHTXLUHGE\WKHDXWKRUVWRFRPSLOHWKHOLWHUDWXUH in this review. Moreover, different experts informed our research team of studies that were not publicly available, or that were lost in time. Greater attention is needed to make research both publicly available and easily searchable. x There is limited transparency in government regarding basic data that is critical for research, including detailed budget and budget execution information, and various decision-making processes. Public access to this data is necessary for research. x $XWKRUVVKRXOGEROVWHUWKHHPSLULFDOTXDOLW\RIUHVHDUFK$WWLPHVVWDWHPHQWVDUHPDGH without a solid empirical basis, or anecdotal evidence is portrayed as fact. xii The Main Points Emerging from Literature 15. Overall, the literature on the health sector provides limited but important analyses RI JRYHUQPHQW HIIHFWLYHQHVV ZKLFK ZH GLYLGH LQWR SXEOLF ¿QDQFLDO PDQDJHPHQW 3)0 KXPDQ UHVRXUFH PDQDJHPHQW +50 DQG RUJDQL]DWLRQDO HIIHFWLYHQHVV The PFM literature primarily focuses on the budget and budget execution, and particularly the challenges to executing the development budget. An analysis of public health spending shows that Bangladesh is near the median when compared with other countries in the region, but the budget has dropped from 6.87 percent in 2007-08 to 4.87 percent in the current annual budget. As for budget execution, MoHFW under-spends its development budget, where the execution rate was just 73.32 percent in FY 2011/12, due to several factors, such as procurement process delays, capacity concerns DQG FHQWUDOL]HG SURFHGXUHV :RUOG %DQN E 0R+): E (XUR +HDOWK *URXS FMRP, 2005). Also, a dated public expenditure tracking survey showed that payments of a large minority of the staff of MoHFW are often delayed by six months and not made in full (FMRP, 7KHUHDUHPDQ\DUHDVIRUIXUWKHUUHVHDUFKLQSXEOLF¿QDQFLDOPDQDJHPHQWLQFOXGLQJWKH planning process, the informal budget preparation process and challenges to the execution of the development budget. 16. The literature on HRM covers a number of issues, including the lengthy process of recruitment, the relatively simple transfer process, and the large increases in public and private medical education institutions. Bangladesh maintains high vacancy rates for government doctors, nurses and other staff, with an average of 23.7 percent, but ranging from 5.7 percent to 47.7 percent by district. The high vacancy rates for select districts are GXH WR WKH GLI¿FXOW\ LQ VWDI¿QJ UHPRWH DUHDV 7KHUH DUH D QXPEHU RI RI¿FLDO VWHSV LQYROYHG in the hiring process, and its intensity may contribute to the vacancies (World Bank et al., 2WKHU IDFWRUV VXFK DV ORZ TXDOLW\ RI OLIH DQG VLPSOH WUDQVIHU SURFHGXUHV PD\ DOVR contribute to the vacancies found in remote and rural areas. (Luoma et al., 2009; World Bank HW DO )XUWKHUPRUH WKHUH DUH FRQFHUQV UHJDUGLQJ WKH TXDOLW\ RI KHDOWK FDUH VHUYLFHV and particularly doctor capacity. The institutions building the capacity of the health sector are growing in numbers, especially in the private sector, with an increasingly large graduating class of doctors and nurses each year (BHW, 2007). Aside from the urban bias, the reasons that the numerous graduates from these institutions do not enter the public service may be that wages DUHFRPSUHVVHGDQGWKHUHLVZLGHVSUHDGMREGLVVDWLVIDFWLRQ7KHOLWHUDWXUHUHTXLUHVIXUWKHUVWXG\ mainly of actual HRM practices, including the informal ways in which recruitment and transfer GHFLVLRQVDUHPDGH$VUHODWHVWRPHGLFDOHGXFDWLRQDOLQVWLWXWLRQVWKHTXDOLW\RIWKHHGXFDWLRQ should be further examined. 17. 7KH OLWHUDWXUH RQ RUJDQL]DWLRQDO HIIHFWLYHQHVV LV OLPLWHG PDLQO\ IRFXVLQJ RQ WKH KHDOWK6:$SDQGWKHGLYLVLRQRIWKH'LUHFWRUDWH*HQHUDORI+HDOWK6HUYLFHV '*+6 DQG WKH 'LUHFWRUDWH *HQHUDO RI )DPLO\ 3ODQQLQJ '*)3 Within the Ministry of Health and Family Welfare, DGHS and DGFP have separate management and delivery structures from the national to the ward level. This continued division, viewed through a political economy lens, highlights the strength of government bureaucracies to resist reform efforts (Sundewall et al., 2006). The ambitious health SWAp program has achieved many of its goals; however, several RIWKHRXWFRPHVWKDWIRUPHGWKHUDWLRQDOHIRUWDNLQJRQWKH6:$SLGHDZHUHVORZWRPDWHULDOL]H LQFOXGLQJ RZQHUVKLS RI WKH SURJUDP KDUPRQL]HG SODQQLQJ DQG FRRUGLQDWLRQ EHWZHHQ WKH *R% xiii DQGGHYHORSPHQWSDUWQHUV 0DUWLQH] :RUOG%DQN 6LQFHWKLVVWXG\VRPHSURJUHVV ZDV QRWHG LQ DUHDV RI ¿QDQFLDO PDQDJHPHQW JRYHUQPHQW RZQHUVKLS DQG FRRUGLQDWLRQ EHWZHHQ GoB and DPs following the second phase of the SWAp program (World Bank, 2012). These HIIRUWVQRQHWKHOHVVUHPDLQLQDGHTXDWHIRUDFKLHYLQJWKHGHVLUHGUHVXOWVLQWKHKHDOWKV\VWHPDQG several reforms have been planned accordingly to address these issues (HPNSDP, 2012). The OLWHUDWXUHRQRUJDQL]DWLRQDOHIIHFWLYHQHVVGRHVQRWFRYHUQXPHURXVWRSLFVHVSHFLDOO\DQDQDO\VLV RIGHFHQWUDOL]DWLRQRUODFNWKHUHRILQWKHVHFWRUDQGWKHGLYLVLRQRIUHVSRQVLELOLWLHVLQWKHVHFWRU which includes the responsibilities for urban health care found in the Ministry of Local Government, Rural Development and Cooperatives. 18. The literature on corruption primarily focuses on government procurement and corruption at the facility level, suggesting there are a number of challenges in the sector. Procurement procedures at the national level are substandard, with competitive bidding and other standard principles sometimes not followed, though more recently a number of initiatives have been taken by the Ministry (MoHFW, 2011b). However, since this study, several measures in the HNPSDP have been taken to strengthen the procurement systems and functions of MoHFW (HPNSDP, 2012). There is evidence of losses in drug stocks, but the source of these losses is QRWFOHDUDQGUHTXLUHVIXUWKHUUHVHDUFK )053 7KHUHDUHSUREOHPVZLWKWKHSUHVFULSWLRQ of drugs that are partly explained by corruption (FMRP, 2005). Patients must pay illegal fees to receive treatment, which is often enforced by lower level staff (Euro Health Group, 2004; FMRP, 2005; TIB, 2007 & 2010). Moreover, there is also evidence that public doctors unnecessarily refer patients to private clinics or practices (SIDA, 2007; TIB, 2010; BHW, 2009). A large portion RI 0R+): HPSOR\HHV PXVW PDNH LQIRUPDO SD\PHQWV WR RI¿FLDOV LQ WKH $FFRXQWDQW *HQHUDO RI¿FHVDQGWKH'LUHFWRUDWH*HQHUDORI¿FHV )053 2YHUDOODQGXQRI¿FLDODEVHQWHHLVPRI health care professionals are high, with one absenteeism estimate reaching as high as 44 percent for doctors in union health facilities (Chaudhury & Hammer, 2003; FMRP, 2005). Auditing in 0R+):LVRIWHQZHDNDQGUHTXLUHVJUHDWHUIUHTXHQF\DQGLPSURYHGIROORZXS )053 :RUOG %DQN E )LQDOO\ VXSHUYLVRU\ YLVLWV WR KRVSLWDOV DUH IUHTXHQW EXW PRVW RI WKHVH YLVLWVZHUHIRFXVHGRQDGPLQLVWUDWLYHPDWWHUVLQVWHDGRIVFUXWLQL]LQJVWRFNUHFRUGVDQGSDWLHQW UHJLVWHUV )053 7KHUHYLHZDOVRLGHQWL¿HVDUHDVIRUIXUWKHUUHVHDUFKWKDWLQFOXGHGUXJ stock management, transparency and the integrity of the regulation of private hospitals and pharmaceuticals. 19. The literature on voice and accountability in the health sector primarily focuses on the local level. 2I¿FLDOYRLFHLQLWLDWLYHVIDFHOLPLWDWLRQVWRLPSOHPHQWDWLRQVXFKDVDZHDN PRELOL]DWLRQRIFLWL]HQVDQGOLPLWHGWUDLQLQJDVZHOODVDODFNRIJRYHUQPHQWUHVSRQVLYHQHVVWR GHFLVLRQV 0DKPXG 7KRPDV $QXPEHURIXQRI¿FLDOERGLHVIRUFLWL]HQRYHUVLJKW suffer from similar implementation challenges (Thomas, 2003). One new initiative is the mobile feedback system under the Management Information System (MIS-Health) services of the DGHS, which has resolved primarily mild complaints, but not moderate and serious ones. A review of this OLWHUDWXUHLGHQWL¿HVDUHDVIRUIXUWKHUUHVHDUFKVXFKDVWKHVWXG\RIYRLFHDQGDFFRXQWDELOLW\DWWKH national level and a more detailed impact evaluation of efforts to date. xiv 20. Regulatory quality includes government oversight of private health providers and pharmaceutical companies. Included among private health providers are allopathic providers, village doctors, drugstore salespeople, traditional healers, non-secular faith healers, traditional ELUWK DWWHQGDQWV KRPHRSDWKV SULYDWH IRU SUR¿W DQG QRWIRUSUR¿W FOLQLFV DQG KRVSLWDOV 5HFHQW UHVHDUFKHPSKDVL]HVWKHLPSRUWDQFHRIWKHSOXUDOLVWLFKHDOWKV\VWHPLQFRQWULEXWLQJWRWKHPDMRU KHDOWKDFKLHYHPHQWVLQWKHVHFWRUEXWUHFRJQL]HVWKDWHIIRUWVDUHQHHGHGWRUHJXODWHE\JRYHUQPHQW (Adams et al., 2013; Ahmed et al., 2013; Chowdhury et al., 2013). Ahmed et al. (2013) identify a general role for government to aid in implementing participatory governance, accountability and regulation, information systems, and capacity development in this pluralistic system, which are areas for further research. The relevant literature on regulatory control mainly focuses on PHDVXULQJWKHTXDOLW\RIFDUHIURPSULYDWHSURYLGHUVDQGWKHTXDOLW\RISKDUPDFHXWLFDOV,QIRUPDO providers have poor training, making incorrect prescriptions for drug treatment (Ahmed et al., 'DWD RQ SULYDWH KRVSLWDOV LQ %DQJODGHVK VKRZ WKDW SDWLHQWV DUH JHQHUDOO\ VDWLV¿HG EXW PHDVXUHVRITXDOLW\RIVHUYLFHDUHSRRU :RUOG%DQN $QGDOHHEHWDO 6LGGLTXH .KDQGDNHU $VIRUWKHUROHRIJRYHUQPHQWWKH*R%KDVDTXLWHFRPSUHKHQVLYHUHJXODWRU\ legal structure for the private hospital sector, but the main issues arise in implementation (World Bank, 2003). The Bangladesh Medical and Dental Council and Bangladesh Nursing Council, two Government regulatory bodies, suffer from low capacity and a lack of independence (BHW, ,QVSLWHRIWKHLPSRUWDQFHRIQRQJRYHUQPHQWKHDOWKVHFWRUIXUWKHUUHVHDUFKLVUHTXLUHGRQ DQXPEHURIIURQWV0RUHFRPSUHKHQVLYHDQGFRQVLVWHQWGDWDRQWKHTXDOLW\RISURYLVLRQRISULYDWH health care is necessary, whether from informal providers or private hospitals. Research is also needed on the different roles of government in overseeing and supporting private providers. Other Observations regarding the Literature 21. At times, the health literature provides evidence of problems with little analysis of the systems involved in addressing the problems, nor an explanation for why the systems may fail. For instance, the public health budget has been shrinking relative to the national budget, but WKHOLWHUDWXUHKDVQRWDQDO\]HGWKHEXGJHWGHFLVLRQPDNLQJSURFHVVHVWKDWOHDGWRWKLVRXWFRPH,W VKRXOGGLVWLQJXLVKEHWZHHQWKHRI¿FLDOSURFHVVHV de jure) including the laws and regulations, as opposed to action (de facto VFUXWLQL]LQJWKHZD\WKDWRI¿FLDOVDQGYDULRXVDFWRUVDFWXDOO\EHKDYH $QDQDO\VLVRIWKHEXGJHWV\VWHPVKRXOGLQTXLUHLQWRERWKWKHRI¿FLDOSURFHVVRIFRQVWUXFWLQJWKH budget, but also the informal agreements that go into it, the use of analytical work, and the political SUHVVXUHVWKDWLQÀXHQFHWKHVHGHFLVLRQV5HIRUPHIIRUWVWKDWGRQRWWDNHWKHVHLQIRUPDOSURFHVVHV into account are likely to fail. 22. Often, statements are made without an empirical basis, and anecdotal evidence may be portrayed as facts. )XUWKHUTXDQWLWDWLYHDQGTXDOLWDWLYHUHVHDUFKLVQHHGHGEDVHGRQULJRURXV methods. At the same time, a variety of consistent measures should be gathered and tracked, VXFKDVWKHTXDOLW\RIFDUHRIIHUHGE\JRYHUQPHQWKHDOWKIDFLOLWLHVDQGQRQVWDWHSURYLGHUV7KHVH measures should be publicly accessible. Additionally, much of the health governance research LVGDWHGZLWKPDMRU¿HOGZRUNIRUWKHVWXGLHVRFFXUULQJSULPDULO\LQWKHHDUO\DQGPLGV LQ RWKHUZRUGVDWWKHWLPHRIWKLVUHYLHZWKHVHVWXGLHVDUHDOPRVWDGHFDGHROGUHTXLULQJIROORZ up research. xv 23. Efforts are required to make research accessible for a variety of audiences, particularly online in an easily searchable format. There is also a need to better evaluate the effects of the research completed thus far. Based on such an evaluation, the research community can better FRPPXQLFDWHWKHLU¿QGLQJVWRNH\DXGLHQFHVWRHQVXUHLPSDFW xvi 1. Introduction 1. The purpose of this systematic review is to inform the World Bank, development partners and other stakeholders on the state of governance in the health sector of Bangladesh. With billions3 of Bangladeshi Taka invested in the government-run health sector every year, ¿QDQFHG E\ GRPHVWLF DQG LQWHUQDWLRQDO VRXUFHV WKHUH KDYH EHHQ QXPHURXV HIIRUWV WR EHWWHU understand the governance challenges in the sector. This report reviews sixty such reports and studies written by NGOs, academics, government entities, research institutions, consultants and development partners, in the last fourteen years. However, translating that research into policy dialogue and improvement has been challenged due to poor knowledge management, a lack of D V\VWHPDWLF DSSURDFK WR UHVHDUFK EXLOGLQJ RQ HDUOLHU VWXGLHV ¿QGLQJV DQG OLPLWHG HIIRUWV WR place the work in the public domain and discourse. This paper takes a systematic approach to the OLWHUDWXUHUHYLHZEULQJLQJWKHNH\¿QGLQJVWRJHWKHUDQGHYDOXDWLQJWKHZHLJKWRIHYLGHQFHRQWKH governance problems in the sector, as well as the gaps that should be addressed by future research HIIRUWV 7KLV UHYLHZ IXUWKHUPRUH HPSKDVL]HV WKH QHHG WR XQGHUVWDQG WKH IDFWRUV ± DQG SROLWLFDO economy factors in particular – that explain the current state of affairs. 2. The review is structured to systematically assess this literature, leading to several broad conclusions. )LUVW LW LGHQWL¿HV WKH VWUXFWXUH DQG PHWKRG RI WKH UHYLHZ DQG RXWOLQHV WKH FDWHJRUL]DWLRQRIWKHJRYHUQDQFHLVVXHVUHYLHZHGDQGSURYLGHVDEDFNJURXQGWRWKHKHDOWKVHFWRU ,WWKHQPHWKRGLFDOO\VXPPDUL]HVWKHUHOHYDQWOLWHUDWXUHIRUHDFKJRYHUQDQFHLVVXHKLJKOLJKWLQJWKH lessons and identifying the gaps and weaknesses. The review ends by highlighting these gaps in research, with a view to improve its scope and impact. Structure and Methods for the Systematic Review 3. The review disaggregates the term governance using the categories of the Worldwide Governance Indicators. 7KHWHUPJRYHUQDQFHLVRIWHQRYHUO\VLPSOL¿HGDQGQDUURZO\GH¿QHG )RUWKHSXUSRVHVRIWKHUHYLHZZHVWDUWZLWKDZLGHO\XVHGGH¿QLWLRQ ³JRYHUQDQFHLVWKHWUDGLWLRQV and institutions by which authority in a country is exercised”4 and a broader concept than a focus on corruption which is often used synonymously with governance. We draw upon the WGI as a way of breaking governance down into characteristics of government effectiveness, control of FRUUXSWLRQ YRLFH DQG DFFRXQWDELOLW\ DQG UHJXODWRU\ TXDOLW\5 Challenges emerged with using WKLV FDWHJRUL]DWLRQ HVSHFLDOO\ JLYHQ PDQ\ JRYHUQDQFH LVVXHV DUH DOVR RYHUODSSLQJ ZLWKLQ WKLV FDWHJRUL]DWLRQ 7DEOH FODUL¿HV KRZ VSHFL¿F JRYHUQDQFH LVVXHV DUH JURXSHG LQ WKLV UHSRUW according to the WGI approach. 3 Billions means 1,000 millions. 4 Kaufmann et al., 2000. 5 Two categories of indicators in WGI are less applicable at the sector level–rule of law and political stability–because WKH\SULPDULO\UHIHUWRWKHODUJHUJRYHUQDQFHHQYLURQPHQWDQGQRWWRVHFWRUVSHFL¿FLVVXHVLQWKHKHDOWKVHFWRUWKH\KDYH therefore not been used here. 1 4. This systematic review brings together research to date on governance and VXPPDUL]HVLWDURXQGFRPPRQWKHPHVSXOOLQJWRJHWKHUSXEOLVKHGPDWHULDODVZHOODVVHOHFWHG grey literature. The source of literature includes publicly available articles, books, and reports covering the Bangladesh health sector since 2000; it also includes an analysis of the grey literature, especially the main program documents (program plans, evaluations and other reviews), as well as a selection of the most recent technical documents such as annual program reviews, audits and ¿QDQFLDOUHSRUWV:KLOHWKHUHYLHZZDQWHGWRH[SORUHRWKHUTXHVWLRQVDQGLQLWLDWLYHVLWZDVOLPLWHG by the research and documentation available. Also, though potentially fruitful this report does not JREH\RQG%DQJODGHVKWRFRPSDUH¿QGLQJVZLWKVLPLODUUHVHDUFKLQRWKHU6RXWK$VLDQFRXQWULHV on common issues such as absenteeism, corruption and informal payments for services. While the initial scope for the review intended to include a review of solutions to governance problems and whether there is some evidence on what has served to improve governance outcomes, this was not possible due to the scarcity of evidence and research. Similarly, innovative efforts to reform government systems are generally not documented or evaluated, preventing the review IURP LQFOXGLQJ VXFK LQLWLDWLYHV LQ LWV DQDO\VLV 2XU WHDP GLG QRW DWWHPSW WR VXPPDUL]H PRUH KLVWRULFDOUHVHDUFKSUHDQGWKH¿QGLQJVRIROGHUUHSRUWVZHUHJLYHQD³UHDOLW\FKHFN´WKURXJK informal consultations. The report is not based on a comprehensive data-mining exercise, though this exercise would be a useful. Table-1.1: A Description of the Categories of Issues for the Systematic Review Governance Category Governance Issues x 3XEOLF¿QDQFLDOPDQDJHPHQW SODQQLQJEXGJHWLQJDQG budget execution) Government Effectiveness x +XPDQUHVRXUFHPDQDJHPHQW VWDI¿QJSXEOLFVHFWRU management, capacity) x 2UJDQL]DWLRQDOHIIHFWLYHQHVV x Integrity in procurement processes Political Economy – x Financial and facility management, including management Cross cutting oversight Control of Corruption x Integrity in human resource management x Integrity in the regulation of the private sector x Transparency x 2SSRUWXQLWLHVIRUFLWL]HQVWRSURYLGHLQSXWWRGHFLVLRQ making Voice and Accountability x Oversight of service delivery x 2WKHUPHDQVIRUFLWL]HQVWRKROGJRYHUQPHQWVHUYLFH providers accountable x 5HJXODWLRQRIWKHTXDOLW\DQGDFFHVVLELOLW\RIVHUYLFH Regulatory Quality provision in the private sector, with appropriate standards and enforcement 2 5. 7KH*RYHUQPHQWRI%DQJODGHVKKDVVWURQJO\HPSKDVL]HGJRYHUQDQFHFRQFHUQVDQG each of the governance issues reviewed here is related to actions in the sixth 5 Year Plan and the Strategic Plan for Health, Population and Nutrition Sector Development Program +316'3 RIThe current 5 Year Plan lays out a comprehensive proposal to strengthen WKHKHDOWKFDUHV\VWHPLQ%DQJODGHVK7KH3ODQUHFRJQL]HVJRYHUQDQFHLVVXHVSDUWLFXODUO\WKHODFN RILQWHUPLQLVWHULDOFRRUGLQDWLRQFHQWUDOL]HGSURFXUHPHQWV\VWHPVDQGFDSDFLW\FRQVWUDLQWVDVZHOO as the need to strengthen partnerships with NGOs and the private sector. The Strategic Plan for Health, Population and Nutrition Sector Development Program (HPNSDP) of 2011-2016 includes a number of priority governance areas, including hospital management and oversight, increasing WKHVL]HDQGTXDOLW\RIWKHKHDOWKZRUNIRUFHLPSURYHGSURFXUHPHQWHVSHFLDOO\IRUSKDUPDFHXWLFDOV GHFHQWUDOL]DWLRQDQG FLWL]HQ SDUWLFLSDWLRQDQ LPSURYHG PRQLWRULQJ DQG HYDOXDWLRQV\VWHPV DQG coordination with private sector service providers. 6. :LWKLQHDFKFDWHJRU\WKHUHYLHZGRFXPHQWVWKH¿QGLQJVIURPWKHOLWHUDWXUHDFFRUGLQJWR A. What evidence is available in the literature in terms of governance outcomes? B. What analysis is available regarding the main government systems to achieve these outcomes? In other words, how does government work in practice? 7. While the review wanted to explore other questions and initiatives, it was limited by the research and documentation available. We sought out explanations for why the main government systems take the form that they do, but such an analysis was generally not available. Such research often takes the form of political economy, as many of the current government systems are shaped by interests, historical legacy and other factors. Similarly, innovative efforts to reform government systems are generally not documented or evaluated, preventing the review from including such initiatives in its analysis. 8. From this systematic review, we conclude that the available evidence as a whole is relatively weak and dated for the governance concerns in the sector, and there is a need to strengthen the knowledge base. Throughout the report, areas in which information is not available on governance are highlighted, especially when it pertains to governance issues that are RIWHQTXRWHGDQHFGRWDOO\$WWHPSWVWR¿QGOLWHUDWXUHWKDWH[DPLQHVJRYHUQDQFHWKURXJKWKHSROLWLFDO economy lens were largely fruitless, and this is a gap in the research agenda. Political economy factors could play a strong role in explaining the failure of government systems to address well- known governance problems. Background to the Public Health Sector of Bangladesh 9. Bangladesh has seen vast improvements in critical health indicators in the recent past, in spite of a poor governance environment. Bangladesh exhibits substandard performance on each of the World Governance Indicators, particularly government effectiveness and control of corruption, scoring percentile rankings of 22.5 and 21.1 respectively (World Bank, 2013a).6 According to the Corruption Perceptions Index of Transparency International of 2012, Bangladesh achieved a score of 26 out of 100, placing it at the position of 144 out of 176 countries. Nonetheless, the country has made good progress in the health sector. Notable achievements include the dramatic reduction in the infant mortality rate from 87 infant deaths per 1,000 live 6 Percentile ranks indicate the percentage of countries worldwide that rank lower than the indicated country, so that higher values indicate better governance scores. 3 births in 1993 to 43 in 2011, as well as 133 to 53 for the child mortality rate in the same years. The prevalence of underweight children under 5 declined from 56.3 percent in 1996 to 36 percent in 7KHUHFHQW/DQFHWVHULHVRIDUWLFOHVHPSKDVL]HVWKDW%DQJODGHVKKDVXVHGLQQRYDWLYHPHDQV to make these achievements, including pluralistic service provision from a variety of actors and community workers; but a greater role of government remains in regulating and supporting these actors (Adams et al., 2013; Ahmed et al., 2013; Chowdhury et al., 2013). 10. Despite this progress, challenges to providing quality health care remain, and improving governance could be central to improvements.3HUIRUPDQFHPHDVXUHVIRUWKHTXDOLW\ of care given in the public health sector are limited, but survey evidence suggests that there is much room for improvement. In the recent health facility survey (USC & ACPR, 2012), responses suggested that the standard protocol for treating children – such as weighing them and using a growth chart - is often not followed, implying that much greater efforts are needed to provide TXDOLW\FDUH 7DEOH 7DEOH 2XWSDWLHQW([SHULHQFHVZLWK3XEOLF+HDOWK6HUYLFHV LQ Un All Indicators DHs UHCs MCWC USC HFWC Patients Provider asked age of the child 95 98 96 100 100 97 Provider weighed the child 0 18 20 18 16 9 Growth chart used 0 18 20 14 14 9 Physically examined the child 45 68 61 55 62 56 For each medicine, caregiver 80 100 100 100 97 89 knows how much to give For each medicine, caregiver 65 85 91 95 93 76 knows the days of treatment Source: USC & ACPR, 2012 Note: Data based on exit interviews. Note:'+ 'LVWULFW+RVSLWDOV8+& 8SD]LOD+HDOWK&RPSOH[HV0&:& 0DWHUQDODQG&KLOG:HOIDUH&HQWHUV UnHFWC = Union Health and Family Welfare Centers, USC = Union Sub-centers 11. The legislative basis for the health sector includes both articles in the constitution and numerous acts. The provision of primary healthcare is a constitutional obligation of the Government of Bangladesh (GoB), which is responsible for ensuring that basic medical care reaches HYHU\FLWL]HQDVSHU$UWLFOH $ DQGIRUGHYHORSLQJWKHKHDOWKDQGQXWULWLRQRIHYHU\FLWL]HQDV per Article 18(1) of the Constitution. Numerous acts shape the health sector of Bangladesh, and fall under 7 broad areas that include: Vital Registration and Welfare Legislation, Public Health, Communicable Disease Control, Food and Drugs Control, Health Education and Health Practice, Environmental Health and Protection of Children and Women (Barkat et al., 2001). 12. The health sector of Bangladesh is made up of a wide variety of providers. Included among non-state providers are allopathic providers, village doctors, drugstore salespeople, traditional healers, non-secular faith healers, traditional birth attendants, homeopaths, private clinics, private hospitals and NGO-provided healthcare; traditional healers are by far the most common healthcare provider (Figure-1.1). 4 Figure-1.1: Density of Different Types of Healthcare Providers (Per 10,000 populations) Source: Bangladesh Health Watch (BHW), 2007. Note: TBA = Traditional Birth Attendant, TTBA = Trained Traditional Birth Attendant, CHWs = Community Health Workers 13. Moreover, the pharmaceutical industry is one of the largest industrial sectors of Bangladesh and provides the majority of local drugs, partly due to its heavily protected market. With 250 licensed manufacturers, the pharmaceutical industry represented approximately 1 percent of the total GDP in 2011. Bangladesh manufactures approximately 450 generic drugs IRUUHJLVWHUHGEUDQGV2QHHVWLPDWHLVWKDWWKHGRPHVWLFUHWDLOPDUNHWVL]HZDVZRUWK%'7 ELOOLRQLQ 6DDG 3URWHFWLRQLVTXLWHVWURQJ RQ0DUFK WKH*RYHUQPHQW HVWDEOLVKHGDSROLF\ZKHUHE\WKHGUXJVDQGPHGLFLQHVWKDWDUHORFDOO\PDQXIDFWXUHGLQVXI¿FLHQW numbers would not be imported. 14. While the health sector receives prominence in the government priorities, the budget IRUWKH0LQLVWU\RI+HDOWKDQG)DPLO\:HOIDUH 0R+): UHSUHVHQWVMXVWSHUFHQWRIWKH annual budget, a decline from 6.87 percent in 2007-08. (See Table-1.3 7KH¿QDQFLQJRIWKH development side of the budget is strongly supported by the health sector wide program, a multi- GRQRU¿QDQFLQJPHFKDQLVPZLWKDWRWDORIELOOLRQ¿QDQFLDOFRQWULEXWLRQSURJUDPPHGIRUWKH current Health Population Nutrition Sector Development Plan. Table-1.3: Budget of MoHFW Total GoB Budget MoHFW Budget MoHFW Budget Share Fiscal Year %'7%LOOLRQV %'7%LOOLRQV 2007-08 796.14 54.70 6.87 2008-09 999.62 58.62 5.86 2009-10 1,138.19 69.80 6.13 2010-11 1,321.70 81.29 6.15 2011-12 1,635.89 88.69 5.42 2012-13 1,917.38 93.33 4.87 2013-14 2,224.91 94.70 4.26 Source: Ministry of Finance, 2013. Note: Billion is 1,000 millions. 5 2. Government Effectiveness in the Health Sector 15. Overall, the literature on the health sector provides limited but important analyses of government effectiveness. /LNH µJRYHUQDQFH¶ WKH WHUP µJRYHUQPHQW HIIHFWLYHQHVV¶ FDQ EH interpreted in numerous ways. To break down the term, we present three aspects of government HIIHFWLYHQHVV SXEOLF ¿QDQFLDO PDQDJHPHQW KXPDQ UHVRXUFH PDQDJHPHQW DQG RUJDQL]DWLRQDO effectiveness. The Literature on Public Financial Management Table-2.1: Summary of the Literature on Public Financial Management Ministry Processes to Achieve Outcomes and Outcomes their Limitations - Processes to align revenue budget to plans Plan are weak (World Bank et al., 2010; MoHFW, - 2011b) - Spending on health by government tends towards the median compared - Lack of coordination between revenue and to other countries in the region (World Budget development budgets (World Bank et al., Bank, 2010b). 2010; Northway, 2013) - Various non-salary expenditures are relatively under-funded (FMRP, 2005) - The process for releasing funds is slow and LQHI¿FLHQW :RUOG%DQNHWDO - Limited FM and Procurement capacity in MoHFW impede budget execution (World Bank, 2010b; Northway, 2013) - MoHFW under-spends its budget allocation, especially development - &HQWUDOL]HG¿QDQFLDOPDQDJHPHQWDOVR budget (MoHFW, 2011b) impedes spending at the hospital level (Euro Budget Health Group, 2004) - Various disbursements to the local level Execution face large delays (World Bank et al., - Personnel registers and payroll information 2010) are manual, not updated and not available comprehensively (MoHFW, 2011b) - Staff payments face delays and are often not made in full (FMRP, 2005) - Discrepancies in expenditure reports (FMRP, 2005) - MIS systems are not used effectively (World Bank, 2010b) 6 16. The PFM literature primarily focuses on the budget and budget execution, particularly the challenges to executing the development budget. 7DEOH VXPPDUL]HV WKH ¿QGLQJV DQG gaps in the available literature on PFM in the public health sector. For many of the topics covered, the data is not publicly available, limiting our ability to track performance in recent years. 17. An analysis of public health spending shows that Bangladesh is near the median when compared with other countries in the region. As seen in Figure-2.1, the Governments of Pakistan and India spent less than Bangladesh on health as a portion of GDP (World Bank, 2010b). However, it is interesting to note that in terms of life expectancy, maternal and child mortality rates, Bangladesh mostly outperforms several other countries in the region, such as India, Pakistan and Afghanistan (World Bank, 2010b). Figure- 2.1: Public Health Expenditure as a Percentage of GDP, 2011 Source: Calculated from World Bank, 2013. 18. There is a lack of funding for various critical expenditures, especially running costs LQ WKH VHFWRU :RUOG %DQN E :RUOG%DQN E DQDO\]HGWKHEXGJHWV IURP to 2005/06 and found a falling portion of the budget for district hospital and UHC level, which may undermine service delivery given that these units represent the main source of public health services for users. The declining share is also found in the budget for medical and surgical UHTXLVLWHVLQFOXGLQJPHGLFLQHV$FFRUGLQJWRDQDQDO\VLVE\)053 WKHFRPELQHGPHDQ LQWKHEXGJHWRIWKH0R+):IRUXSD]LODOHYHOVSHQGLQJZDV%'7 RU86 SHUFDSLWDIRU WKH\HDU7KHUHSRUWFLWHGWKLVDVLQVXI¿FLHQWWRSURYLGHDEDVLFUDQJHRIVHUYLFHVZLWK universal coverage. 19. Different parts of the budget of MoHFW are uncoordinated, and the revenue budget is primarily incremental from year to year, instead of based on an assessment of performance DQG QHHGV :RUOG %DQN E 1RUWKZD\ World Bank (2010b) points the fact that the development and revenue budgets are prepared separately, by different civil servants (Joint Secretary Administration for revenue budget and Joint Chief Planning for the development budget) and according to different processes, as mentioned above. Another limiting factor to a coordinated budget is the fact that the OP does not include projects funded by development partners, which represent approximately one-third of development expenditure. World Bank (2010b) asserts that KHDOWKFDUHIDFLOLWLHVDUHXSJUDGHGDQGQHZHTXLSPHQWSXUFKDVHGXVLQJGHYHORSPHQWIXQGVZLWKRXW FRQFRPLWDQW LQFUHDVHV LQ UHFXUULQJ H[SHQVHV VXFK DV VWDI¿QJ 065 RU PDLQWHQDQFH WKRXJK QR 7 evidence is presented to support this claim. The World Bank (2010b) describes that the revenue budget is prepared after the submission of input-based budgets by various units. Moreover, budget allocations are not linked to past performance, as the Ministry has only limited data on performance DYDLODEOHDQGQRPHDQVWRDOORZWKLVGDWDWRLQÀXHQFHEXGJHWDU\DOORFDWLRQV :RUOG%DQNE 20. As for budget execution, MoHFW under-spends its development budget, where the execution rate was just 73.32 percent in FY 2011/12. The precise budget execution rates from FY 2009/10 to FY 2011/12 appear in Table-2.2. The execution rates in the development budget declined from 80.26 percent in FY 2009/10 to 73.32 percent in FY 2011/12, while the execution UDWHVLQWKHUHYHQXHEXGJHWUHPDLQTXLWHKLJKDERYH SHUFHQWIRUHDFK\HDU$OVRDFFRUGLQJWR an analysis of expenditures from FY 2004/05, the main budget items that are under-spent include such items as travel-related costs, utilities and other operating costs (FMRP, 2005). Table-2.2: Ministry of Health and Family Welfare Budget Execution 2009/10 2010/11 2011/12 Budget Actual Execution Budget Actual Execution Budget Actual Execution (BDT (BDT Rate (BDT (BDT Rate (BDT (BDT Rate billion) billion) (%) billion) billion) (%) billion) billion) (%) Revenue 39.05 38.03 97.38 46.56 47.36 101.71 53.07 50.55 95.25 budget Development 30.75 24.68 80.26 34.73 25.51 73.45 35.62 26.12 73.32 budget Total 69.80 62.71 89.84 81.29 72.87 89.64 88.69 76.67 86.44 Source: Ministry of Finance, 2013. Note: This table uses original (non-revised) budget estimates. 21. The under-spending of the development budget is due to several factors, such as SURFXUHPHQW SURFHVV GHOD\V FDSDFLW\ FRQFHUQV DQG FHQWUDOL]HG SURFHGXUHV :RUOG %DQN E 0R+): E (XUR +HDOWK *URXS )053 7KH OLPLWHG ¿QDQFLDO management and procurement capacity within the MoHFW is described as a major impediment to executing the budget, though this observation is not documented with evidence or measurement of the extent to which this is the main limitation (World Bank, 2010b). World Bank (2010b) further contends that high staff turnover limits an increase capacity, given the consistent training initiatives at the Ministry. MoHFW (2011b) agrees that procurement delays, due mainly to numerous and FHQWUDOL]HGUHTXLUHGDSSURYDOVDUHRIWHQEODPHGIRUXQGHUVSHQGLQJLQWKHGHYHORSPHQWEXGJHW 7KH¿QGLQJLVHFKRHGE\WKH(XUR+HDOWK*URXS ZKLFK¿QGVWKH¿QDQFLDOPDQDJHPHQW V\VWHPLVKLJKO\FHQWUDOL]HGDQGKDPSHUVWKHSXUFKDVHRIQHFHVVDU\EXWVPDOOLWHPVDQGVHUYLFHV in hospitals. While these purchases do not necessarily represent large expenditures (so do not H[SODLQODUJHYDULDWLRQVLQEXGJHWRXWWXUQ WKH\GRLQÀXHQFHWKHHIIHFWLYHGHOLYHU\RIVHUYLFHV 3XEOLF KRVSLWDO PDQDJHUV UHTXLUH FHQWUDO DXWKRULW\ IRU DOO SD\PHQWV H[FHHGLQJ %'7 ZLWK DXWKRUL]DWLRQRIWHQWDNLQJDORQJSHULRGRIWLPH$VDUHVXOWGUXJVVSDUHSDUWVDQGUHSDLUVDUHRIWHQ needed urgently, but cannot be procured due to the lengthy approval process involved. FMRP 8 ¿QGVGHOD\VLQUHOHDVLQJIXQGVIURPWKH'LUHFWRU*HQHUDORI+HDOWK6HUYLFHV '*+6 WR FRVWFHQWHUVVRWKDWPXFKRIWKHVSHQGLQJDWWKHXSD]LODOHYHOWDNHVSODFHDWWKHHQGRIWKH¿QDQFLDO year – which would contribute to the under spend. The report cites delays in releasing of up to two PRQWKVODWHLQWKH¿UVWDQGODVWTXDUWHURIWKH¿QDQFLDO\HDU7KHPDMRULW\RIWKHGHOD\LQUHFHLYLQJ DOORWPHQWVLVLQWKHDSSURYDODQGLVVXDQFHRIDOORWPHQWOHWWHUVDWWKH'LUHFWRUDWHKHDGRI¿FHDQG FHQWUDOPLQLVWU\OHYHO )053 $OVRLQWKHEXGJHWH[HFXWLRQSURFHVVWKHRI¿FLDOEXGJHW IXQGUHOHDVHSURFHVVJRHVWKURXJKVHYHUDOVWDJHVZLWKUHJXODUDQGWLPHO\UHOHDVHLGHQWL¿HGDVD SUREOHP :RUOG%DQNHWDO 3UREOHPVLQFROOHFWLQJIXQGXWLOL]DWLRQVWDWHPHQWVIURP''2V RIWHQ UHVXOW LQ IXQG UHOHDVH GHOD\V LQ WKH ¿QDO TXDUWHU 6HH $QQH[ 7KH RI¿FLDO EXGJHW IXQG release process goes through several stages, which may affect regular and timely release of funds DFURVVGLIIHUHQWPLQLVWU\OHYHOV :RUOG%DQNHWDO 3UREOHPVLQFROOHFWLQJIXQGXWLOL]DWLRQ VWDWHPHQWVIURP''2VIRUVXEPLVVLRQWRFHQWUDOOHYHOZDVLGHQWL¿HGDVRQHRIWKHLVVXHVLQIXQG UHOHDVHGHOD\VLQWKH¿QDOTXDUWHU 6HH$QQH[ 0R+): QRWHVWKDWGHOD\VLQIXQGUHOHDVH RIWHQRFFXUIURP0R)WR0R+):FRQWULEXWLQJWRDIXQGLQJJDSLQ+136'37KHUHSRUWEULHÀ\ mentions that actual donor funds are lower than committed amounts, resulting from duplications RIIXQGLQJFRPPLWPHQWVDQGRYHUVWDWHPHQWRIIXQGLQJVXSSRUWE\'3V$VDFRQVHTXHQFHZKHUH funds are on-budget and over-stated, MoF proceeds to hold back budget releases as it perceives WKDWWKHFXUUHQWEXGJHWLVQRWEHLQJIXOO\XWLOL]HG 22. Payments of a large minority of the staff of MoHFW are often delayed by six months DQGQRWPDGHLQIXOO )053 Across the MoHFW as a whole, nearly 28 percent of key workers reported being paid late, with 19 percent for more than 6 months (FMRP, 2005). 38 percent of respondents claimed to have received less than their full salary payment in the last installment, though for the majority of these, it was a loss of less than BDT 500. A contributing factor is that SD\UROOLQIRUPDWLRQ±DORQJZLWKSHUVRQQHOUHFRUGV±LVODUJHO\PDQXDODQGGHFHQWUDOL]HGWR/LQH 'LUHFWRUVDQGWRORZHUOHYHORI¿FHVLQWKHGLVWULFWDQGXSD]LODOHYHO 0R+):E $V\VWHPIRU monthly reconciliation between personnel records with payroll data is lacking. Such weaknesses make payroll susceptible to corruption, though no evidence is available regarding its existence (MoHFW, 2011b). 23. There are also problems with expenditure information between the MoF and MoHFW, and expenditures are not linked with performance data. World Bank (2010b) states that there DUHGLIIHUHQFHVEHWZHHQH[SHQGLWXUHUHSRUWLQJFKDQQHOVIURP8SD]LODVZKHWKHUIRU0LQLVWU\RI Finance or MoHFW, while FMRP (2005) notes discrepancies mainly between the accounts of the Controller General of Accounts and the MoHFW, by as much as 156 percent. Also, measures from management information systems of MoHFW are not regularly examined against the expenditures incurred by the functional units– whether service delivery facilities or public health programs– that produce the outputs being tracked (World Bank, 2010b).7 Health Metrics Network (2009) argues 7 On the outcome side, the government currently collects data on a variety of indicators (World Bank et al., 2010), including: Activity reports: patients, bed occupancy rate (BOR), emergency obstetric care, community clinics, antenatal care and SRVWQDWDOFDUHLQWHJUDWHGPDQDJHPHQWRIFKLOGKRRGLOOQHVVH[SDQGHGSURJUDPRILPPXQL]DWLRQ (3, 7XEHUFXORVLV DQG OHSURV\ UHSRUW 0RUELGLW\ DQG PRUWDOLW\ UHSRUW 'LVHDVHVSHFL¿F UHSRUWV GLDUUKHD ELUG ÀX PDODULD NDODD]DU HQFHSKDOLWLVGLSKWKHULD¿ODULDOKHSDWLWLVPHDVOHVPHQLQJLWLVSQHXPRQLDSROLRVH[XDOO\WUDQVPLWWHGGLVHDVHVWHWDQXV W\SKRLGXSSHUUHVSLUDWRU\WUDFWLQIHFWLRQVDQGZKRRSLQJFRXJK 7KHTXDOLW\RIPDQ\RIWKHVHUHSRUWVLVLQGRXEWDV the average health assistant who is responsible for collection would have to visit 1,400 households a month in order to complete the reports (World Bank et al., 2010). Moreover, the reports are primarily manually completed, with reports aggregating reports as they move up the chain. 9 WKDWLQDGHTXDWHVWDI¿QJDQGFDSDFLW\DW0R+):UHSUHVHQWNH\LPSHGLPHQWVWRIXUWKHUDGYDQFLQJ the current Management Information System of the Ministry. Gaps in the Literature on the Public Financial Management 24. 7KHUHDUHPDQ\DUHDVIRUIXUWKHUUHVHDUFKLQSXEOLF¿QDQFLDOPDQDJHPHQWLQFOXGLQJ the planning process, the informal budget preparation process and challenges to the execution of the development budget. Table-2.3 shows that such gaps are found across the PFM topics, ZKLFKDUHFDWHJRUL]HGE\SODQQLQJWKHEXGJHWIRUPXODWLRQSURFHVVDQGEXGJHWH[HFXWLRQ$VVHHQ LQ 7DEOH WKHUH LV D QHHG WR VFUXWLQL]H WKH LQIRUPDO SUDFWLFHV WR SUHSDUH SODQV DQG EXGJHWV SDUWLFXODUO\JLYHQWKHLQÀXHQFHRIGLIIHUHQWLQWHUHVWVJURXSV8 25. $ SUHFLVH DQDO\VLV IRU EXGJHW H[HFXWLRQ LV GLI¿FXOW JLYHQ WKDW WKHUH LV QRW SXEOLFO\ DYDLODEOHLQIRUPDWLRQRQEXGJHWH[HFXWLRQUDWHVE\OLQHLWHP DOVRJLYHQWKHLPSRUWDQFHRI the issue, factors that relate to budget execution deserve a fresh review. Data on projected and actual expenditure by budget item are not publicly available on the MoHFW website. Also, only limited information on the development and non-development budgets is available from the Ministry of Finance website.9 The limited availability of expenditure information prevents a detailed and consistent analysis of precisely where the over- and under-spending of budget occurs within the Ministry (World Bank, 2011). Impediments to budget execution, including capacity FRQVWUDLQWV KLJK VWDII WXUQRYHU LQ ¿QDQFLDO PDQDJHPHQW DQG SURFXUHPHQW DQG WKH QXPHURXV processes for approval, deserve are areas for further research, and studies should detail and track steps taken. Table-2.3: Gaps in the Literature on Public Financial Management Ministry Processes to Achieve Outcomes Outcomes and their Limitations - 3ODQVIRUPXODWHGZLWKDGHTXDWH - Plans represent country needs Plan technical input and country Political Economy - 3ODQVLQÀXHQFHWKHUHYHQXHEXGJHW ownership - Processes that determine health - ,QDGHTXDWHFRPSOHPHQWDU\LQSXWV budget Budget - Info on link between results and public - Processes to determine within- health services, especially spending budget allocations - Precise budget execution rates by item Budget - and geography, due to limited detailed Execution budget and expenditure information 8 For an in-depth description of the formal budget preparation process in MoHFW, see MoHFW, 2011b; the basic process is described in Annex-2. 9 The Ministry of Finance website provides some information on budget allocation and expenditures in the health sector WKURXJKGLIIHUHQWUHSRUWV7KHVHLQFOXGHDQQXDOEXGJHWVWDWHPHQWVPRQWKO\¿VFDOUHSRUWVDQG$'3XWLOL]DWLRQUHSRUWV 7KRXJKWKHVHUHSRUWVSURYLGHUHFRUGVRIRYHUDOO¿JXUHVDQGVWDWXVRIGHYHORSPHQWDQGQRQGHYHORSPHQWH[SHQGLWXUHV across the ministries, including MoHFW, they lack a detailed breakdown of the budget expenditure items. 10 26. Political economy could contribute substantially to understanding PFM in the health sector, in such areas as the interests present in the planning and budget process and the rents extracted from budget execution. Hossain & Osman (2007) broadly discuss the overall political value placed on the health sector as the main explanatory factor for the notable improvements in some health indicators, but that would fail to explain the declining budgets devoted to public KHDOWK3ROLWLFDOHFRQRP\PD\PRUHRYHUSURYLGHH[SODQDWLRQVIRUWKHFRQWLQXHGFHQWUDOL]DWLRQRI numerous PFM systems. The Literature on Human Resource Management 27. The literature on HRM covers a number of issues, including the lengthy process of recruitment, the relatively simple transfer process, and the large increases in public and private medical education institutions. The topics addressed by this research appear in Table-2.5. Issues related to corruption in Human Resource Management, including doctor absenteeism, are SULPDULO\GLVFXVVHGLQWKHVXEVHTXHQW&RQWURORI&RUUXSWLRQVHFWLRQ Table-2.4: Summary of the Literature on Human Resource Management Ministry Processes to Achieve Outcomes Outcomes and their Limitations - 2I¿FLDOKLULQJSURFHVVLQFOXGHVQXPHURXV steps and checks and balances (World Bank et al., 2010) - Vacancy rates are elevated health workers, mostly in - 2I¿FLDOWUDQVIHUGHFLVLRQVDUHFRQFHQWUDWHGLQ more distant regions (original analysis) the Division Director control (World Bank et - 6WDIIWXUQRYHUTXLWHIUHTXHQWO\ )053 al., 2010). - 'RFWRU NQRZOHGJH UHÀHFWHG LQ SUDFWLFHV LV TXLWH - ,QVXI¿FLHQWFRRUGLQDWLRQEHWZHHQ0LQLVWU\ poor (USC & ACPR, 2012) and Directorates in posting and transfer of &ODVVRI¿FHUV :RUOG%DQNHWDO - 'RFWRUVDQGQXUVHVDUHTXLWHXQVDWLV¿HGZLWKWKHLU jobs (Hadley et al., 2007; Cockroft et al., 2011) - Medical and nursing training institutions produce an increasingly large number of graduates (BHW, 2007) 28. Bangladesh maintains high vacancy rates for government doctors, nurses and other staff. Table-2.5 shows that the vacancy rate varies for overall staff by district, from 5.7 percent to 47.7 percent, with an average of 23.7 percent. The highest vacancy for in a district is 80.5 percent for physicians, the district of Gaibandha. The vacancy rate for all medical staff is low in 'KDNDGLYLVLRQEXWRIWHQULVHVVLJQL¿FDQWO\ZLWKLQFUHDVLQJGLVWDQFHIURPWKHFHQWHU )LJXUH Similarly, a breakdown of medical staff across physicians and nurses (See Annex-5) for different districts shows that vacancy rates remain low in the capital and in most of the districts surrounding it. 11 7DEOH 9DFDQF\5DWHIRU3XEOLF+HDOWK6WDIIE\'LVWULFW Lowest Highest Average Overall Staff 5.7 47.7 23.7 Vacancy Rate Physician Vacancy Rate 0.0 80.5 43.3 Nurse Vacancy Rate 0.0 79.4 21.9 Note: N = 63 districts. Source: $XWKRUV¶FDOFXODWLRQVRI'*+6'DWDEDVH )LJXUH 0DSRI+XPDQ5HVRXUFH9DFDQF\5DWHDW'LVWULFW/HYHO LQ3HUFHQW Source: DGHS Database, 2013. 12 29. 7KHUHDUHDQXPEHURIRI¿FLDOVWHSVLQYROYHGLQWKHKLULQJSURFHVVDQGLWVLQWHQVLW\ PD\FRQWULEXWHWRWKHYDFDQFLHV :RUOG%DQNHWDO These steps appear in Table-2.6. This process is applicable to Class 1 candidates – who include all doctors, but Class 2 – including nurses – through to Class 4 do not involve the Ministry of Public Administration or Bangladesh Public Service Commission. Table-2.6: Process of Filling Vacancies among Health Facilities Bangladesh Public MoHFW Ministry of Establishment Service Commission x )DFLOLW\LGHQWL¿HVQHHGWR x 5HTXHVWIRU36&WR x Job offers made ¿OOYDFDQF\ recruit for vacant post x Candidate hired x 5HTXHVWWR¿OOYDFDQF\ x Conducts hiring process x Posting assigned submitted to DGHS/DGFP x Compiles short list of x '+6'+)3UHTXHVW successful applicant DSSURYDORI0R)WR¿OO vacancy Source: World Bank et al., 2010. 30. Other factors, such as quality of life issues and high turnover rates, may also contribute to the vacancies found in remote and rural areas. Doctors and nurses resist a posting in remote areas, due to challenging living and working conditions (Luoma et al., 2009). Also, turnover UDWHVDUHHOHYDWHGIRUKLJKHUOHYHOORFDORI¿FLDOVZKRDUHRIWHQSRVWHGIRUOHVVWKDQD\HDUZKLFK means that doctors remain in remote area posts for less time (FMRP, 2005). Around 41 percent RIRI¿FLDOVLQWKH&ODVV,SD\UROO ZKLFKLQFOXGHVPHGLFDORI¿FHUVDFURVVGLUHFWRUDWHV KDGDUULYHG DWWKHLUGHVLJQDWHGXSD]LODGXULQJWKH\HDUDQGDVLPLODUSURSRUWLRQKDGOHIW7UDQVIHUSURFHGXUHV provide substantial decision-making power among Division Directors, but further research should H[DPLQHDQHFGRWHVWKDWWKHUHDUHLQIRUPDOSUHVVXUHVWKDWLQÀXHQFHWKHVHGHFLVLRQV :RUOG%DQNHW al., 2010). 31. There are also concerns regarding the quality of care. According to a test on child and maternal health administered by USC & ACPR (2012), the average scores for doctors were TXLWHORZDWSHUFHQWIRUFKLOGKHDOWKSHUFHQWIRUPDWHUQDOKHDOWKDQGSHUFHQWIRU67'V meanwhile, just 9 percent of child out-patients were weighed during their visit, and 56 percent were examined physically (USC & ACPR, 2012). The precise connection between these performance measures and the capacity of the medical staff involved has not been studied, though. 32. The institutions building the capacity of the health sector are growing in numbers, HVSHFLDOO\LQWKHSULYDWHVHFWRUZKHUHWKHQXPEHURIVFKRROVKDVVZHOOHG %+: The number such institutions have mushroomed since the early 1990s, when they were made legal. As seen in Figure-2.3, other than nursing institutions/colleges, private medical training institutions outnumber public ones. Together, public and private medical training institutions have 4,186 SODFHV ZKLFK FDQ FRQWULEXWH WR ¿OOLQJ WKH FXUUHQW YDFDQFLHV RI GRFWRUV ZKLFK QXPEHU DW MXVW XQGHU %+: $VIRUWUDLQLQJ)053 UHSRUWVWKDWWKHIUHTXHQF\RIRQWKHMRE training varies with designations, but that only 22 percent of doctors in UHCs have received such WUDLQLQJDVWDWLVWLFWKDWLVTXLWHORZ 13 Figure-2.3: Number of Public and Private Medical Training Facilities Source: Data compiled from MoHFW, 2011c. 33. The reasons that the numerous graduates from these institutions do not enter the public service include such factors as wage compression, widespread job dissatisfaction and the desire to go abroad. However, this issue deserves more systematic study, given the continued challenges of high vacancy rates. According to BHW (2007), the desires for private practice and for moving abroad substantially reduce the number of doctors who would enter the public sector. FMRP (2005) shows that the highest level doctors in public hospitals have a salary from 150 percent to 190 percent of the lowest level ones. Further research comparing doctor salaries relative to the ORFDOODERUPDUNHWDUHQHHGHG7ZRVWXGLHVDOVRSURYLGHVXUYH\DQGTXDOLWDWLYHHYLGHQFHUHJDUGLQJ the perceptions of doctors and nurses of their profession, highlighting widespread dissatisfaction (Hadley et al., 2007; Cockroft et al., 2011). The main issues raised include the lack of supplies, bad behavior of patients, poor housing facilities and the excessive number of patients relative to the number of doctors and nurses. Nurses face particular social stigma when they are female, due WRZRUNDFWLYLWLHVWKDWUHTXLUHXQSOHDVDQWLQWHUDFWLRQVZLWKSDWLHQWV +DGOH\HWDO Gaps in the Literature on Human Resource Management Table-2.7: Gaps in the Literature on Human Resource Management Ministry Processes to Achieve Outcomes Outcomes and their Limitations Economy Political - Level of education for health staff - Informal processes to create posts, recruit, - 0HDVXUHVRIHGXFDWLRQTXDOLW\LQPHGLFDO transfer and promote and nursing schools 34. The literature requires further study of the informal HR processes and staff education. Table-2.7 highlights these gaps. An analysis of HRM practices should move beyond a summary RIWKHRI¿FLDOSURFHGXUHVDQGVFUXWLQL]HWKHDFWXDOSUDFWLFHVLQYROYHGDVZHOO7KHLQIRUPDOPHDQV by which recruitment and transfer decisions are made would be highly relevant to both efforts to ¿OOYDFDQWSRVWVDQGWRVWDIIUHPRWHDUHDV0HDQZKLOHPHGLFDODVVRFLDWLRQVDUHSRSXODUO\NQRZQ WREHTXLWHLQÀXHQWLDOEXWWKHLUSURPLQHQFHKDVQRWEHHQDQDO\]HGLQWKHOLWHUDWXUH 14 35. The connection between medical training and quality of care deserves further study, as does the quality of the education provided by the blossoming medical education sector. :KLOH GRFWRUV RIWHQ SHUIRUP SRRUO\ DFFRUGLQJ WR PHDVXUHV RI WKH TXDOLW\ RI FDUH WKH SUHFLVH connection between education and performance has not been established, and therefore deserves study. Also, the effectiveness of medical training institutions to create a capable workforce has not yet been established, particularly in the public sector. Further research is needed to gauge the TXDOLW\RIWKDWHGXFDWLRQ 7KH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV 7DEOH 6XPPDU\RIWKH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV Ministry Processes to Achieve Outcomes Political Economy Outcomes and their Limitations - DGHS & DGFP divided (Sundew all et al., 2006) - Resistance to unifying DGHS - & DGFP (Sundew all et al., - SWAp is implemented with some 2006) GLI¿FXOWLHV 0DUWLQH] 36. 7KH OLWHUDWXUH RQ RUJDQL]DWLRQDO HIIHFWLYHQHVV LV OLPLWHG PDLQO\ IRFXVLQJ RQ WKH division of DGHS and DGFP, and the implementation of the SWAp. The main points in this OLWHUDWXUHDUHSUHVHQWHGLQ7DEOH)XUWKHUUHVHDUFKLVWKHUHIRUHUHTXLUHGRQDQXPEHURIIURQWV HVSHFLDOO\UHJDUGLQJGHFHQWUDOL]DWLRQLQWKHVHFWRUJLYHQLWLVDSULRULW\XQGHUWKHFXUUHQW+136'3 Figure-2.4: Main Government Entities in the Public Health Sector in Bangladesh Note: Others include the National Institute of Population Research and Training, Directorate General of Drug Administration, 'LUHFWRUDWHRI1XUVLQJ6HUYLFHV&RQVWUXFWLRQ0DQDJHPHQWDQG0DLQWHQDQFH8QLW7UDQVSRUWDQG(TXLSPHQW0DLQWHQDQFH 2UJDQL]DWLRQ1DWLRQDO(OHFWUR0HGLFDO0DLQWHQDQFH:RUNVKRSDQGWKH(VVHQWLDO'UXJV&RPSDQ\/LPLWHG 37. The Government of Bangladesh involves several different institutions in the delivery of health care services. 7KHVHFWRULVVSUHDGDFURVVQXPHURXVRUJDQL]DWLRQVZLWKLQJRYHUQPHQW including the Ministry of Local Government, Rural Development and Cooperatives (MoLGRDC) and the Directorate General of Family Planning (DGFP) within the Ministry of Health and Family Welfare (MoHFW). 15 38. The continued division between DGHS and DGFP, viewed through a political economy OHQVKLJKOLJKWVWKHVWUHQJWKRIJRYHUQPHQWEXUHDXFUDFLHVWRUHVLVWUHIRUPHIIRUWV 6XQGHZDOO HWDO The MoHFW is responsible for national level policy, planning and decision-making, which are then implemented by different executing and regulatory authorities. Of the executive departments under MoHFW, the DGHS and DGFP are by the largest. The managerial structure of '*+6DQG'*)3UXQIURPWKHQDWLRQDOGRZQWRGLYLVLRQDOGLVWULFWXSD]LODXQLRQDQGZDUGOHYHO Previous efforts to integrate the two directorates ended up in failure. Sundew all et al., (2006) argue that this outcome is due to the power of bureaucrats to resist administrative changes (Sundew all et al., 2006). Many development partners supporting the health sector continued to push for this integration of the two directorates, while the main resistance emerged from employees in the Directorate General of Family Planning. Eventually, after conducting two studies on the topic in 2003, the MoHFW decided not to continue with the integration, despite the protests and even threats from various development partners. 39. Starting in 1998, the health SWAp of Bangladesh has made progress toward program goals, while the various outcomes that formed the rationale for a SWAp approach have not DOO EHHQ DWWDLQHG 0DUWLQH] +316'3 The sector wide approach represents an LQQRYDWLYH PHDQV RI RUJDQL]LQJ WKH SODQQLQJ DQG ¿QDQFLQJ RI WKH KHDOWK VHFWRU LQ %DQJODGHVK implemented previously through its Health and Population Sector Program (HPSP) and continuing today under the current Health, Population and Nutrition Sector Development Program (HPNSDP). %DVHGRQDQDQDO\VLVRIDQQXDOSURJUDPUHYLHZVIURPWKH¿UVWWZR\HDUVRIWKH+1363LQDQG ZKLFKWKHDXWKRUOHDG WKH0DUWLQH]VWXG\¿QGVLQDGHTXDFLHVLQSURJUDPLPSOHPHQWDWLRQ These include a lack of government ownership of some components of the program, as well as ZHDN ¿QDQFLDO PDQDJHPHQW ,Q IDFW PDQ\ RI WKHVH FKDOOHQJHV VWHP IURP ORZ FDSDFLW\ LQ WKH PLQLVWU\ZKLFKUHTXLUHVDWWHQWLRQWR+50LVVXHV'HYHORSPHQWSDUWQHUVRQWKHRWKHUKDQGDUH IRXQGWRVRPHWLPHVIDFHFKDOOHQJHVLQKDUPRQL]LQJGHFLVLRQVDQGVHYHUDORIWKHPDUHVWLOOVHHNLQJ WRDSSO\WKHLURZQ¿QDQFLDODQGPRQLWRULQJV\VWHPV6LQFHWKLVVWXG\VRPHSURJUHVVZDVQRWHGLQ DUHDVRI¿QDQFLDOPDQDJHPHQWJRYHUQPHQWRZQHUVKLSDQGFRRUGLQDWLRQEHWZHHQ*R%DQG'3V following the second phase of the SWAp program (World Bank, 2012). These efforts nonetheless UHPDLQLQDGHTXDWHIRUDFKLHYLQJEHWWHUUHVXOWVLQWKHKHDOWKV\VWHPDQGVHYHUDOUHIRUPVKDYHEHHQ planned accordingly to address these issues (HPNSDP, 2012). *DSVLQWKH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV 7DEOH *DSVLQWKH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV Ministry Processes to Achieve Outcomes and Outcomes Economy their Limitations Political - MoHFW & MoLGRDC - 2UJDQL]DWLRQDOHIIHFWLYHQHVV - &HQWUDOL]HGGHFLVLRQPDNLQJ outcomes 16 40. 7KH OLWHUDWXUH RQ RUJDQL]DWLRQDO HIIHFWLYHQHVV GRHV QRW FRYHU QXPHURXV WRSLFV HVSHFLDOO\DQDQDO\VLVRIWKHFHQWUDOL]DWLRQRIWKHVHFWRUDQGWKHGLYLVLRQRIUHVSRQVLELOLWLHV across ministries. 7DEOH SUHVHQWV D VXPPDU\ RI WKH JDSV LQ UHVHDUFK 2WKHU WRSLFV UHTXLULQJ analysis include the precise nature of the division of MoHFW and MoLGRDC. Finally, despite the SULRULW\RIGHFHQWUDOL]DWLRQXQGHUWKHFXUUHQW+136'3WKHLVVXHRIGHFHQWUDOL]DWLRQLQWKHVHFWRU KDVQRWEHHQVWXGLHGFRPSUHKHQVLYHO\UHTXLULQJPXFKPRUHDQDO\VLV 41. 7KHUHLVYHU\OLWWOHFRPSUHKHQVLYHUHVHDUFKRQWKHODUJHO\FHQWUDOL]HGV\VWHPVXQGHU which the MoHFW operates. Quite often, studies suggest that greater autonomy would serve to PDNHORFDOSURYLGHUVDFFRXQWDEOHWRFLWL]HQVDQGDOVRSURYLGHORFDORI¿FLDOVZLWKWKHDXWRQRP\ QHFHVVDU\WRDGGUHVVLVVXHVDVWKH\DULVHZLWKRXWRIWHQLQHI¿FLHQWFHQWUDOEXUHDXFUDFLHVJHWWLQJ involved (HNPSP, 2009a). Overall, very few decisions are made at the facility level or even at the district level, in terms of planning and budget, budget execution, staff recruitment, and other decisions. Many of these areas have not been properly documented, such as the planning process, WKHVWDIIUHFUXLWPHQWSURFHVVWKHÀRZRIIXQGVIURPKRVSLWDOUHYHQXHVDQGRWKHUV 42. The delivery of public primary health care in urban areas, including the ability of MoHFW and MoLGRDC to coordinate, has not been a particular topic of research. Projects on urban health care seek to bridge the divide between the Ministries (MoHFW and MoLGRDC) through committees, such as National Urban Primary Health Care Committee and the National Project Steering Committee under the Urban Primary Health Care Project (World Bank et al., 2010). However, despite the increasing importance of public health in urban areas, this division and its effects on service delivery have not been studied. 43. 3ROLWLFDOHFRQRP\LVQRWDIRFXVRIWKHFXUUHQWUHVHDUFKRQRUJDQL]DWLRQDOHIIHFWLYHQHVV with the exception of the resistance to integrating DGFP and DGHS. Importantly, research VKRXOGVFUXWLQL]HWKHUHVLVWDQFHWRZDUGGHFHQWUDOL]DWLRQIRXQGLQWKHJRYHUQPHQWDVZHOODVWKH SRWHQWLDOLQWHUHVWVWKDWZRXOGLPSHGHRUXQGHUPLQHIXUWKHUGHFHQWUDOL]DWLRQ'HYHORSPHQWSDUWQHU LQWHUHVWVDUHDOVRKLJKO\UHOHYDQWWRWKHRUJDQL]DWLRQRIWKHVHFWRUSDUWLFXODUO\WKH6:$S 17 3. Control of Corruption in the Health Sector 44. 5HVHDUFKRQWKHFRQWURORIFRUUXSWLRQLVQRWRULRXVO\GLI¿FXOWWRFRPSOHWHEXWRYHU DGR]HQVWXGLHVKDYHPDGHDWWHPSWVWRPHDVXUHWKHLQFLGHQFHRIFRUUXSWLRQDQGWRDQDO\]H the implementation of systems to control it. The challenge in researching this topic stems from LWVIUHTXHQWO\LOOHJDOQDWXUHPHDQLQJWKDWFRUUXSWLRQUHPDLQVFRYHUW,QWKLVVHFWLRQZHGHVFULEH WKHFXUUHQWVWDWHRIWKHUHVHDUFKVXPPDUL]LQJQRWMXVWWKHDYDLODEOHPHDVXUHVRIFRUUXSWLRQEXW the systems to control corruption, including rules for public procurement, audit systems, oversight functions and transparency. The Literature on Corruption & Control Measures Table-3.1: Summary of the Literature on Corruption & Control Measures Area Primary Control Measures Form of Corruption - Procurement process is weak at national level (MoHFW, 2011b) - There is no evidence of procurement Procurement - Procurement functions well in corruption in district hospitals (Euro Dhaka hospitals (Euro Health Health Group, 2004) Group, 2004) - Distribution of drugs to facilities experience losses (Euro Health - Oversight at the local level is Group, 2004; FMRP, 2005) LQVXI¿FLHQWDQGIRFXVHGRQ administrative matters (FMRP, - Patients face a variety of illegal fees 2005) and charges (Euro Health Group, Financial and 2004; FMRP, 2005; TIB, 2010 & - National auditing practices are 2007) facility management weak (FMRP, 2005; World Bank, 2010b) - Drug prescriptions are partly driven by corruption (FMRP, 2005) - /RFDODXGLWLQJLVVXI¿FLHQWO\ IUHTXHQW )053 - 2I¿FLDOVPDNHVSHHGSD\PHQWVWRJHW bills passed at the local level (FMRP, 2005). - Oversight at the local level is - Absenteeism and unexplained LQVXI¿FLHQWDQGIRFXVHGRQ Staff absenteeism substantial (Chaudhury administrative matters (FMRP, & Hammer, 2003; FMRP, 2005) 2005) Regulation - - 18 45. The literature on corruption primarily focuses on procurement and corruption at the facility level. Table-3.1 provides a summary of this literature. Measures of corruption are primarily drawn from the local level, with very little data on the national level. 46. Procurement practices at the national level are often weak, with competitive bidding and other standard practices are not followed, though recent initiatives at improvement have potential (MoHFW, 2011b). According to an estimate from MoHFW (2011b), approximately half of procurement processes award a contract without an open competition. Similarly, the analysis cites observations made by Comptroller and Auditor General (CAG) audit reports, which note that tendering processes and contract execution fail to follow the proper processes. The Government has however undertaken initiatives on procurement such as the Electronic Government Procurement (e-GP) and the Procurement Management Information System (PROMIS), which may improve these processes.10 Also, since this study, several other measures following recommendations made in the PAD of HNPSDP have been taken to strengthen the procurement systems and functions of MoHFW (HPNSDP, 2012).11 & 12 47. 0HDQZKLOHDQLQYHVWLJDWLRQRI¿YHKRVSLWDOVLQ'KDNDIRXQGQRHYLGHQFHRIFRUUXSWLRQ LQSURFXUHPHQWDQGDJHQHUDOUHVSHFWIRUWKHUXOHVRQWKHSURFHVV (XUR+HDOWK*URXS %DVHGRQDVXUYH\RI¿YHSXEOLFDQGSULYDWHKRVSLWDOVFRQGXFWHGLQWKHUHSRUW¿QGVWKDWRI the total funds received by the hospitals for procurement of MSR, about 60 to 70 percent was spent RQGUXJVIURPWKHOLVWRIWKH(VVHQWLDO'UXJ&RPSDQ\/LPLWHGPHDQLQJWKHUHZHUH¿[HGSULFHV DQG OLPLWHG TXDQWLWLHV PHDQZKLOH WKH UHPDLQLQJ WR SHUFHQW ZDV SURFXUHG FRPSHWLWLYHO\ EDVHGRQSULFHDQGQRWTXDOLW\ (XUR+HDOWK*URXS 2YHUDOOZKLOHORZHVWFRVWSURFXUHPHQW PD\KDYHLWVRZQLVVXHVLQWHUPVRIWKHDSSURSULDWHTXDOLW\RIWKHVXSSOLHVWKHUHSRUWGRHVQRW uncover any corruption in this process. Further research should investigate procurement in other health facilities. 48. There is evidence of losses in drug stocks, but the source of these losses is not clear DQGUHTXLUHVIXUWKHUUHVHDUFK )053 The FMRP survey team performed two separate investigations: a reconciliation of receipts between district stores and health facilities, and a comparison of drug receipts with information from patient interview. The former showed that the values recorded by UHC were a mean of 99 percent of the value recorded at district level, while the latter revealed that the value recorded by Union level facilities were on average 92.7 percent value recorded of the issuer. The reason for this the difference in values may be due to measurement error, losses at the facility, or losses further up the supply chain, a topic for further study. 10 Further information on the MoHFW processes and bodies involved in procurement are available in World Bank et al. (2010). 11 These include: (a) Procurement and Logistics Management Cell (PLMC) formed and partly operational; (b) Technical Assistance is ongoing from USAID by Management Sciences for Health; (c) A web-based procurement portal of 02+):LVSDUWLDOO\IXQFWLRQDODQGSLORWLQJZLOOEHFRPSOHWHGQH[W\HDU G 'HVNRI¿FHUVDW&HQWUDO0HGLFDO6WRUDJH Depot (CMSD) and DGFP will be included in the Tender/Bid Evaluation Committee according to the nature and value of the contract; (e) Procurement focal persons (PFPs) have been assigned at CMSD, DGFP and Health Engineering Department (HED); and (f) capacity building measures are now more routine and structured. For goods procurement in particular, the document mentions that procurement planning would be conducted on a needs-basis long before UHTXLUHPHQWDQGV\QFKURQL]HGZLWK$'3 12 $UHFHQWPHGLFDOHTXLSPHQWVXUYH\SURYLGHVLQVLJKWVLQWRWKHSURFXUHPHQWDQGGLVWULEXWLRQSURFHVVIRUPHGLFDO HTXLSPHQW6LPHG,QWHUQDWLRQDO 19 49. Evidence also suggests that corruption partly explains problems with the prescription RIGUXJV )053 According to the FMRP survey, 65 percent of patients were prescribed DQ LQDSSURSULDWH RU SRWHQWLDOO\ LQDSSURSULDWH GUXJ RU DQ LQDSSURSULDWH GRVDJH IUHTXHQF\ DQG duration. The authors attribute this primarily to a practice whereby the patient is given an initial prescription and advised to buy the full dosage in a private pharmacy, implying that the practice LVGRQHIRUWKHSHUVRQDOEHQH¿WRIGRFWRUV )053 %DQJODGHVK+HDOWK:DWFK FLWHG a month-long investigation by the Daily New Age newspaper that revealed that, as an incentive for prescribing medicines of selected pharmaceutical companies, physicians get a wide range of rewards including monthly payments, air tickets, payments of mobile phone bills, etc.; such SUDFWLFHVDUHLOOHJDODFFRUGLQJWRWKHODZ3DWLHQWSHUFHSWLRQVDFFRUGLQJWRTXDOLWDWLYHLQWHUYLHZV by SIDA (2007) are that doctors may prescribe unnecessary drugs because of alliances with SKDUPDFLHVIRUWKHLURZQEHQH¿W 50. Patients must pay illegal fees to receive treatment, which is often enforced by lower OHYHOVWDII KRZHYHUWKHLQFLGHQFHDQGWKHDPRXQWRILOOHJDOIHHVSDLGDSSHDUVWREHGHFOLQLQJ (XUR +HDOWK *URXS )053 7,% Euro Health Group (2004) DQDO\]HV LOOHJDO IHHV VKRZLQJ WKDW WKH SHUFHQWDJH RI LQSDWLHQWV WKDW SDLG WKHP DSSHDUV WR YDU\ ZLGHO\EHWZHHQWKH¿YHKRVSLWDOVLQWKHVWXG\ZLWKWKHORZHVWDWDSSUR[LPDWHO\SHUFHQWDQGWKH highest at 94 percent. More recent surveys of TIB show that a notable portion of respondents face illegal fees in accessing health services from government and private hospitals, though that portion has declined somewhat over time. In 2007, about 44 percent of households reported experiencing some form of corruption in accessing health services which declined to about 33 percent in 2010 (TIB, 2007 & 2010). Also, the reports show that the incidence (16.3 percent vs. 13.2 percent) DQGDYHUDJHDPRXQW %'7YV%'7 RI³LOOHJDOSD\PHQWV´IRUUHFHLYLQJGLIIHUHQWKHDOWK services had dropped slightly during this period.13 Euro Health Group (2004) describes the system RI LQIRUPDO IHHV LQ ¿YH KRVSLWDOV ZKLFK LQYROYH LQWHUPHGLDULHV ZKR ZRUN DV ORZHU OHYHO QRQ PHGLFDO VWDII 7KH LQGLYLGXDOV UHTXHVWLQJ WKHVH IHHV ZHUH IURP DOO OHYHOV RI VWDII EXW PRVWO\ included lower levels of non-medical staff such as clerks, administrative personnel and ward boys. Focus group discussions from the study revealed that patients paid these fees to ensure that they UHFHLYHGWUHDWPHQWDVZHOODVWRDYRLGGHOD\HGDQGORZTXDOLW\KHDOWKVHUYLFHV7RUHFHLYHLQIRUPDO permission to operate, these intermediaries paid around BDT 100,000 to higher authorities. 51. Moreover, evidence also indicates that public doctors unnecessarily refer patients WR SULYDWH FOLQLFV RU SUDFWLFHV 6,'$ 7,% %+: The TIB Corruption Survey of 2010 found that around 36 percent of the users of government health services claimed that doctors recommended use of their private clinic. These practices are not necessarily illegal DQG PHULW IXUWKHU LQYHVWLJDWLRQ EXW VRPH OLPLWHG TXDOLWDWLYH HYLGHQFH VXJJHVWV WKDW LW RIWHQ LV illegal. As described in Bangladesh Health Watch (2009), doctors of Dhaka Medical College Hospital referred half of their patients to private diagnostic centers in spite of having laboratory facilities at the hospital where 90 percent of the tests were available. Respondents from the SIDA interviews perceived that there is increased pressure to have diagnostic tests, and that there was an 13 However, illegal practices may be under-taken by medical staff in efforts to cope with limited resources in government health facilities. Zaman (2006) showed in his ethnographic study of a government medical facility that corrupt practices VXFKDVH[WUDFWLQJPRQH\IURPULFKSDWLHQWVDQGKLULQJXQRI¿FLDOVWDIIDUH³LQYHQWLYHVWUDWHJLHV´E\ZKLFKGRFWRUVFRSH ZLWKWKHOLPLWHG¿QDQFLDODQGDGPLQLVWUDWLYHUHVRXUFHV 20 ³XQKRO\DOOLDQFHEHWZHHQWKHGRFWRUDQGWKHGLDJQRVWLFFHQWUHV´ 6,'$ 7KH\REVHUYH a suspicion that this practice was motivated by side payments from diagnostic centers to public referring doctors (SIDA, 2007). 52. $ODUJHSRUWLRQRI0R+):HPSOR\HHVPXVWPDNHLQIRUPDOSD\PHQWVWRRI¿FLDOVLQWKH $FFRXQWDQW*HQHUDORI¿FHVDQGWKH'LUHFWRUDWH*HQHUDORI¿FHV )053 This was either XVHGWRIDFLOLWDWHWKHUHFHLSWRIDOORWPHQWOHWWHUVIURPFHQWUDO'*RI¿FHVRUWRSDVVH[SHQGLWXUH ELOOVE\WKH$*DFFRXQWVRI¿FH,QWKHVXUYH\DFFRXQWDQWVZHUHTXHVWLRQHGDERXWWKHSUHYDOHQFH IRUPDWDQGYDOXHRIVSHHGSD\PHQWVWKDWWKH\PDGH7KHEULEHVFRXOGUHSUHVHQWHLWKHUDÀDWUDWH or a percentage per transaction, the most common being 5 percent. Also, as seen in Table-3.2 the VXUYH\¿QGLQJVVXJJHVWWKDWWKHGHPDQGLQJRIVSHHGSD\PHQWVLVFRPPRQHVSHFLDOO\WRKDYHWKH expenditure bill passed, and travel expenses in particular (FMRP, 2005). 7DEOH $FFRXQWDQWV5HSRUWLQJ,QIRUPDO3D\PHQWV To Receive Allotment To Have Expenditure Letters Bills Passed $FFRXQWDQWVIURP&LYLO6XUJHRQ¶V2I¿FH 37 73 $FFRXQWDQWVIURPWKH8SD]LOD±'*+6 59 67 $FFRXQWDQWVIURPWKH8SD]LOD±'*)3 29 61 Source: FMRP, 2005. 53. Overall absenteeism and unexplained absenteeism rates of health care professionals DUHKLJKZLWKVHULRXVFRVWVWRVHUYLFHGHOLYHU\ &KDXGKXU\ +DPPHU )053 Chaudhury and Hammer (2003) estimate that the absentee rate of physicians in public health centers is more than 40 percent on average, though this does not distinguish excused absenteeism, such as training or other responsibilities, from unexcused absenteeism (Table-3.3). FMRP (2005) reports a relatively high rate of absenteeism for doctors and nurses as well, but unexplained absenteeism is greatest for nurses (28 percent) and doctors at the union level (21 percent), and less SURPLQHQWIRUGRFWRUVLQ8+&V SHUFHQW 4XDOLWDWLYHHYLGHQFHVXJJHVWVWKDW0LQLVWU\RI¿FLDOV do not feel they have recourse in the case of absenteeism or poor performance of doctors and QXUVHV +RVVDLQHWDO ,QLQWHUYLHZV8QLRQ+HDOWKDQG)DPLO\3ODQQLQJ2I¿FHUVFODLPHG that they have few incentives or disincentives by which they might promote good performance of doctors and nurses. 21 7DEOH $EVHQWHHLVP9DULRXV6WXGLHV Unexplained Total Absenteeism Absenteeism Rate Absenteeism Rate 5DWH Chaudhury& FMRP FMRP Hammer 'RFWRU±8+& 8SD]LOD 35 8 41 Doctor – Union 42 21 44 Nurse 56 28 58 3DUDPHGLF±8+& 8SD]LOD 23 13 17.6 Paramedic – Union 12 8 Family Welfare Visitor 6 3 5 (20 for senior) Sources: FMRP, 2005 and Chaudhury & Hammer, 2003. 54. Auditing in MoHFW is often weak, and requires greater frequency and improved IROORZXS )053 :RUOG%DQNE World Bank (2010b) reports that internal audits DW0R+):DUHIUDJPHQWHGE\GHSDUWPHQWDQGQRWZHOOUHVRXUFHG DVDUHVSRQVHDSULYDWH¿UP was hired under the HNPSP, which indicates that the Ministry experiences capacity constraints, RSHUDWLRQDO LQHI¿FLHQFLHV DQG ZHDN LQWHUQDO FRQWUROV 7KH H[WHUQDO DXGLWV H[HFXWHG E\ YDULRXV departments under the Comptroller and Auditor General, have noted some serious irregularities, EXWWKHVHDUHQRWIROORZHGXSTXLFNO\E\WKH0LQLVWU\±MXVWUHVROYHGRXWRIFDVHVIURP)< WR)< :RUOG%DQNE 7KH)053VXUYH\LQYHVWLJDWHGWKHIUHTXHQF\DQG W\SHVRIDXGLWVFRPSOHWHGDWWKHXSD]LODDQG&62I¿FHVHVWLPDWLQJWKDWSHUFHQWRI&6RI¿FHV DQGSHUFHQWRIXSD]LODVKDYHKDGQRDXGLWVRIDQ\NLQGLQWKHODVWWKUHH\HDUV )053 55. Finally, supervisory visits to hospitals are frequent, but most of these visits were focused on administrative matters )053 Divisional directors were reported to visit EHWZHHQRQH¿IWKDQGRQHTXDUWHURIWKH8+&VHDFKPRQWKZKLOHERWKWKH&6DQGWKH'LUHFWRUDWH General of Family Planning (DGFP) deputy director were also said to be active in these visitations. However, FMRP (2005) also found that most discussions concentrated on administrative matters and only 4 percent discussed on-the job training and 20 percent discussed clinical matters. Stock records and patient registers were usually not investigated. 34 percent of union heads-of-facilities indicated that these visitations had brought about change, while 40 percent said there was no FKDQJHDQGSHUFHQWUHSRUWHGWKDWQRSUREOHPVKDGEHHQLGHQWL¿HG Gaps in the Literature on the Control of Corruption 56. 7KHUHYLHZLGHQWL¿HVDUHDVIRUIXUWKHUUHVHDUFKWKDWLQFOXGHGUXJVWRFNPDQDJHPHQW transparency, HRM issues and the regulation of private hospitals and pharmaceuticals. Table-3.4 highlights topics where research should focus. Moreover, studies should pay attention QRWMXVWWRWKHRI¿FLDOSURFHVVHVWRFRQWUROFRUUXSWLRQEXWWRWKHDFWXDOSUDFWLFHVDVZHOO 22 Table-3.4: Gaps in the Literature on Corruption & Control Measures Area Primary Control Measures Form of Corruption - The procurement process - Corruption at national and local level for a -----------Political Economy---------- Procurement at the local level variety of goods Financial and - Prescription of drugs from private clinics Facility - Transparency - Sale of free medicines in the market Management - Oversight at the local level -Favoritism in hiring, appointments, - Meritocratic recruitment transfers and promotions decisions Staff processes, transfers, promotions - Ghost workers - Transparency - Bribes for salary payments Regulatory - Oversight - Corruption in regulation of private health Quality - Transparency providers and drug manufacturers 57. While survey evidence suggests that there are problems in drug stock management, WKHSUHFLVHVRXUFHRIWKHSUREOHPKDVQRWEHHQVFUXWLQL]HG )053 As mentioned, it is unclear whether the issue is with record keeping, upstream challenges, or mismanagement of stocks DWWKHORFDOOHYHO$SXEOLFH[SHQGLWXUHWUDFNLQJVXUYH\MXVWRQWKLVWRSLFZRXOGEHTXLWHXVHIXO 58. While there is anecdotal evidence of corruption in the hiring and transfer of health workers, the topic merits further examination. Perception surveys of health workers regarding the fairness of such decisions would provide a better measure of the extent of corruption, while a GHWDLOHGDQDO\VLVRIDFWXDO+50SUDFWLFHVFRXOGXQFRYHUVWHSVZKHUHWKLVLQÀXHQFHPD\EHDFWLYH 59. There is little literature regarding corruption in health regulatory systems, whether in the regulation of private sector providers or of pharmaceutical companies. Regulation in the health sector is the focus of a later section, but the only mention of corruption in this literature LVWKDWRI¿FLDOVLQODERUDWRULHVIRUWHVWLQJGUXJVDPSOHVSXUSRUWHGO\VXVSHFWWKDWWKHVDPSOHVWKH\ receive are not random, due to collusion between regulators in the Drug Directorate Administration (DDA) and factory owners; no substantive evidence on this is available, however. 60. The level of transparency of MOHFW whether on its website, through documentation, or at the facility level, has hardly been covered in the research. Transparency is a cross- cutting issue that is relevant to each of corruption. At the national level, and mainly via an analysis of websites, World Bank (2011) examines six dimensions of transparency: annual budget GRFXPHQWDWLRQ LQ\HDU EXGJHW H[HFXWLRQ UHSRUWV \HDUHQG ¿QDQFLDO VWDWHPHQWV H[WHUQDO DXGLW reports, contract awards and resources available to primary service units. It makes the following observations: x Aggregate annual MOHFW budgets are available, but not detailed budgets x In-year budget execution reports are generally available x $JJUHJDWH02+):\HDUHQG¿QDQFLDOVWDWHPHQWVDUHDYDLODEOHEXWGHWDLOHGVWDWHPHQWV are not 23 x Access to a small number of audit reports x Contract awards information transparent mainly via the Central Procurement Technical Unit (CPTU) website, but limited information regarding tenders x 1RWUDQVSDUHQF\RIIDFLOLW\OHYHO¿QDQFHV $WWKHVDPHWLPHDUHFHQWO\FRQGXFWHGVXUYH\E\1LHOVHQ VKRZVWKDWZKHQFLWL]HQVDUH asked which types of information would be most useful, they identify information on health services DVPRVWFRPPRQLWHPDWSHUFHQW0XFKPRUHDQDO\VLVLVUHTXLUHGUHJDUGLQJWUDQVSDUHQF\WR address the potential and actual areas of corruption mentioned. 61. Another cross-cutting topic that has not been studied is the legal system in cases of FRUUXSWLRQLHZKDWKDSSHQVZKHQDQRI¿FLDOKDVEHHQDFFXVHGRIFRUUXSWLRQLQYLRODWLRQ of the law. The main government body responsible for effective, fair and speedy disciplinary proceedings against civil servants is the Bangladesh Public Service Commission. It does not execute disciplinary measures, but rather makes recommendations to the relevant Ministry or government ERG\7KH3XEOLF6HUYLFH&RPPLVVLRQKDVEHHQFULWLFL]HGIRULWVORZOHYHORILQGHSHQGHQFHDQG slow handing of many disciplinary measures (IGS, 2008). It is unclear whether this system SURYLGHVDQDGHTXDWHGLVLQFHQWLYHIRUFRUUXSWLRQDPRQJFLYLOVHUYDQWVZRUNLQJLQWKHKHDOWKVHFWRU 62. Furthermore, this literature requires further political economy analysis of interests behind corruption as well as of the resistance to implement control measures. Such topics include the interests involved in mis-procurement, and the precise system of the illegal fees that are sometimes applied in facilities. Furthermore, efforts to control corruption, such as audits and managerial oversight, may not be applied due to rents and interests of key individuals. 24 4. Voice and Accountability in the Health Sector 63. Bangladeshis have implemented a variety of initiatives on voice and accountability in the health sector at the local level. A deep understanding of the dynamics at present is needed to EHWWHULQIRUPHIIRUWVDWIXUWKHUGHFHQWUDOL]DWLRQDQGORFDOHPSRZHUPHQW$WWKHVDPHWLPH7KRPDV DQG%+: LGHQWLI\WKHODFNRIGHFHQWUDOL]DWLRQRIGHFLVLRQPDNLQJWRKRVSLWDOVDVD NH\LPSHGLPHQWZKLFKDOVRUHTXLUHVIXUWKHUUHVHDUFK The Literature on Voice and Accountability Table-4.1: Summary of Voice and Accountability in the Literature National Level Local Level Outcomes Plan or - None, but limited scope due to lack of Budget GHFHQWUDOL]DWLRQ 7KRPDV %+: - 2I¿FLDORYHUVLJKWRIEXGJHWH[HFXWLRQLV generally weak (Thomas, 2003; Mahmud, Budget 2008) (Not relevant) Execution - Hospital feedback mechanisms yield results for mild complaints Outside - 8QRI¿FLDORYHUVLJKWRIKHDOWKIDFLOLWLHVLV Gov’t generally weak (Thomas, 2003) XQRI¿FLDO 64. The literature on voice and accountability in the health sector focuses primarily on the local level. Table-4.1 shows that the main subjects that are studied include a variety of interventions through case studies and assessments, focusing mainly on implementation challenges. 65. 2I¿FLDO YRLFH LQLWLDWLYHV DW WKH ORFDO OHYHO IDFH OLPLWDWLRQV WR LPSOHPHQWDWLRQ VXFK DV D ZHDN PRELOL]DWLRQ RI FLWL]HQV DQG OLPLWHG WUDLQLQJ DV ZHOO DV D ODFN RI JRYHUQPHQW UHVSRQVLYHQHVV WR GHFLVLRQV 0DKPXG 7KRPDV 14 According to case studies of community groups and Health Watch Committees under the Health and Population Sector Program in 1998, Mahmud (2008) highlights several limitations to the participatory spaces that OLPLWHGWKHLULPSDFW)LUVWWKH\GLGQRWDFWLYHO\PRELOL]HDQGWUDLQFLWL]HQVVXI¿FLHQWO\IRUHIIHFWLYH SDUWLFLSDWLRQ WKHVH FLWL]HQV ZHUH QDWXUDOO\ VNHSWLFDO RI WKHVH QHZ IRUXPV HVSHFLDOO\ JLYHQ WKH WLPHFRVWVLQYROYHGDQGWKH\ODFNHGH[SHULHQFH6HFRQGWKHUHZDVOLWWOH¿QDQFLDOVXSSRUWRUOHJDO 14 The two studies on direct public participation at the local level were also limited methodologically in several ways (Mahmud, 2008; Thomas, 2004). While the case study methods provide important ideas regarding dynamics in the cases, the universality of the observations in Bangladesh was not tested. Also, the outcomes of the variety of experiences, ZKLFKDUHDGPLWWHGO\GLI¿FXOWWRPHDVXUHZHUHQRWVFUXWLQL]HGLQWKLVUHVHDUFK 25 EDFNLQJIRUWKHVHIRUXPV7KLUGWKHIRUXPVZHUHXQGHUXWLOL]HGLQRI¿FLDOGHFLVLRQPDNLQJLQVXFK areas as sites for constructing health facilities. Thomas (2003) uses evaluations and focus group GLVFXVVLRQV WR VFUXWLQL]H H[DPSOHV RI SDUWLFLSDWLRQ LQFOXGLQJ $GYLVRU\ &RPPLWWHHV RI 'LVWULFW Hospitals, the Community Health Schemes, and the Community Clinic Management Committees. 7KRPDVHPSKDVL]HVSUREOHPVVXFKDVHOLWHFDSWXUHDQGJHQGHUELDVWKDWDURVHLQWKHSUDFWLFHRI participation in these experiences. 66. $QXPEHURIXQRI¿FLDOERGLHVIRUFLWL]HQRYHUVLJKWVXIIHUIURPVLPLODULPSOHPHQWDWLRQ FKDOOHQJHV 7KRPDV Thomas focuses on a sample of voice and accountability activities WKDWZHUHQRWSXEOLFO\VDQFWLRQHGVXFKDVWKH&RPPLWWHHVRI&RQFHUQHG&LWL]HQVLI7,%HIIRUWV to monitor state interventions (Nijera Kori and Nari Pokkho), and the Union Health Committee of Addin. The author again describes problems of elite capture and gender bias. 67. One new initiative is the mobile feedback system under the Management Information 6\VWHP 0,6+HDOWK VHUYLFHVRIWKH'*+6ZKLFKKDVUHVROYHGSULPDULO\PLOGFRPSODLQWV but not moderate and serious ones. This system has been implemented in around 800 public KHDOWKIDFLOLWLHVLQWKHFRXQWU\DQGDOORZVFLWL]HQVWRWH[WFRPSODLQWVLQWRDGDWDEDVHWKDWVWUHDPV DV D GDVKERDUG LQ WKH FRPSXWHUV RI WKH 0LQLVWU\ +HDG RI¿FH DQG HYHQ WR WKH GLUHFWRU¶V RI¿FH Data collected in the period of October 2012 to March 2013 from the complaints database show that the majority of complaints received from the public health facilities were of a mild nature (Figure-4.1). However, over 80 percent of the moderate and serious level complaints remained XQVROYHG VXJJHVWLQJ WKDW WKH V\VWHP UHTXLUHV VWURQJ LPSURYHPHQWV LQ UHVSRQGLQJ WR FLWL]HQ feedback in order to increase the accountability of public hospitals. Figure-4.1: Distribution of the Different Types of Complaints Received Source: $XWKRUV¶FDOFXODWLRQVRI0R+): 26 Figure-4.2: Complaint Outcomes across Different Complaint Types (% of Total Complaints) Source: $XWKRUV¶FDOFXODWLRQVRI0R+): Gaps in the Literature on Voice and Accountability Table-4.2: Gaps in the Literature on Voice and Accountability National Level Local Level Outcomes Political Economy - Public Plan or Budget - - consultation Budget Execution - - Comprehensive evaluation Outside Gov’t - Media - Comprehensive evaluation - XQRI¿FLDO - CSO oversight 68. $ UHYLHZ RI WKLV OLWHUDWXUH LGHQWL¿HV DUHDV IRU IXUWKHU UHVHDUFK VXFK DV WKH VWXG\ of voice and accountability at the national level and a more detailed impact evaluation of efforts to date. 7DEOH VXPPDUL]HV WKHVH JDSV 2YHUDOO D PRUH FRPSUHKHQVLYH HYDOXDWLRQ of voice and accountability efforts would be useful to determine if they achieved their intended RXWFRPHVGHVSLWHDOORIWKHFKDOOHQJHVLQWKHSURFHVV&LWL]HQSDUWLFLSDWLRQLQFRPPXQLW\FOLQLFV also represents a novel topic where research can make a contribution. 69. There is little analysis of voice and accountability initiatives in the health sector at the national level, whether regarding consultations on plans and budgets, or media and civil society. :RUOG%DQNHWDO EULHÀ\PHQWLRQVDQXPEHURILQLWLDWLYHVIURP*R%WRHVWDEOLVK national level institutions, including a National Stakeholder Committee formed in 1999 under +363EXWZKLFKFRQYHQHGRQO\IHZWLPHV DQGD1DWLRQDO+HDOWK6HUYLFH8VHUV¶)RUXPSURSRVHG XQGHU+1363EXWQHYHULPSOHPHQWHG DQG¿QDOO\D+HDOWK$GYLVRU\&RPPLWWHHFUHDWHGLQ under HNPSP which has been mostly inactive. This gap in the literature arises despite the role that Bangladesh Health Watch, a multi-stakeholder network whose secretariat is at the James P. Grant School of Public Health, plays a sectoral watchdog role, while the media often carries stories about the sector. 27 70. Further in-depth political economy research is needed to better understand the dynamics of voice and accountability, as well as the resistance to implementing such initiatives. Thomas (2004) offers some mention of political economy when referring to factors VXFKDVHOLWHGRPLQDWLRQDQGSUHYDLOLQJJHQGHULQHTXLWLHVWKDWOLPLWWKHHIIHFWLYHQHVVRIWKHSRRU LQVXFKLQLWLDWLYHV7KHODFNRIGHFHQWUDOL]DWLRQLQWKHKHDOWKVHFWRUDQGWKHLQFRQVLVWHQWHIIRUWVWR LPSOHPHQWYRLFHDQGDFFRXQWDELOLW\LQLWLDWLYHVUHTXLUHVIXUWKHUSROLWLFDOHFRQRP\DQDO\VLV 28 5. Regulatory Quality in the Health Sector 71. Regulatory quality includes government oversight of private health providers and pharmaceutical sectors. Included among non-state providers are allopathic providers, village doctors, drugstore salespeople, traditional healers, non-secular faith healers, traditional birth DWWHQGDQWV KRPHRSDWKV SULYDWH IRU SUR¿W DQG QRWIRUSUR¿W FOLQLFV DQG KRVSLWDOV 2QH HVWLPDWH YDOXHV WKH GRPHVWLFUHWDLOSKDUPDFHXWLFDOPDUNHWVL]HDW%'7ELOOLRQLQ 6DDG In order to ensure the health of the population of Bangladesh, the GoB has a clear role to play; however, as outlined below, the research agenda has yet to catch up with this need for intelligent interventions. The Literature on Regulatory Quality Table-5.1: Summary of the Literature on Regulatory Quality Ministry Processes to Achieve Outcomes Regulatory Outcomes And their Limitations - 3RRUTXDOLW\RIWUDLQLQJIRULQIRUPDOSURYLGHUV and superior performance of private large hospitals (Andaleeb et al., 2007; Ahmed et al., - BMDC and BNC have low capacity 2009) - 3RRUTXDOLW\RIVDPSOHRISKDUPDFHXWLFDO products(World Bank, 2008) 72. The relevant literature on regulatory quality mainly focuses on measuring the quality of a limited sample private providers and pharmaceuticals. The main points of the literature DSSHDULQ7DEOH0DQ\RIWKHVHPHDVXUHVDUHLQFRPSOHWHDQGGDWHGUHTXLULQJIXUWKHUUHVHDUFK However, they provide some insight into the overall challenges faced by the health sector. 73. Survey evidence suggests that informal providers have poor training and make LQFRUUHFWGHFLVLRQVRQGUXJWUHDWPHQW $KPHGHWDO Through a survey in 2007, Ahmed HW DO ¿QG WKDW WKHUH LV H[WHQVLYH LUUDWLRQDO SUHVFULSWLRQ RI GUXJV VXFK DV DQWLELRWLFV E\ informal workers, while community health workers generally prescribe an appropriate mix of drugs for patient needs. This may be due to poor professional training of these providers, though community health workers appear to be the exception. 74. 'DWDRQSULYDWHKRVSLWDOVLQ%DQJODGHVKVKRZWKDWSDWLHQWVDUHJHQHUDOO\VDWLV¿HGEXW PHDVXUHVLQGLFDWHDSRRUTXDOLW\RIVHUYLFH :RUOG%DQN $QGDOHHEHWDO 6LGGLTXH .KDQGDNHU Andaleeb et al. (2007) conducted a survey on patient satisfaction across two SXEOLFKRVSLWDOVDQGWKUHHSULYDWHKRVSLWDOVLQ'KDNDFLW\¿QGLQJWKDWDYHUDJHVDWLVIDFWLRQVFRUHV 29 RI DQG RXWRID¿YHSRLQWOLQNHUVFDOHDFURVVSXEOLFDQGSULYDWHKRVSLWDOVUHVSHFWLYHO\15 2WKHUVXUYH\HYLGHQFHEDVHGRQSDWLHQWV¶SHUFHSWLRQDOVRIRXQGWKDWSULYDWHKRVSLWDOVLQ'KDND VFRUHG KLJKHU WKDQ SXEOLF KRVSLWDOV LQ WHUPV RI TXDOLW\ RI VHUYLFH LQ DUHDV RI QXUVLQJ FDUH DQG WDQJLEOHKRVSLWDOPDWWHUVLHFOHDQOLQHVVVXSSO\RIXWLOLWLHVDQGDYDLODELOLW\RIGUXJV 6LGGLTXH .KDQGDNHU :RUOG%DQN KLJKOLJKWHGWKHRFFDVLRQDOO\SRRUTXDOLW\RIVHUYLFHLQ SULYDWHVHUYLFHV7KHPDLQLQGLFDWRUXVHGWRDVFHUWDLQWKHTXDOLW\RISULYDWHKHDOWKSURYLGHUVZDV whether standard medical protocols were being followed in treating different ailments in these private health facilities. Based on a background study conducted, it was found that 60 percent of all private practitioners used standard medical protocols in delivering treatment. However, whereas 98 percent of private doctors recommended ORS in treating acute diarrhea, only two-thirds were able to identify the necessary test needed to detect tuberculosis while only 61 percent could correctly conduct an examination for female patients with postpartum bleeding. 75. As for the role of government, the GoB has a quite comprehensive regulatory legal structure for the private hospital sector, but the main issues arise in implementation :RUOG %DQN 7KH PDLQ UHVSRQVLEOH DJHQF\ LV WKH '*+6 DW 0R+): 7KH RI¿FLDO SURFHVV RI SULYDWH KRVSLWDO UHJLVWUDWLRQ E\ WKH 0R+): LPSRVHV D QXPEHU RI UHTXLUHPHQWV :RUOG %DQN 2008).16 Capacity may be a main reason for the lack of implementation, but – while this is an issue – there may be other reasons that motivate the government not to act in regulating the private sector. 76. The Bangladesh Medical and Dental Council and Bangladesh Nursing Council, two Government regulatory bodies, suffer from low capacity and a lack of independence %+: The Bangladesh Medical and Dental Council (BMDC)are tasked with the responsibility of the registration of physicians and dentists and monitoring medical educational institutions. BHW (2009) observes that the BMDC fails to perform its intended functions, with the exception of UHJLVWHULQJPHPEHUV WKHUHSRUWFLWHVNH\LQIRUPDQWLQWHUYLHZV¿QGLQJWKDWRIWKHIHZFDVHVWKDW DUHLQYHVWLJDWHGE\WKHFRXQFLOQRQHDUH¿QDOL]HGRUKDYHUHVXOWVWKDWDUHPDGHSXEOLF0RUHRYHU despite regulations to the contrary, BHW (2009) claims that unregistered foreign doctors practice IUHHO\LQ%DQJODGHVK7KHUHSRUWLGHQWL¿HVVHYHUDOVKRUWFRPLQJVWKDWXQGHUPLQHWKHHIIHFWLYHQHVV of BMDC, including a lack of independence from the Executive in the registration of members, ODFNRIFDSDFLW\WRFRQGXFWLQYHVWLJDWLRQVDQGDJHQHUDODWURSK\LQWKHLQVWLWXWLRQDVH[HPSOL¿HG by the fact that, in 2009, the BMDC had not conducted a council election for 18 years. According to the report, the Bangladesh Nursing Council suffers from similar problems, including the LQDELOLW\WRKDQGOHFRPSODLQWVSUHYHQWXQUHJLVWHUHGQXUVHVIURPSUDFWLFLQJDQGHQVXUHWKHTXDOLW\ of education institutions, due to the same root problems. 77. 5HFHQW UHVHDUFK HPSKDVL]HV WKH LPSRUWDQFH RI WKH SOXUDOLVWLF KHDOWK V\VWHP LQ FRQWULEXWLQJWRWKHPDMRUKHDOWKDFKLHYHPHQWVLQWKHVHFWRUEXWUHFRJQL]HVWKDWHIIRUWVDUH QHHGHGWRUHJXODWHE\JRYHUQPHQW $GDPVHWDO $KPHGHWDO &KRZGKXU\HW 15 7KRXJKWKH¿QGLQJFRQWUDGLFWVJHQHUDOUHSRUWVRIORZSDWLHQWVDWLVIDFWLRQWKHUHVHDUFKDFNQRZOHGJHVWKDWWKHUHVXOWV could be due to the fact that the surveyed hospitals were well-reputed healthcare providers in the city. 16 &RQGLWLRQVIRULVVXLQJDQGFRQWLQXLQJDOLFHQVHIURPWKH0LQLVWU\LQFOXGH DGHTXDWHVSDFHDQGKHDOWK\HQYLURQPHQW DPLQLPXPRIVTXDUHIHHWSHUSDWLHQWDLUFRQGLWLRQHGRSHUDWLQJWKHDWUHDSSURSULDWHLQVWUXPHQWVDVSHUSUHVFULEHG JXLGHOLQHVDGHTXDWHOLIHVDYLQJGUXJVDQGRWKHUPHGLFLQHVIXOOWLPHGRFWRUVQXUVHVDQGRWKHUVWDIIDVSHUSUHVFULEHG guidelines - for every 10 beds, three doctors, six nurses, three cleaners, specialist doctors for surgery and follow up (World Bank, 2008). 30 DO Ahmed et al. (2013) identify a general role for government to aid in implementing participatory governance, accountability and regulation, information systems, and capacity development in this pluralistic system, which are areas for further research. Gaps in the Literature on Regulatory Quality Table- 5.2: Gaps in the Literature on Regulatory Quality Ministry Processes to Achieve Outcomes Regulatory Outcomes Political Economy And their Limitations - Consistent and systematic measures of - Government oversight of private providers TXDOLW\RIKHDOWKFDUHDPRQJVWSULYDWH - Government oversight of pharmaceutical providers companies - Consistent and systematic measures of TXDOLW\RISKDUPDFHXWLFDOSURGXFWV 78. In spite of the importance of non-government health sector, further research is required on a number of fronts. As seen in Table-5.2, these include consistent and systematic PHDVXUHVRIWKHTXDOLW\RIKHDOWKFDUHDPRQJSULYDWHSURYLGHUVDQGSKDUPDFHXWLFDOSURGXFWVDV ZHOODVLQTXLULHVLQWRWKHQXPHURXVJRYHUQPHQWLQWHUYHQWLRQVLQWKHQRQJRYHUQPHQWKHDOWKVHFWRU amongst others. The political economy of government regulation, particularly given the strong ¿QDQFLDOLQWHUHVWVLQWKHVHVHFWRUVLVDQRWKHUWRSLFIRUUHVHDUFK 79. More comprehensive and consistent data on the quality of provision of private health care is necessary, whether from informal providers or private hospitals. Given the scale of the sector and its importance for health service delivery, increased information to track the performance of each type of provider would be a start; beyond this, an analysis of the system for regulating private provision is needed, focusing on the relevant government interventions that seek to improve the care offered by these providers. 80. Research is also needed on the different roles of government in overseeing and supporting private providers. +RVSLWDOVPXVWRI¿FLDOO\PHHWDYDULHW\RIVWDQGDUGVLQRUGHUWR receive approval from government, but studies have not determined whether these standards are enforced. Also, while not a common topic of research, World Bank (2003) notes a number of pilots conducted, mainly with the support of development partners. Also, while there was also progress in establishing formal training centers for informal private providers, the impact of these efforts has not been measured. According to World Bank (2003), there were nine unani colleges and six D\XUYHGLFFROOHJHVRI¿FLDOO\UHFRJQL]HGE\JRYHUQPHQW 81. The literature requires comprehensive measures of drug quality and focused research on government oversight of the pharmaceutical industry. In its annual testing of 5,000 drug samples in 2004, the Public Health and Drug Testing Laboratory (PHDTL) detected 300 drugs that DUHHLWKHUFRXQWHUIHLWRURIYHU\SRRUTXDOLW\ ,VODP 0HGLFDOSURIHVVLRQDOVDQGSKDUPDFLVWV LQWHUYLHZHGLQ:RUOG%DQN SHUFHLYHGWKDWWKHTXDOLW\RIGLIIHUHQWEUDQGVRIGUXJVYDULHG ZLGHO\ZLWKVRPHFRQVLVWHQWO\SRRUDQGRWKHUVDFFHSWDEOH&RQVLVWHQWPHDVXUHVRIGUXJTXDOLW\ ZLWKGDWDSXEOLFO\DYDLODEOHZRXOGDOORZIRUWUDFNLQJDQGUHVHDUFKLQWRWKHFDXVHVRISRRUTXDOLW\ 31 drugs. The Directorate General of Drug Administration (DGDA), under the jurisdiction of the 0R+):LV%DQJODGHVK¶VSULPDU\GUXJUHJXODWRU\DXWKRULW\,WLVODUJHO\XQGHUVWDIIHGDQGXQGHU resourced, which represent part of the reason it is considered to be ineffective (World Bank, 2008; 0R+):D 7KH'*'$KDVGLVWULFWRI¿FHVDQGLWVRI¿FHUVLQVSHFWSULYDWHSKDUPDFHXWLFDO companies to ensure application of the relevant drug laws. Other committees such as Drug Control &RPPLWWHH '&& 6WDQGLQJ&RPPLWWHHIRUSURFXUHPHQWDQGLPSRUWRIUDZPDWHULDOVDQG¿QLVKHG drugs, and Pricing Committee support the DDA. The Ministry ran two drug-testing laboratories WRSUREHWKHTXDOLW\RIGUXJVDQGPHGLFLQHVZLWKSODQVWRLQFUHDVHWKHLUFDSDFLW\$FFRUGLQJWR $UWLFOHRIWKH'UXJ &RQWURO 2UGLQDQFH WKHUHLVDSHQDOW\RI¿YH\HDUVLPSULVRQPHQWDQG RUD%'7¿QHIRUWKHPDQXIDFWXULQJRUVDOHRIVXEVWDQGDUGGUXJV,VODP FODLPV that the Government has not taken legal action against any illegal traders to date. Although an increase in the counterfeiting of drugs is an issue mentioned in some studies (Chowdhury, 1995; Islam, 2006; World Bank, 2008), no study has been conducted on the institutions themselves. The XQHWKLFDOSUDFWLFHVRIRI¿FLDOVRIWKHGUXJUHJXODWLQJDXWKRULW\DUHPRVWO\DQHFGRWDO 32 6. Conclusion 82. 7KHV\VWHPDWLFUHYLHZQRWRQO\VXPPDUL]HVWKHGRFXPHQWHGJRYHUQDQFHNQRZOHGJH to date, but also lays the foundation for developing further research that is needed to inform efforts to improve service delivery in the health sector. 'HVSLWH WKH FRQVLGHUDEOH ¿QDQFLDO resources invested in the sector by the government and development partners, there are relatively few systematic and empirically rigorous studies on governance challenges, even though this is a well-known concern affecting performance in Bangladesh. 83. ,Q HDFK VHFWLRQ WKLV UHYLHZ LGHQWL¿HV D ODUJH QXPEHU RI JDSV LQ UHVHDUFK EXW WKLV VHFWLRQZLOOSULRULWL]HWKHPDLQJDSVXVLQJWZRFULWHULD First, we identify the main areas for that represent government priorities and for which there is little information available. The main government documents establishing these priorities include the Sixth Five Year Plan of Bangladesh, the Health Policy and the HPNSDP Program Implementation Plan. Through assessing the priorities in these documents, and checking them against the available literature, the following topics emerge DVPDMRUJDSV6HFRQGZHH[FOXGHDUHDVRIUHVHDUFKWKDWDUHGLI¿FXOWWRPHDVXUHVXFKDVRXWFRPHV RIYRLFHDQGDFFRXQWDELOLW\PHDVXUHVRUWKHTXDOLW\RIQRQJRYHUQPHQWKHDOWKSURYLVLRQ 84. Very little research has focused on the role of government to oversee and support the private health sector. The private sector features prominently in the Sixth Five Year Plan of Bangladesh, as well as other relevant plans. This sector is large and diverse: private providers range from commercial hospitals to neighborhood drug stores and village doctors; it also encompasses pharmaceutical companies, which make up one of the largest industrial sectors in Bangladesh. )XUWKHUUHVHDUFKPXVWQRWRQO\VHHNWRV\VWHPDWLFDOO\JDWKHUTXDOLW\PHDVXUHVEXWDOVRFULWLFDOO\ DQDO\]HWKHUROHRIJRYHUQPHQWWRVXSHUYLVHDQGVXSSRUWWKHSULYDWHKHDOWKVHFWRU6XFKREVHUYDWLRQV were made in recent Lancet articles (Adams et al., 2013; Ahmed et al., 2013). 85. &XUUHQW UHVHDUFK KDV QRW H[DPLQHG VXI¿FLHQWO\ WKH SUDFWLFH DQG HIIHFWLYHQHVV RI public urban health care, as well as detailed the effects of the institutional arrangement given the assignment of coordination responsibilities to the MoLGRDC.17 The current HPNSDP HPSKDVL]HVWKHLPSRUWDQFHRIXUEDQKHDOWKDQGWKHQHHGIRUDFOHDURUJDQL]DWLRQIRUKHDOWKVHUYLFH delivery in urban areas. Further research should examine the current state of affairs and necessary reforms, due to the rapidly expanding urban population of Bangladesh and need for health services, particularly in informal settlements. 86. Vacancies of critical health staff, especially remote area, as well as larger HR issues is an issue that represents another gap in the literature. The need for smart human resource PDQDJHPHQWDQGGLVWULEXWLRQLVHPSKDVL]HGLQWKHVL[WK)LYH<HDU3ODQRI%DQJODGHVKDVZHOODV the HPNSDP. Some research has documented the disinterest from doctors and nurses in working in 17 A related overview study was completed in preparing the national urban health strategy, available on the health consortium website, but the DXWKRUVDUHQRWGHWDLOHG0RUHRYHUWKHWRSLFLVPHQWLRQHGLQ2VPDQ ZKREULHÀ\ GHVFULEHVWKHRUJDQL]DWLRQRIXUEDQKHDOWKFDUHDQGDFFHVVE\WKHSRRU 33 remote areas. Meanwhile, government has instituted measures such as fast track promotion in order to address this, but the impact of these measures is unclear. A more comprehensive study is needed, including the relative market wages for doctors, as well as the formal and informal HR processes related to transfers and promotions, and the effect of current initiatives, in order to identify further LQWHUYHQWLRQV WR DGGUHVV WKLV SUHVVLQJ VWDI¿QJ QHHG 0RUHRYHU HTXDO DWWHQWLRQ VKRXOG EH SDLG WR HIIRUWVWRSUHYHQWXQRI¿FLDODEVHQWHHLVPJLYHQWKDWLWZLOOXQGHUPLQHUHGXFWLRQVLQWKHYDFDQF\UDWH 87. The distribution and management of drug supplies also requires further research. 7KH+316'3SODQHPSKDVL]HVWKHQHHGWRLPSURYHGUXJPDQDJHPHQWDQGSURYLVLRQZLWKWDUJHWV tracked that show under 20 percent of facilities with over 75 percent of 37 basic drugs available in 2012, though the ministry is taking initiatives in this regard. The precise cause of these stock outs has not been detailed. As such, further research is needed regarding the drug distribution and management system, and a Public Expenditure Tracking Survey that focuses on this issue would be particularly useful. 88. From government priorities, other potential topics of research include: particular details on facility management practices that may contribute to absenteeism and other forms of corruption, budgetary decisions to increase the budget allocation for health, and the means to HQVXUHWKHTXDOLW\RIGRFWRUHGXFDWLRQDQGWUDLQLQJ 89. In-depth political economy research may also explain persistent problems in the sector. One particular topic that has been studied, but which continually impedes service delivery is the failure to dramatically increase the development budget execution rate. Other useful areas for such UHVHDUFKWRXFKRQDZLGHUDQJHRIWRSLFVWKDWLQFOXGHWKHVWURQJLQÀXHQFHRIGRFWRURUJDQL]DWLRQV WKHQXPHURXVLQWHUHVWVWKDWLQÀXHQFHWKHEXGJHWSURFHVVWKHUHQWVGHULYHGIURPSURFXUHPHQWDQG ORFDOKHDOWKH[SHQGLWXUHVDQGFRQWLQXHGUHVLVWDQFHWRGHFHQWUDOL]DWLRQ 90. 6HYHUDO LQWHUHVWLQJ ¿QGLQJV RQ WKH OLWHUDWXUH HPHUJH UHJDUGLQJ WKH JRYHUQDQFH RI health in Bangladesh: x )LUVW WKH OLWHUDWXUH RQ WKH FRQWURO RI FRUUXSWLRQ LGHQWL¿HV QXPHURXV LVVXHV LQ WKH KHDOWK sector, both at the national and local level. These include losses in drug stocks, illegal IHHVLQFRUUHFWGUXJSUHVFULSWLRQVSULYDWHUHIHUUDOVE\GRFWRUVXQRI¿FLDODEVHQWHHLVPDQG LQIRUPDOSD\PHQWVE\ORZHUOHYHO0LQLVWU\RI+HDOWKDQG:HOIDUH 0R+): RI¿FLDOVWR higher level ones. Control of corruption measures, such as national procurement processes, MoHFW audits and managerial oversight, are similarly weak. On the plus side, evidence suggests that the incidence and amount of illegal fees at public hospitals have been declining. Moreover, the MoHFW has taken numerous initiatives to address these issues, though the impact has not yet become clear. x Second, the literature on voice and accountability, while limited, provides a primarily negative account of initiatives so far. These initiatives face impediments such as lack RI ¿QDQFLDO VXSSRUW JHQGHU ELDV DQG HOLWH FDSWXUH 5HVHDUFK DOVR LGHQWL¿HV OLPLWHG GHFHQWUDOL]DWLRQ DV DQ LPSHGLPHQW EXW WKHUH KDV QRW EHHQ D FRPSUHKHQVLYH VWXG\ RQ GHFHQWUDOL]DWLRQWRGDWH x 7KLUG WKH OLWHUDWXUH RQ KHDOWK VWDII YDFDQFLHV LGHQWL¿HV VHULRXV SUREOHPV RYHUDOO DQG particularly in remote areas. We present original data on such vacancies, including by district, showing variation in physician vacancy rates ranging from 0 to 80.5 percent. At 34 the same time, there are an increasing number of graduates from public and private medical schools and institutes. Several factors may explain these contradictory trends, including WKH FRPSUHVVHG GRFWRUV¶ ZDJH VFDOH D ORZ OHYHO RI MRE VDWLVIDFWLRQ DQG WKH LQWHQVLYH UHFUXLWPHQWSURFHVV)RUWKHVHUHDVRQVZHLGHQWLI\WKLVDUHDDVUHTXLULQJIXUWKHUUHVHDUFK 91. Through the systematic review, several other conclusions emerged regarding the literature: x The review included research since 2000, but much of the data is out of date. We therefore hold many of the following conclusions from the literature to be tentative, and recommend updates to the existing studies. x Knowledge management is necessary so that governance research may have an impact. A FRQVLGHUDEOHDPRXQWRIHIIRUWZDVUHTXLUHGE\WKHDXWKRUVWRFRPSLOHWKHOLWHUDWXUHLQWKLV review. Moreover, different experts informed our research team of studies that were not publicly available, or that were lost in time. Greater attention is needed to make research both publicly available and easily searchable. x There is limited transparency in government regarding basic data that is critical for research, including detailed budget and budget execution information, and various decision-making processes. Public access to this data is necessary for research. x $XWKRUV VKRXOG EROVWHU WKH HPSLULFDO TXDOLW\ RI UHVHDUFK$W WLPHV VWDWHPHQWV DUH PDGH without a solid empirical basis, or anecdotal evidence is portrayed as fact. Other Observations regarding the Literature 92. At times, the health literature provides evidence of problems with little analysis of the systems involved in addressing the problems, nor an explanation for why the systems may fail. For instance, the public health budget has been shrinking relative to the national budget, but WKHOLWHUDWXUHKDVQRWDQDO\]HGWKHEXGJHWGHFLVLRQPDNLQJSURFHVVHVWKDWOHDGWRWKLVRXWFRPH,W VKRXOGGLVWLQJXLVKEHWZHHQWKHRI¿FLDOSURFHVVHV de jure) including the laws and regulations, as opposed to action (de facto VFUXWLQL]LQJWKHZD\WKDWRI¿FLDOVDQGYDULRXVDFWRUVDFWXDOO\EHKDYH $QDQDO\VLVRIWKHEXGJHWV\VWHPVKRXOGLQTXLUHLQWRERWKWKHRI¿FLDOSURFHVVRIFRQVWUXFWLQJWKH budget, but also the informal agreements that go into it, the use of analytical work, and the political SUHVVXUHVWKDWLQÀXHQFHWKHVHGHFLVLRQV5HIRUPHIIRUWVWKDWGRQRWWDNHWKHVHLQIRUPDOSURFHVVHV into account are likely to fail. 93. Often, statements are made without an empirical basis, and anecdotal evidence may be portrayed as facts. )XUWKHUTXDQWLWDWLYHDQGTXDOLWDWLYHUHVHDUFKLVQHHGHGEDVHGRQULJRURXV methods. At the same time, a variety of consistent measures should be gathered and tracked, such as WKHTXDOLW\RIFDUHRIIHUHGE\JRYHUQPHQWKHDOWKIDFLOLWLHVDQGQRQVWDWHSURYLGHUV7KHVHPHDVXUHV should be publicly accessible. Additionally, much of the health governance research is dated, with PDMRU¿HOGZRUNIRUWKHVWXGLHVRFFXUULQJSULPDULO\LQWKHHDUO\DQGPLGV LQRWKHUZRUGVDW WKHWLPHRIWKLVUHYLHZWKHVHVWXGLHVDUHDOPRVWDGHFDGHROGUHTXLULQJIROORZXSUHVHDUFK 94. Efforts are required to make research accessible for a variety of audiences, particularly online in an easily searchable format. There is also a need to better evaluate the effects of the research completed thus far. Based on such an evaluation, the research community can better FRPPXQLFDWHWKHLU¿QGLQJVWRNH\DXGLHQFHVWRHQVXUHLPSDFW 35 Annexes Annex-1: Satisfaction of Patients with Different Aspects of Inpatient Stay Type of Facility Aspects of Satisfaction in Inpatient Care 8SD]LOD Total District Health MCWC Hospital Care 9HU\VDWLV¿HGLQJHQHUDO 12.00 15.50 28.99 14.80 9HU\VDWLV¿HGZLWKSROLF\RQUHODWLYHKHOSHUWR 13.00 15.50 24.64 14.99 stay with patient Very easy to get admitted 46.50 61.76 65.22 57.59 Very reasonable waiting time for admission 64.50 72.35 69.56 70.11 Staff members in admission dept very helpful 36.00 44.70 50.73 42.41 9HU\VDWLV¿HGZLWKDGPLVVLRQGHSWH[SODLQLQJ 31.50 36.18 40.58 34.97 policies SATISFACTION WITH NURSING SERVICES 9HU\VDWLV¿HGZLWKQXUVH¶VDYDLODELOLW\ZKHQHYHU 18.00 19.90 28.99 19.55 needed during the day 9HU\VDWLV¿HGZLWKQXUVH¶VDYDLODELOLW\DWQLJKW 16.00 16.02 24.64 16.19 9HU\VDWLV¿HGZLWKWKHFDUHFRQFHUQVKRZQE\ 12.50 14.73 26.08 14.34 nurses, ayas 9HU\VDWLV¿HGZLWKPHGLFDWLRQVEHLQJEURXJKWWR 12.50 17.83 26.08 16.52 patient on time by the nurse 9HU\VDWLV¿HGZLWKQXUVH¶VH[SODQDWLRQRI 11.00 17.57 27.53 15.95 treatment or drugs given 9HU\VDWLV¿HGZLWKWKHQXUVHVLQUHVSHFWLQJ 12.00 15.50 21.74 14.66 privacy 9HU\VDWLV¿HGZLWKWKHSURPSWQHVVRIQXUVHVLQ 12.50 14.99 21.74 14.43 providing services, supplies and drugs needed 9HU\VDWLV¿HGZLWKWKHQXUVHVD\DVLQWHUPVRI 12.00 16.02 17.39 14.93 respect shown towards patient SATISFACTION WITH PHYSICIAN SERVICES +RZVDWLV¿HGDUH\RXZLWKSK\VLFLDQDYDLODELOLW\ 13.50 16.02 27.53 15.55 whenever needed during the day? +RZVDWLV¿HGDUH\RXZLWKSK\VLFLDQ¶V 8.50 10.85 20.29 10.39 availability at night? +RZVDWLV¿HGDUH\RXZLWKWKHFDUHDQGFRQFHUQ 11.00 12.92 18.84 12.51 shown by the physicians? +RZVDWLV¿HGDUH\RXZLWK\RXUGRFWRU¶V explanation of the cause of your illness/medical 13.50 12.66 20.29 13.05 condition? 36 +RZVDWLV¿HGDUH\RXZLWK\RXUGRFWRU¶V 16.00 14.73 21.74 15.22 explanation of your treatment? +RZVDWLV¿HGDUH\RXZLWKWKHGRFWRUVLQ 12.00 12.14 30.44 12.48 respecting your privacy? $UH\RXVDWLV¿HGZLWKWKHWLPHVSHQWE\GRFWRUV 10.00 12.66 21.74 12.11 in treating your health conditions? +RZVDWLV¿HGDUH\RXZLWKWKHIUHTXHQF\WKDWD 7.50 11.37 20.29 10.48 doctor comes to check on you? +RZVDWLV¿HGDUH\RXZLWKWKHSROLWHQHVVDQG 8.00 13.44 21.74 12.09 respectfulness of the doctors? +RZVDWLV¿HGDUH\RXZLWKWKHVNLOOVDQGDELOLWLHV 12.50 11.63 24.64 12.14 of the health care providers in this hospital? SATISFACTION WITH HOUSEKEEPING SERVICES +RZVDWLV¿HGDUH\RXZLWKFOHDQOLQHVVDQG 9.00 11.89 26.08 11.37 maintenance of the hospital in general? +RZVDWLV¿HGDUH\RXZLWKWKHFOHDQOLQHVVRIEHG 8.00 9.56 14.49 9.23 sheets and pillow cases? +RZVDWLV¿HGDUH\RXZLWKWKHTXDOLW\DQG 8.00 8.27 15.94 8.35 comfort of the bed mattress and pillows? Are ceiling fans working here? 65.00 56.60 66.70 59.10 +RZVDWLV¿HGDUH\RXZLWKWKHFOHDQOLQHVVDQG maintenance of bathroom and toilet in your ward 3.50 7.80 13.00 6.70 or cabin? SATISFACTION WITH FOOD SERVICE +RZVDWLV¿HGDUH\RXZLWKWKHIRRGVHUYLFHRIWKH 8.70 9.60 0.00 9.30 hospital? 2SLQLRQRQTXDOLW\RIIRRGVXSSOLHG 5.30 7.20 0.00 6.70 4XDQWLW\RIIRRGVXSSOLHGSHUPHDOLVDGHTXDWH 70.70 70.90 33.30 70.80 Get all the three meals always on a timely basis 49.30 49.70 33.30 49.50 Plates and utensils provided by the hospital very 5.30 9.60 0.00 8.40 clean OTHER ISSUES +RZVDWLV¿HGDUH\RXZLWKWKHDPRXQWRIWLPH your family members/attendants are allowed to 14.50 19.40 27.50 18.20 spend with you? +RZVDWLV¿HGDUH\RXZLWKWKHFRVWRI\RXU 13.00 15.50 30.40 15.10 treatment in this hospital? +RZVDWLV¿HGDUH\RXZLWKWKHW\SHVRIVHUYLFHV 8.50 12.90 24.60 11.90 provided by this hospital? If you or someone in your family is sick in the future, how likely are you to return to this 20.50 23.30 39.10 22.80 hospital? Source: USC & ACPR, 2012. 37 $QQH[ 6XPPDU\RIWKH2I¿FLDO%XGJHW&\FOH3URFHVV Stage/Activity Deadline Responsibility Remarks Strategic Phase Activities Includes review of previous MTBF exercise; 1. Preparation of updated deadlines for MTBF and budget MTBF and budget 15 Aug FD &PC SUHSDUDWLRQ LGHQWL¿FDWLRQRINH\VWUDWHJLHVDQG guidelines priorities; guidelines for line ministry statement of spending program priorities. 2. First update of ,QFOXGHVPDFURHFRQRPLFDQG¿VFDOIRUHFDVWV macroeconomic and 30 Sept FD & MFWG projections of budget aggregates; analysis of ¿VFDOIUDPHZRUN underlying national policies and priorities. 3. Line ministry Includes policy objectives; associated actions; statements of policy BWGs in line resource implications in main program areas; 30 Sept objectives and ministries expenditure reform measures; key performance spending priorities indicators. 4. Review of line Result of review provides input into determining ministry spending 20 Oct FD & PC BWGs sector policy statements ministry MTBF resource ceilings. 5. Expenditure Includes analysis of recent expenditure trends; review and selected determining FD & PC assisted 25 Oct cross-cutting resource use issues; intersectoral expenditure by EPWG expenditure priorities linked to policy priorities; resource ceilings recommendations and sector and ministry resource ceilings. 6HWVRXWPDFUR¿VFDOIUDPHZRUN PHGLXPWHUP )LQDOL]DWLRQRI FD & MFWG budget draft MTBPS and its 31 Oct and EPWG strategy; and sector and ministry resource approval by BMRC FHLOLQJVDQGWKHLUMXVWL¿FDWLRQ Budget Estimates Phase 7. Preparation and Involves review and updating of instructions issuing of Budget 07 Nov FD & PC to line ministries; budget forms; and IT Call Circular applications. 8. Preparation Involves desegregation of resource ceilings; Departments of departmental guidance to 31 Dec in line estimates departments; preparation of budget proposals by ministries submissions departments; submission to parent ministry. 9. Ministry review Involves compilation and technical review; DQG¿QDOL]DWLRQ ministry estimates review meetings; approval 31 Jan BWGs of estimates by ministry Budget Management Committee; submissions submission to FD and Ministry of Planning. 38 Incorporates latest update of macroeconomic and 10. Second update ¿VFDO of Macroeconomic FD & MFWG 28 Feb forecast; analysis of implications for budget and Fiscal and EPWG sector and Framework ministry resource ceilings. Involves review; resolution of technical issues; 11. Review of and ministry budget 15 Mar FD & PC LGHQWL¿FDWLRQRINH\LVVXHVIRUEXGJHW submissions discussions. 12. Budget Final resource allocation proposals for MTBF. discussions with line 30 Apr FD & PC 5HYLVHGHVWLPDWHVIRUFXUUHQW¿VFDO\HDU ministries %XGJHW)LQDOL]DWLRQDQG$SSURYDO Involves revision of draft MTBPS to )LQDOL]DWLRQRI accommodate updated macroeconomic and 30 Apr FD & PC MTBPS ¿VFDOIRUHFDVWV ¿QDOEXGJHWDJJUHJDWHVDQG sector resource allocations. Incorporates adjustments following discussion 14. Compilation and with lineministries; supporting commentary for ¿QDOL]DWLRQ 07 May FD & PC Cabinet. of draft budget 15. Submission of MTBPS and 15 May FD draft budget to Cabinet 16. Revision of draft budget to 22 May FD include cabinet decisions 17. Printing of Comprises MTBPS; Ministry spending 31 May FD budget documents. aggregates; detailed budget estimates. 18. Presentation of budget and 7 July Finance Minister MTBF to Parliament Source: World Bank et al., 2010 39 Annex-3: Summary of the Planning and Monitoring Cycle Approximate date Planning action Monitoring action Budget announced in parliament July 1 Minister of Finance OP revised to meet Administrative approval DOORFDWHGEXGJHWDQGRI¿FLDOO\ Secretary July approved by line directors, and fund release coordinated by Planning Wing Joint Secretary (Finance) Annual planning guidelines issued September for next year Planning Wing Line directors prepare reports on activities under previous \HDU¶VDQQXDORSHUDWLRQDOSODQ Reports consolidated. Output October monitoring indicators added Line directors coordinated by line directors Planning & Planning Wing/ PCC Preparation of Annual Programme Implementation Report Planning Wing/PCC November Annual Programme Review Part 1. Review of consolidated UHSRUWDQG³UHDOLW\WHVWLQJ´ Government and donors facilitated by consultants Mid-year review of current annual OP commences 0LOHVWRQHVDQG¿QDQFLDO disbursement assessed as plans line directors January revised 3UHSDUDWLRQRIQH[W\HDU¶VDQQXDO Line directors, Planning Wing/ OP commences PCC, Secretary line directors 40 Revised current year annual OP consolidated and matched February to resource envelope/approved budget. Next year annual OP consolidated, revised and matched to estimated next year resource March envelope Coordinated by line directors Planning & Planning Wing Annual Programme Review Part 2. Proposed next year AOPs and annual Program Implementation April Plan (PIP) reviewed and agreed Government and donors facilitated by consultants Annual OP revised May line directors, coordinated by Planning Wing AOPs approved by MOHFW June Joint donor/government committees Budget announced in parliament July 1 Minister of Finance Source: World Bank et al., 2010 41 $QQH[ 2I¿FLDO)XQG5HOHDVH3URFHVV Source: World Bank et al., 2010. 42 Annex-5: Maps of Physician and Nurse Vacancy rates )LJXUH 3K\VLFLDQ9DFDQF\5DWH LQ3HUFHQW DQG0053HU/LYH%LUWKV Source: DGHS Database, 2013. 43 )LJXUH 1XUVH9DFDQF\5DWH LQ3HUFHQW DQG0053HU/LYH%LUWKV Source: DGHS Database, 2011. 44 Bibliography Adams, Alayne M. Tanvir Ahmed. Shams El Arifeen. Timothy G. Evans. Tanvir Huda. Laura Reichenbach. 2013. Innovation for Universal Health Coverage in Bangladesh: a call to action. Lancet Bangladesh Series. Paper No. 6. Ahmed, Sayed Masud. Timothy G Evans. Hilary Standing and Simeen Mahmud. 2013. 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Bangladesh Public Expenditure and Institutional Review: Towards a Better Quality of Public Expenditure (PEIR). Volume II: Sectoral Analysis. Poverty Reduction and Economic Management Sector Unit, South Asia Region. :RUOG%DQN+/630RWW0F'RQDOG/LPLWHGDQG:RUOG+HDOWK2UJDQL]DWLRQ Bangladesh +HDOWK6HFWRU3UR¿OH World Bank. 2008. Public and Private Sector Approaches to Improving Pharmaceutical Quality in Bangladesh. Bangladesh Development Series, Paper No. 23, Human Development Unit, South Asia Region. World Bank. 2003. Bangladesh Health Private Sector Assessment. South Asia Human Development Sector Unit Report No. 27005. Bangladesh. World Bank. 2002. Taming Leviathan : Reforming Governance in Bangladesh : An Institutional Review. Dhaka. =DPDQ6KDKDGX]3RYHUW\DQG9LROHQFH)UXVWUDWLRQDQG,QYHQWLYHQHVV +RVSLWDO:DUG/LIH in Bangladesh. Social Science & Medicine 59(10): 2025–2036. =XUQ3DVFDO0DULR'DO3R]%DUEDUD6WLOZHOODQG2UYLOO$GDPV,PEDODQFHVLQWKH+HDOWK :RUNIRUFH :RUOG +HDOWK 2UJDQL]DWLRQ (YLGHQFH DQG ,QIRUPDWLRQ IRU 3ROLF\ +HDOWK Service Provision. 50 BANGLADESH: GOVERNANCE IN SECTORS Working Paper Bangladesh Governance in the Primary Education Sector: A Systematic Literature Review i :RUOG%DQN2I¿FH'KDND Plot - E-32, Agargaon, Sher-e-Bangla Nagar, Dhaka- 1207, Bangladesh Tel: 880-2-8159001-28 Fax: 880-2-8159029-30 www.worldbank.org.bd World Bank 1818 H Street, N.W. Washington DC 20433, USA Tel: 1-202-4731000 Fax: 1-202-477-66391 www.worldbank.org All Bangladesh Development Series (BDS) publications are downloadable at: www.worldbank.org.bd/bds Standard Disclaimer: This volume is a product of the staff of the International Bank for Reconstruction and Development/ 7KH :RUOG %DQN7KH ¿QGLQJV LQWHUSUHWDWLRQV DQG FRQFOXVLRQV H[SUHVVHG LQ WKLV SDSHU GR QRW QHFHVVDULO\UHÀHFWWKHYLHZVRIWKH([HFXWLYH'LUHFWRUVRIWKH:RUOG%DQNRUWKHJRYHUQPHQWVWKH\ represent. The World Bank does not guarantee the accuracy of the data included in this work. The boundaries, colors, denominations and other information shown on any map in this work do not imply any judgment on the part of the World Bank concerning the legal status of any territory or the endorsement or acceptance of such boundaries. Copyright Statement: The material in this publication is copyrighted. The World Bank encourages dissemination of this work and will normally grant permission to reproduce portion of the work promptly. Cover Photo: Ismail Ferdous Printed in Bangladesh ii BANGLADESH: GOVERNANCE IN SECTORS Working Paper Bangladesh Governance in the Primary Education Sector: A Systematic Literature Review September 2014 Jonathan Rose, Tracey M. Lane and Tashmina Rahman1 1 Tracey Lane is a senior economist at the World Bank. Jonathan Rose and Tashmina Rahman are consultants at the :RUOG%DQN7KH¿QGLQJVDQGFRQFOXVLRQVRIWKHSDSHUDUHHQWLUHO\WKRVHRIWKHDXWKRUVDQGVKRXOGQRWEHDWWULEXWHG WRWKH:RUOG%DQNLWVDI¿OLDWHGRUJDQL]DWLRQVRUWRPHPEHUVRILWV%RDUGRI([HFXWLYH'LUHFWRUVRUWKHFRXQWULHVWKH\ represent. iii Abstract This working paper provides a systematic review of the literature on governance issues in the %DQJODGHVK SULPDU\ HGXFDWLRQ VHFWRU 2QH RI WKH PDLQ ¿QGLQJV LV WKH JHQHUDO ODFN RI UHFHQW quantitative analysis and published, peer-reviewed literature on governance in the primary education sector, the review additionally draws upon more informal and anecdotal reports or “grey” literature. What information is available shows that a relatively well educated workforce is attracted to teach in primary schools, especially government primary schools, and governance concerns such as absenteeism while found in the health sector are less of an issue in the primary education sector – although time on task remains a problem. Furthermore, vacancies can be a problem in government schools (but not in non-government schools). There are also indications of several governance concerns arising from a lack of control of corruption in the allocation of stipends and concerns expressed on collusion in the process of teacher recruitment and payment in non-government schools. School management committees and parent teacher associations can provide greater oversight and encourage performance, but they are not always found to be active. Overall the government’s budget resources to the sector are below the averages in the region, although increasing over time. Improvements to the management of the schools and stronger oversight especially over non-government schools (which are a considerable provider and receive public funds) could help to sustain the gains being made in primary education sector outcomes. iv Table of Contents Executive Summary .............................................................................................................. ix The Main Points Emerging from Literature .................................................................. xii 1. Introduction . ..........................................................................................................................1 Structure and Methods for the Systematic Review ......................................................... 1 Background to the Primary Education Sector of Bangladesh ......................................... 4 2. Government Effectiveness in the Primary Education Sector ................................................. 9 The Literature on Public Financial Management ............................................................ 9 Gaps in the Literature on Public Financial Management .............................................. 14 The Literature on Human Resource Management ........................................................ 15 Gaps in the Literature on Human Resource Management ............................................ 18 7KH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV ........................................................... 19 *DSVLQWKH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV ............................................... 20 3. Control of Corruption in the Primary Education Sector ...................................................... 22 The Literature on Corruption and Control Measures .................................................... 22 Gaps in the Literature on the Control of Corruption ..................................................... 25 4. Voice and Accountability in the Primary Education Sector................................................. 29 The Literature on Voice and Accountability ................................................................. 29 Gaps in the Literature on Voice and Accountability ..................................................... 30 5. Regulatory Quality of the Primary Education Sector .......................................................... 32 The Literature on Regulatory Quality ........................................................................... 32 Gaps in the Literature on Regulatory Quality ............................................................... 33 6. Conclusion ........................................................................................................................... 35 List of Tables Table-1: A Description of the Categories of Issues for the Systematic Review ........................... ix Table-2: Number of Primary Education Studies across the Governance Areas ............................ x v Table-1.1: A Description of the Categories of Issues for the Systematic Review ....................... 12 Table-1.2: Number of Primary Education Studies across the Governance Areas ......................... 3 Table-1.3: Government and Non-Government Primary Schools and Government Support, 2007 ...... 7 Table-1.4: MoPME Budget Share in Total Government Budget .................................................. 8 Table-2.1: Summary of the Literature on Public Financial Management ................................... 10 Table-2.2: Ministry of Primary and Mass Education, BDT crore ................................................11 Table-2.3: Incidence of Public Primary Revenue Expenditure (in percent) .................................11 Table-2.4: MoPME Budget Execution Rates for Fiscal Years .................................................... 12 Table-2.5: Gaps in the Literature on Public Financial Management ........................................... 14 Table-2.6: Summary of the Literature on Human Resource Management .................................. 15 Table-2.7: Various Characteristics of Primary School Teachers, Percent ................................... 16 Table-2.8: Gaps in the Literature on Human Resource Management ......................................... 18 Table-2.9: Departments and Entities under MoPME and MoE ................................................... 19 Table- $6XPPDU\RIWKH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV ............................... 20 Table- *DSVLQWKH/LWHUDWXUHRQ2UJDQL]DWLRQDO(IIHFWLYHQHVV ........................................... 21 Table-3.1: Summary of the Literature on Corruption & Control Measures ................................ 22 Table-3.2: Gaps in the Literature on Corruption & Control Measures ........................................ 25 Table-4.1: Summary of Voice and Accountability in the Literature ........................................... 29 Table-4.2: Gaps in the Literature on Voice and Accountability .................................................. 30 Table-5.1: Average Number of Competencies Achieved, 2000 and 2008 .................................. 32 Table-5.2: Student Performance of GPS and RNGPS in 2012 (Average Scores Attained) ........ 33 Table-5.3: Gaps in the Literature on Regulatory Quality ............................................................ 33 List of Figures Figure 1.1: Percentage of Students Achieving Competencies in GPSs and RNGPSs ................... 5 Annexes Annex-1: PEDP III Planned Contributions to the MoPME Budget (US$ Million) ..................... 38 Annex-2: Mean Monthly Paid Salary for Teachers (BDT) ......................................................... 38 Bibliography ................................................................................................................................ 39 vi Acknowledgements This report was written by a World Bank team comprised of Jonathan Rose (Consultant, Governance Researcher, SASGP), Tracey M. Lane (Task Team Leader, Senior Economist, SASGP), and Tashmina Rahman (Consultant, Research Analysts, SASGP). Mariha Khalid (Consultant, 5HVHDUFK $QDO\VWV 6$6*3 SURYLGHG UHVHDUFK VXSSRUW ,W ZDV ¿QDQFHG E\ WKH 'HSDUWPHQW IRU International Development (DFID) under the Joint Technical Assistance Program. Kamrun Nahar Chowdhury (SASEP) provided support in formatting the report and aiding in the process. The DXWKRUV EHQH¿WWHG IURP SHHU UHYLHZ FRPPHQWV IURP <DVXKLNR 0DWVXGD 6HQLRU 3XEOLF 6HFWRU Specialist, SASHD), Bénèdicte de la Brière (Senior Economist, HDNCE), and Richard Butterworth (Governance Adviser, DFID). The team is grateful to Ernesto May (former Sector Director, PREM South Asia), Tony Verheijen (former Sector Manager, SASGP), Salman Zaidi and Zahid Hussain (Lead Economists, SASEP), Roland Lomme (Governance Adviser, SASGP) and Andras Horvai (former Country Program Coordinator, Bangladesh) for their guidance, and to Khaled Ahsan (SASGP), Ayesha Vawda (SASED), Syed Rashed Al-Zayed (SASED) and Yumiko Yamakawa (SASED) for extensive comments on earlier drafts, as well as technical advice from Shinsaku Nomura (SASED). vii Currency Equivalents (Exchange Rate Effective June 11, 2013) Currency Unit = Bangladesh Taka US$ 1.00 = BDT 76 FISCAL YEAR July 1 – June 30 List of Abbreviations and Acronyms AUEO Assistant Upa]LOD(GXFDWLRQ2I¿FHU ACC Anti-Corruption Commission AEMs Attached Ebtedayee Madrassas BANBEIS Bangladesh Bureau of Educational Information & Statistics BGMEA Bangladesh Garment Manufacturers and Employers Association BNP Bangladesh Nationalist Party BRAC Bangladesh Rural Advancement Committee CAMPE Campaign for Popular Education &62 &LYLO6RFLHW\2UJDQL]DWLRQ ''2 'UDZLQJDQG'LVEXUVHPHQW2I¿FHUV DPE Directorate of Primary Education '3(2 'LVWULFW3ULPDU\(GXFDWLRQ2I¿FHU FBCCI Federation of Bangladesh Chambers of Commerce and Industry FMRP Financial Management Reform Programme FM Financial Management GoB Government of Bangladesh GPS Government Primary School IER Institute of Education and Research IGS Institute of Governance Studies JBIC Japan Bank for International Cooperation MEB Madrassa Education Board MoE Ministry of Education MoF Ministry of Finance MoPME Ministry of Primary and Mass Education MP Member of Parliament MPO Monthly Pay Order MTBF Medium Term Budget Framework 1*2 1RQ*RYHUQPHQW2UJDQL]DWLRQ 175&$ 1RQ*RYHUQPHQW7HDFKHUV¶5HJLVWUDWLRQ &HUWL¿FDWLRQ$XWKRULW\ PEDP Primary Education Development Program PFM Public Financial Management PTA Parent Teacher Association RNGPS Registered Non-Government Primary School ROSC Reaching Out of School Children RTI Right to Information SIDA Swedish International Development Cooperative Agency SLIP School Level Improvement Plan SMCs School Management Committee SWAP Sector Wide Approach TIB Transparency International Bangladesh 8(& 8SD]LOD(GXFDWLRQ&RPPLWWHH 8(2 8SD]LOD(GXFDWLRQ2I¿FHU WGI Worldwide Governance Indicator viii Executive Summary 1. The purpose of this systematic review of the literature is to inform the World Bank, development partners and other stakeholders on the state of governance in the primary education sector of Bangladesh. Through a systematic review of the literature over the last ten \HDUVWKHUHYLHZVXPPDUL]HVWKHH[WHQWRIWKHOLWHUDWXUHRQJRYHUQDQFHRIWKHVHFWRUDQGEULQJV WRJHWKHUGLVSDUDWHSLHFHVWRSURYLGHVXPPDULHVRIWKHPDLQ¿QGLQJVLQSXEOLF¿QDQFLDOPDQDJHPHQW (PFM) practices, human resources management, public procurement, corruption, transparency and DFFRXQWDELOLW\2QHRIWKHPDLQ¿QGLQJVRIWKLVUHYLHZLVWKHODFNRISXEOLVKHGSHHUUHYLHZHG literature on governance, and the review therefore also draws upon informal and anecdotal reports. Furthermore, many of the documents cited in the review are now dated. 2. The term governance is disaggregated in the review using the categories of the Worldwide Governance Indicators. 7KH WHUP JRYHUQDQFH LV RIWHQ RYHUO\ VLPSOL¿HG DQG QDUURZO\GH¿QHG7KH:RUOGZLGH*RYHUQDQFH,QGLFDWRUV :*, DOORZIRUDEURDGLQFOXVLRQRI governance issues and distinguish between characteristics of government effectiveness, control of corruption, voice and accountability, and regulatory quality, as presented in Table-1. We use this rubric to group the aspects of governance discussed in the systematic review within each category in an approach similar to Lewis (2006). Each of these governance issues is also relevant in the Bangladesh context and addressed in the National Plan of Action II of the Ministry of Primary and Mass Education (MoPME). Table-1: A Description of the Categories of Issues for the Systematic Review Governance Governance Issues Category x 3XEOLF¿QDQFLDOPDQDJHPHQW SODQEXGJHWDQGEXGJHWH[HFXWLRQ Government x +XPDQUHVRXUFHPDQDJHPHQW VWDI¿QJSXEOLFVHFWRUPDQDJHPHQW Effectiveness capacity) x 2UJDQL]DWLRQDOHIIHFWLYHQHVV Political Economy – x Integrity in procurement processes Cross cutting x Financial and facility management, including management oversight Control of x Integrity in human resource management Corruption x Integrity in the regulation of the private sector x Transparency x 2SSRUWXQLWLHVIRUFLWL]HQVWRSURYLGHLQSXWWRGHFLVLRQPDNLQJ Voice and x Oversight of service delivery Accountability x 2WKHUPHDQVIRUFLWL]HQVWRKROGJRYHUQPHQWVHUYLFHSURYLGHUV accountable Regulatory x Regulation of the quality and accessibility of service provision in the Quality private sector, with appropriate standards and enforcement ix :LWKLQHDFKFDWHJRU\WKHUHYLHZGRFXPHQWVWKH¿QGLQJVIURPWKHOLWHUDWXUHDFFRUGLQJWR x What evidence is available in the literature in terms of governance outcomes? x What analysis is available regarding the main government systems to achieve these outcomes? In other words, how does government work in practice? 4. This review brings together research to date pulling together published material as well as selected grey literature. The source of literature includes publicly available articles, books, and reports covering the Bangladesh education sector since 2000; it also includes an analysis of the grey literature, especially the main program documents (program plans, evaluations and other reviews), as well as a selection of the most recent technical documents such as annual SURJUDPUHYLHZVDXGLWV¿QDQFLDOUHSRUWVDQG¿GXFLDU\UHYLHZV$VXPPDU\RIWKHGLVWULEXWLRQ of the literature is provided in Table-2. While the review wanted to explore other questions and initiatives, it was limited by the research and documentation available.2 Also, though potentially IUXLWIXOWKLVUHSRUWGRHVQRWJREH\RQG%DQJODGHVKWRFRPSDUH¿QGLQJVZLWKVLPLODUUHVHDUFKLQ other South Asian countries on common issues such as absenteeism, corruption and informal payments for services. Table-2: Number of Primary Education Studies across the Governance Areas Governance Categories Number of Studies Government Effectiveness 16 Control of Corruption 20 Voice and Accountability 8 Regulatory Quality 7 Total 51 Note: Other research cited relates to the political economy section, adding up to over 60 studies. 6HYHUDO LQWHUHVWLQJ ¿QGLQJV RQ WKH OLWHUDWXUH HPHUJH UHJDUGLQJ WKH JRYHUQDQFH RI primary education in Bangladesh: x First, according to annual school census data from 2011, primary school teachers overall have a high level of educational attainment, particularly in GPS but not in RNGPS. This DOVRGRHVQRWDSSO\WRDOOGLVWULFWVPDQ\RIZKLFKKDYHGLI¿FXOW\¿QGLQJTXDOL¿HGWHDFKHUV At the same time, primary school teachers are underpaid relative to the local labor market. The level of education for teachers is not correlated to student performance, suggesting that the challenge to attaining quality education lays elsewhere. x Second, despite the relatively small portion of the government budget devoted to primary education, Bangladesh has made great progress in the sector, particularly as relates to the gross primary enrollment rate and gender parity. This counter-intuitive outcome raises questions as to what Bangladesh is doing right, including the contribution from non- government primary schools and innovative approaches such as the Reaching Out of School Children program. 2 7KHPDLQJRYHUQPHQWGRFXPHQWVGH¿QLQJWKHSULRULWLHVLQFOXGHWKH6L[WK)LYH<HDU3ODQRI%DQJODGHVKWKH1DWLRQDO Plan of Action II, and the PEDP III. Additionally, even if not represented in the planning and program documents, recent major changes in the primary education sector require informed analysis. x x Third, there are concerns as to the degree to which primary education spending is pro-poor. Measures of the distribution of school stipends (which are again dated) suggest that they are not focused on the poor. Moreover, the incidence of revenue budget expenditures indicates that such spending is becoming less pro-poor over time. :KLOHGHFOLQLQJRYHUWLPHWKHXQRI¿FLDOIHHVVRPHWLPHVSDLGIRUVFKRROHQUROOPHQWDUH concerning. x )RXUWKLQFRQWUDVWWRWKHSXEOLFKHDOWKVHFWRUXQRI¿FLDODEVHQWHHLVPDSSHDUVWREHTXLWH low in the sector. Time on task, however, is still a major concern. 7KLV UHYLHZ LGHQWL¿HV D ODUJH QXPEHU RI JDSV LQ WKH OLWHUDWXUH These gaps provide options for future topics to be researched further. For example, there is little evidence on the effectiveness of government’s role as a regulator of the non-government sector. The Sixth Five <HDU3ODQWKH1DWLRQDO3ODQRI$FWLRQ,,DQG3('3,,,HDFKHPSKDVL]HWKHLPSRUWDQFHRISXEOLF private partnerships in primary education, which includes a critical regulatory role for government. According to the Sixth Five Year Plan, such a role may include standards, accreditation, protecting SXEOLFLQWHUHVWVLQ¿QDQFLDOPDWWHUVDQGHQVXULQJHTXLW\/LPLWHGUHVHDUFKKDVIRFXVHGRQWKHUROH of government to oversee and support non-government primary schools. These schools, including 51*361*2VFKRROVPDGUDVDVDQGSULYDWHVFKRROVDUHUHVSRQVLEOHIRUHGXFDWLQJDOPRVW¿IW\ percent of primary school pupils. A large portion of the government budget is spent aiding these schools through teacher salaries, school books and stipends; however, studies on the effectiveness of this spending, as well as the larger role of government in these schools, are not found. The use of the Monthly Pay Order is similarly critical within this topic, including the integrity of LWVGLVWULEXWLRQDQGXVHDPRQJQRQJRYHUQPHQWVFKRROV)XUWKHUUHVHDUFKPXVWFULWLFDOO\DQDO\]H the role of government to oversee these schools and improve their performance. At the same WLPH WKHVH VFKRROV DUH XQGHUJRLQJ FKDQJHV GXH WR JRYHUQPHQW QDWLRQDOL]DWLRQ HIIRUWV 6WXGLHV VKRXOGDOVRH[DPLQHZKDWWKHVHFKDQJHVPHDQIRUWKHJRYHUQPHQWLQWHUPVRI¿QDQFHVVWDI¿QJ and oversight. 7. Decentralization also appears as a major objective in the Sixth Five Year Plan, the National Plan of Action II and PEDP III; however, there is no comprehensive study demonstrating the challenges and opportunities for implementation. 'HFHQWUDOL]DWLRQ LV FRPSOH[SDUWLFXODUO\DVWKHWUDQVIHURIDGPLQLVWUDWLYHDQG¿QDQFLDOGHFLVLRQVWRWKHORFDOOHYHO may take many forms, and research into how this policy should be implemented should be done before developing more detailed implementation plans. While a number of studies on SMCs KDYH EHHQ FRPSOHWHG WKH\ KDYH QRW SURYLGHG VXI¿FLHQW LQIRUPDWLRQ DV WR ZKHWKHU WKHVH ORFDO ERGLHVKDYHVXI¿FLHQWFDSDFLW\DQGLQFHQWLYHVWRWDNHRQDGGLWLRQDO¿QDQFLDODQGDGPLQLVWUDWLYH responsibilities. Political economy may also be critically important for explaining the government UHVLVWDQFHWRH[WHQVLYHGHFHQWUDOL]DWLRQ 8. While the Sixth Five Year Plan emphasizes the need for a large increase in the government budget for primary education, current allocations are lagging behind, with a decline of 6.62 percent in 2007/08 to 5.36 percent in FY 2013/14 of government spending. Further research may inquire into the reasons behind the low budget dedicated for primary education, including the budgetary decision making process. xi 9. In-depth political economy research may also explain persistent problems in the primary education sector. Particularly important here are the areas in which the policies and regulations are technically sound, but they are not applied. Moreover, the issue of the continuing resistance of government to integrate MoE and MoPME, despite the technical rationale to do so, is another important topic for political economy. Other potential topics of research include the strong LQÀXHQFHRIRUJDQL]DWLRQVLQPDGUDVVDHGXFDWLRQWKHLQWHUHVWVWKDWVZD\WKHEXGJHWSURFHVVWKH UHQWVGHULYHGIURPORFDOH[SHQGLWXUHVDQGFRQWLQXHGUHVLVWDQFHWRGHFHQWUDOL]DWLRQ 10. This review faced a limitation due to the fact that many experts perceive information in the literature to be out of date due to changes initiated by MoPME; updated research is therefore needed. The review included research since 2000, but much of the data is out of date. We therefore hold many of the conclusions from the literature to be tentative, and recommend updates to the available literature. MoPME has undertaken a number of initiatives in order to DGGUHVV PDQ\RIWKHJRYHUQDQFHFKDOOHQJHVLGHQWL¿HGLQWKLVUHYLHZ7KLVVXJJHVWV WKDWIXUWKHU efforts are needed to update the data and analyses in the literature. Furthermore, MoPME should advertise their initiatives to improve governance. 11. Improved knowledge management is necessary so that governance research may have an impact. A considerable amount of effort was required by the authors to compile the literature in this review. Moreover, different experts informed our research team of studies that were not publicly available, or that were lost in time. Greater attention is needed to made research both publicly available and easily searchable. Moreover, efforts are required to make research accessible for a variety of audiences, particularly online in an easily searchable format. There is also a need to better evaluate the effects of the research completed thus far. Based on such an HYDOXDWLRQ WKH UHVHDUFK FRPPXQLW\ FDQ EHWWHU FRPPXQLFDWH WKHLU ¿QGLQJV WR NH\ DXGLHQFHV WR ensure impact. 12. Finally, the quality of evidence in empirical research in governance is frequently weak. Often, statements are made without an empirical basis, and anecdotal evidence may be portrayed as facts. At times, the primary education governance literature does provide evidence of problems, but falls short of an analysis of the systems involved in addressing the problems, nor an explanation for why the systems may fail. For example, the primary education budget is relatively VPDOOEXWWKHOLWHUDWXUHKDVQRWDQDO\]HGWKHEXGJHWGHFLVLRQPDNLQJSURFHVVHVWKDWOHDGWRWKLV RXWFRPH0RUHRYHUOLWHUDWXUHVKRXOGGLVWLQJXLVKEHWZHHQWKHRI¿FLDOSURFHVVHV de jure) including the laws and regulations, as opposed to action (de facto VFUXWLQL]LQJWKHZD\WKDWRI¿FLDOVDQG various actors actually behave. An analysis of the budget system should inquire into both the RI¿FLDOSURFHVVRIFRQVWUXFWLQJWKHEXGJHWDQGDOVRWKHLQIRUPDODJUHHPHQWVWKDWDUHPDGHWKHXVH RIDQDO\WLFDOZRUNDQGWKHSROLWLFDOFRQVLGHUDWLRQVWKDWLQÀXHQFHWKHVHGHFLVLRQV5HIRUPHIIRUWV that do not take these informal processes into account are likely to fail. The Main Points Emerging from Literature 13. Overall, the literature on the primary education sector provides limited but important DQDO\VHV RI JRYHUQPHQW HIIHFWLYHQHVV ZKLFK ZH GLYLGH LQWR SXEOLF ¿QDQFLDO PDQDJHPHQW human resource management and organizational effectiveness. The literature on public ¿QDQFLDO PDQDJHPHQW LQ WKH SULPDU\ HGXFDWLRQ VHFWRU SULPDULO\ IRFXVHV RQ EXGJHW DQG EXGJHW xii execution outcomes. An analysis of budgets indicate that the government budget allocated for the primary education sector is low – half that of other countries in the region as a portion of GNP (World Bank 2010b); moreover, evidence suggests the revenue budget is becoming less pro-poor, contrary to expectations. Budget execution rates are high, and the budget is a relatively good predictor of expenditures. The public expenditure tracking system has improved over time, as evidenced by the decline in discrepancies in salary expenditures (FMRP, 2006; Claussen & $VDGX]]DPDQ +RZHYHUIXQGUHOHDVHGHOD\VDUHRQHRIWKHPDLQIDFWRUVEHKLQGWKHORZHU execution rates for non-salary expenditures, and informal payments to speed up the process was found to be a prevalent problem according to a 2004 survey (FMRP, 2006; Qasem & Company, 2013). There is some evidence that the stipend program was affected in the past by delays and shortfalls in fund release, and also that stipends were not well targeted on the poor; however, there have since been improvements (FMRP, 2006; CAMPE, 2005; World Bank, 2013b). Survey results meanwhile point to a textbook distribution system that functions reasonably well to the school level, but with informal fees sometimes charged from parents (CAMPE, 2005; FMRP 2006). 'HVSLWHWKHVL]HDQGSURPLQHQFHRIWKHSULPDU\HGXFDWLRQVHFWRUWKHOLWHUDWXUHRQSXEOLF¿QDQFLDO PDQDJHPHQWOHDYHVQXPHURXVJDSV5HVHDUFKLQWRVHYHUDODVSHFWVRISXEOLF¿QDQFLDOPDQDJHPHQW were not found in the literature review include: the planning process; school level budgeting and DFFRXQWLQJIRU6/,3IXQGV DQGWKHGHWDLOVRIWKHÀRZRIIXQGVGHOD\V 14. The literature on human resource management covers a number of issues, including recruitment, promotions, training, and salary payments. Evidence suggests that the quality of the teachers, in terms of educational attainment, is quite high, especially for GPS though not for RNGPS. A high level of educational attainment is not achieved among teachers in all districts, PDQ\RIZKRPIDFHGLI¿FXOWLHVLQ¿OOLQJWHDFKLQJSRVLWLRQVSDUWLFXODUO\JLYHQWKHTXRWDV\VWHP Also, data suggest that a higher level of education does not lead to quality teaching. Meanwhile, relative to the local labor market, teachers are not well paid (Asadullah, 2006). The formal process for teacher recruitment includes numerous checks and balances and is also partly de-concentrated, which may partly explain the elevated educational level of government primary school teachers (CAI, 2002). However, despite these efforts, survey evidence suggests that teacher competencies are limited (FMRP, 2006). Further study of the issues of vacant posts and informal recruitment practices, as well as the quality of teacher training is needed. 15. The literature on organizational effectiveness, which is quite limited, mainly focuses on two areas: the division of MoPME and MoE, as well as the Sector Wide Approach. World %DQN LQGLFDWHG WKDW ODFN RI D XQLTXH VFKRRO LGHQWL¿HU DQG SRRU FRRUGLQDWLRQ EHWZHHQ DPE and BANBEIS undermined monitoring and evaluation of the public education system. Two DVVHVVPHQWV VFUXWLQL]H WKH LPSOHPHQWDWLRQ RI WKH 6:$S XQGHU 3('3 ,, GHVFULELQJ VXFFHVVHV such as increased coordination and policy coherence, yet limitations such as capacity and timely GHFLVLRQPDNLQJ $'% $KPHG 7KHOLWHUDWXUHRQRUJDQL]DWLRQDOHIIHFWLYHQHVVOHDYHV numerous topics for further research. Most notably, the PEDP II and PEDP III set objectives for GHFHQWUDOL]DWLRQEXWWKHUHLVYHU\OLWWOHUHVHDUFKRQWKHODUJHO\FHQWUDOL]HGV\VWHPVXQGHUZKLFK MoPME operates. 7KHOLWHUDWXUHRQFRUUXSWLRQDQGFRQWUROV\VWHPVSULPDULO\IRFXVHVRQ¿QDQFLDODQG facility management, with some studies touching on human resource management. Three surveys provide evidence that families sometimes pay illegal fees, mainly for textbooks and for xiii enrollment in primary schools, though it is unclear if this is corruption per se (FMRP, 2006; TIB, 2007 and 2010; Choe et al., 2011). A 2004 FMRP survey shows that illegal payments to DFFRXQWRI¿FHVDUHSUHYDOHQWDWWKHGLVWULFWDQGXSD]LODOHYHO )053 $VIRUFRUUXSWLRQ WZRVXUYH\VRQWHDFKHUDEVHQWHHLVPVKRZDUHODWLYHO\ORZOHYHORYHUDOOIRUXQDXWKRUL]HGWHDFKHU absenteeism (Chaudhury et al., 2004; FMRP, 2006), and few ghost teachers (FMRP, 2006). Audits by the Comptroller and Auditor General observe that “inconsistencies” were found in the foreign DLG¿QDQFHGH[SHQGLWXUHVEXWWKH0LQLVWU\KDVWDNHQVWHSVWRDGGUHVVWKLVFKDOOHQJH 0R30( 2011). The Foreign Aided Project Audit Directorate has been assigned to audit payrolls as per LQWHUQDWLRQDOVWDQGDUGVDUHFHQW¿GXFLDU\UHYLHZQRQHWKHOHVVHPSKDVL]HVWKDWKLJKULVNVUHPDLQ for the Ministry in this area (A. Qasem& Company, 2013). Information from four studies suggests that a misallocation of stipends may be partly due to corruption in the awarding process (Mahmud, 2003; Tietjen, 2003; Hossain and Osman, 2007; SIDA, 2007). Another study anecdotally states WKDW ¿QDO H[DPLQDWLRQ RU HQWUDQFH H[DPLQDWLRQ SDSHUV PD\ EH VROG LQ DGYDQFH WR KLJKSD\LQJ FDQGLGDWHV RU WR IDYRU SDUWLFXODU VWXGHQWV &KRH HW DO 5HVHDUFK VKRXOG DOVR VFUXWLQL]H corruption in the recruitment of teachers in GPSs and in RNGPSs (Hossain & Osman, 2007). The level of public transparency of MoPME, whether on its website, through documentation, or at the facility level, is not a common topic of analysis. Further research is needed, particularly regarding observations that are based on anecdotes. 17. Bangladesh has numerous experiences with voice and accountability initiatives in the primary education sector. This literature focuses primarily on the school level. Five studies on 60&VVKRZWKH\DUHTXLWHDFWLYHWKRXJKZLWKQXPHURXVFKDOOHQJHVVXFKDVSROLWLFL]DWLRQDQG corruption (FMRP 2007; World Bank, 2010; SIDA, 2008; CAMPE, 2009 & 2005). Similarly, two studies provide quantitative and qualitative evidence regarding Parent Teacher Associations and 8SD]LOD(GXFDWLRQ&RPPLWWHHVLQGLFDWLQJWKH\DUHQRWYHU\DFWLYHDWWKHORFDOOHYHO &$03( 2005; FMRP, 2007). The literature on voice and accountability requires much more research on a YDULHW\RIWRSLFVLQFOXGLQJYRLFHDQGDFFRXQWDELOLW\DWWKHQDWLRQDOOHYHODQGLQXQRI¿FLDOFKDQQHOV at the local level, as well as the outcomes of such participation. 18. Given the enormous variety of schools in Bangladesh, many of them operating with support from the GoB, government regulation of non-government schools is an important topic for research. Current literature on government mainly focuses on measuring student performance of the diversity of primary schools, which show a generally low level of performance, but slightly poorer performance for several types of non-government schools. In spite of the importance of the non-government primary education sector, this general topic requires studies on a number of fronts. The lack of systematic data collection on student performance in all non-government schools frustrates quantitative analysis on performance by type of school. There are important issues of regulatory policy that should be informed by further research, such as teacher recruitment standards, curriculum, teaching methods, and UHTXLUHPHQWVIRURSHQLQJQHZVFKRROV7KHPDLQDUHDVRIJRYHUQPHQW¿QDQFLDOFRQWULEXWLRQWR non-government schools include the payment of teacher salaries and the provision of stipends DQGWH[WERRNVVRDQXQGHUVWDQGLQJRIWKHH[WHQWRI¿QDQFLDORYHUVLJKWRIWKHUHVRXUFHVZRXOG also be an important area for investigation. xiv 1. Introduction 1. The purpose of this systematic review of the literature is to inform the World Bank, development partners and other stakeholders on the state of governance in the primary education sector of Bangladesh. With billions3 of Bangladeshi Taka invested in the government- UXQSULPDU\HGXFDWLRQVHFWRUHYHU\\HDU¿QDQFHGE\GRPHVWLFDQGLQWHUQDWLRQDOVRXUFHVWKHUHKDYH been numerous efforts to better understand the governance challenges in the sector. This report reviews sixty such reports and studies written by NGOs, academics, government entities, research institutions, consultants and development partners, in the last ten years. However, translating that research into policy dialogue and improvement has been challenged due to poor knowledge PDQDJHPHQWDODFNRIDV\VWHPDWLFDSSURDFKWRUHVHDUFK EXLOGLQJRQHDUOLHUVWXGLHV¿QGLQJV DQG limited efforts to place the work in the public domain and discourse. This paper takes a systematic DSSURDFKWRWKHOLWHUDWXUHUHYLHZEULQJLQJWKHNH\¿QGLQJVWRJHWKHUDQGHYDOXDWLQJWKHZHLJKWRI evidence on the governance problems in the sector, as well as the gaps that may be addressed by IXWXUHUHVHDUFKHIIRUWV7KHUHYLHZIXUWKHUPRUHHPSKDVL]HVWKHQHHGWRXQGHUVWDQGWKHIDFWRUVDQG political economy factors in particular, that explain the current state of affairs. 2. The review is structured to systematically assess this literature, leading to several broad conclusions. First, it begins by outlining the structure and methods for the review and LQFOXGHVDJHQHUDOEDFNJURXQGWRWKHSULPDU\HGXFDWLRQVHFWRU,WWKHQPHWKRGLFDOO\VXPPDUL]HV WKH UHOHYDQW OLWHUDWXUH IRU HDFK :*, JRYHUQDQFH LVVXH KLJKOLJKWLQJ WKH ¿QGLQJV OHVVRQV DQG identifying the weaknesses and gaps. The review ends by highlighting these gaps in research, with a view to improve its scope and impact. Structure and Methods for the Systematic Review 7R RUJDQL]H WKH OLWHUDWXUH UHYLHZ ZH XVH D EURDG GH¿QLWLRQ RI JRYHUQDQFH DQG categorize governance concerns according to the Worldwide Governance Indicators (WGI). *RYHUQDQFHLVDWHUPWKDWLVRIWHQRYHUO\VLPSOL¿HGWRPDNHLWXQGHUVWDQGDEOH)RUWKHSXUSRVHVRI WKHUHYLHZZHVWDUWHGZLWKDZLGHO\XVHGGH¿QLWLRQ ³JRYHUQDQFHLVWKHWUDGLWLRQVDQGLQVWLWXWLRQV by which authority in a country is exercised” and a broader concept than a focus on corruption which is often used synonymously with governance (Kaufmann et al., 2000). We drew upon the WGI as a way of breaking governance down into characteristics of government effectiveness, control of corruption, voice and accountability, and regulatory quality.4 We use this rubric to group the aspects of governance discussed in the systematic review within each category in a way similar WR /HZLV 6HYHUDO FKDOOHQJHV HPHUJHG ZLWK XVLQJ WKLV FDWHJRUL]DWLRQ WKDW GRHV QRW GHDO explicitly with issues of political economy, a feature that explains governance issues, and as a result of the cross cutting and complex nature of governance issues. Given many governance issues 3 Billions means 1,000 million. 4 Two categories of indicators in WGI are less applicable at the sector level–rule of law and political stability–because WKH\SULPDULO\UHIHUWRWKHODUJHUJRYHUQDQFHHQYLURQPHQWDQGQRWWRVHFWRUVSHFL¿FLVVXHVLQWKHSULPDU\HGXFDWLRQ sector, they have therefore not been used here. 1 DUHDOVRRYHUODSSLQJZLWKLQWKLVFDWHJRUL]DWLRQ7DEOHFODUL¿HVKRZVSHFL¿FJRYHUQDQFHLVVXHV are grouped in this report according to the WGI approach. 4. This systematic review brings together research to date on governance and summarizes it around common themes, pulling together published material as well as selected grey literature. The source of literature includes publicly available articles, books, and reports covering the Bangladesh health sector since 2000; it also includes an analysis of the grey literature, especially the main program documents (program plans, evaluations and other reviews), as well as a selection of the most recent technical documents such as annual program reviews, audits and ¿QDQFLDOUHSRUWV:KLOHWKHUHYLHZZDQWHGWRH[SORUHRWKHUTXHVWLRQVDQGLQLWLDWLYHVLWZDVOLPLWHG by the research and documentation available. Also, though potentially fruitful this report does not JREH\RQG%DQJODGHVKWRFRPSDUH¿QGLQJVZLWKVLPLODUUHVHDUFKLQRWKHU6RXWK$VLDQFRXQWULHV on common issues such as absenteeism, corruption and informal payments for services. While the initial scope for the review intended to include a review of solutions to governance problems and whether there is some evidence on what has served to improve governance outcomes, this was not possible due to the scarcity of evidence and research. Similarly, innovative efforts to reform government systems are generally not documented or evaluated, preventing the review IURP LQFOXGLQJ VXFK LQLWLDWLYHV LQ LWV DQDO\VLV 2XU WHDP GLG QRW DWWHPSW WR VXPPDUL]H PRUH KLVWRULFDOUHVHDUFKSUHDQGWKH¿QGLQJVRIROGHUUHSRUWVZHUHJLYHQD³UHDOLW\FKHFN´WKURXJK informal consultations. The report is not based on a comprehensive data-mining exercise, though this exercise would be a useful. Table-1.1: A Description of the Categories of Issues for the Systematic Review Governance Category Governance Issues x 3XEOLF¿QDQFLDOPDQDJHPHQW SODQQLQJEXGJHWLQJDQGEXGJHW execution, auditing, reporting) Government x +XPDQUHVRXUFHPDQDJHPHQW VWDI¿QJSXEOLFVHFWRU Effectiveness management, capacity) x 2UJDQL]DWLRQDOHIIHFWLYHQHVV x Integrity in procurement processes Political Economy – x Financial and facility management, including management Cross cutting oversight Control of Corruption x Integrity in human resource management x Integrity in the regulation of the private sector x Transparency x 7UDQVSDUHQF\2SSRUWXQLWLHVIRUFLWL]HQVWRSURYLGHLQSXWWR decision making Voice and Accountability x Oversight of service delivery x 2WKHUPHDQVIRUFLWL]HQVWRKROGJRYHUQPHQWVHUYLFHSURYLGHUV accountable x Integrity in the regulation of the private sector Regulatory Quality x Regulation of the quality and accessibility of service provision in the private sector, with appropriate standards and enforcement 2 5. A breakdown of the number of studies covering various topics shows that the vast majority have focused on Control of Corruption and Government Effectiveness, with few for Regulatory Control and Voice and Accountability. Table-1.2 shows this skew in the research agenda to date. Table-1.2: Number of Primary Education Studies across the Governance Areas Governance Categories Number of Studies Government Effectiveness 16 Control of Corruption 20 Voice and Accountability 8 Regulatory Quality 7 Total 51 Note: Other research cited relates to the political economy section, adding up to over 60 studies. 6. The Government of Bangladesh has strongly emphasized governance concerns, and each of the governance issues reviewed here is related to the sixth 5 Year Plan, the National Plan of Action II of MoPME, as well as the PEDP III. The current 5 Year Plan strongly HPSKDVL]HV VWHSV WR LPSURYH WKH JRYHUQDQFH RI HGXFDWLRQ WKDW LQFOXGH VWUHQJWKHQLQJ +50 EULQJLQJJUHDWHUGHFHQWUDOL]DWLRQLQDGPLQLVWUDWLRQDQGHQVXULQJEHWWHUFRRUGLQDWLRQEHWZHHQWKH two education ministries and institutions. The governance concerns raised by the literature are mostly consistent with the actions highlighted in government plans and programs. Priority areas under the plan include improved planning and budget processes; training for quality education; GHPRFUDWLFSUDFWLFHVDWWKHORFDOOHYHO WUDQVSDUHQF\DQGDFFRXQWDELOLW\LQ¿QDQFLDOWUDQVDFWLRQV and facility management; and accountability in the non-government education sector. PEDP III SULRULW\ DUHDV LQFOXGH WHDFKHU WUDLQLQJ FLWL]HQ SDUWLFLSDWLRQ GHFHQWUDOL]DWLRQ HIIHFWLYH WHDFKHU recruitment and deployment, and inter-ministerial coordination. :LWKLQHDFKFDWHJRU\WKHUHYLHZGRFXPHQWVWKH¿QGLQJVIURPWKHOLWHUDWXUHDFFRUGLQJWR A. What evidence is available in the literature in terms of governance outcomes? B. What analysis is available regarding the main government systems to achieve these outcomes? In other words, how does government work in practice? 8. From this systematic review, we conclude that the available evidence as a whole is relatively weak and dated for the governance concerns in the sector, and there is a need to strengthen the knowledge base. Throughout the report, areas in which information is not available on governance are highlighted, especially when it pertains to governance issues that are RIWHQTXRWHGDQHFGRWDOO\$WWHPSWVWR¿QGOLWHUDWXUHWKDWH[DPLQHVJRYHUQDQFHWKURXJKWKHSROLWLFDO economy lens were largely fruitless, and this is a gap in the research agenda. Political economy factors could play a strong role in explaining the failure of government systems to address well- known governance problems. 3 Background to the Primary Education Sector of Bangladesh 'HVSLWH LWV RYHUDOO SRRU JRYHUQDQFH UHFRUG %DQJODGHVK KDV PDGH VLJQL¿FDQW advancements in increasing access to education and achieving gender parity. At the national level, Bangladesh exhibits a poor performance on each of the WGI indicators, particularly in the indicators of government effectiveness and control of corruption, scoring percentile rankings of 22.5 percent and 21.1 percent respectively (World Bank, 2013a)5. According to the Corruption Perceptions Index of Transparency International, Bangladesh scored of 26 out of 100, and ranked 144th out of 176 countries in 2012, indicating very little change over the last four years. Nonetheless, the country has made good progress in the primary education sector. According to WKHJRYHUQPHQW¶VRI¿FLDOVWDWLVWLFVWKHUHZDVDJURVVHQUROOPHQWUDWHRISHUFHQWZKLOHPRUH than 17 million pupils are enrolled in over 78,000 primary level schools and institutions across the country in 2011, with practically no disparity between boys and girls (World Bank, 2013b). Net enrollment rates were 77 percent in 2010 (World Bank, 2013b). There are several indicators of good performance; access to schooling by the poor and by girls has improved over time. The gap between the enrollment rates of the poorest third of pupils and the rest as fallen from 16 percentage points in 2000 to 6 percentage points in 2010. 10. However, challenging issues remain particularly in terms of the quality of education, the high rates of dropouts and average time it takes to complete school, improving governance could be central to addressing these issues. The quality of learning in schools is a concern: only 28 percent of 5th grade students in GPSs achieved competency in Bangla and 35 percent in PDWKHPDWLFVLQ )LJXUH :KLOHORZWKH\H[FHHGHGWKH¿JXUHVIRU51*36V6XFKDORZ level of competency exists despite the high rates of primary school students passing their terminal exam, at over 92 percent in 2010. Primary school completion rates are low but improving. Total primary school completion in Bangladesh increased from 65 to 76 percent between 2000 and 2010. Finally, Bangladesh maintains quite low measures for time on task, a key measure for the quality RIHGXFDWLRQ,QWHUQDWLRQDOQRUPVUHTXLUH FRQWDFWKRXUVEXWRI¿FLDOUHJXODWLRQVUHGXFH the contact hours to 861 in grade 1 schools and 595 in a double shift school, which represent approximately 90 percent of GPSs and RNGPSs. 5 Percentile ranks indicate the percentage of countries worldwide that rank lower than the indicated country, so that higher values indicate better governance scores. 4 Figure-1.1: Percentage of Students Achieving Competencies in GPSs and RNGPSs Source: Reproduced from World Bank (2013b), which uses National Student Assessment (2011). Note: 'LIIHUHQFHVLQDYHUDJHVFRUHDUHVWDWLVWLFDOO\VLJQL¿FDQWDWSHUFHQWLQERWKVXEMHFWVLQERWKJUDGHV*36 *RYHUQPHQW primary schools; RNGPS = Registered non-government primary schools. 11. The legal framework is strong and is being strengthened to include oversight of all state and non-state provided facilities. The importance of the education sector in Bangladesh is long established and is founded in the Constitution of Bangladesh as well as a feature of social policy in all post-Independence governments. According to the Constitution, the State is actually REOLJHG WR SURYLGH HGXFDWLRQ WR DOO FLWL]HQV $UWLFOH DQG XQGHUWDNH HIIHFWLYH PHDVXUHV WKDW establish a free, compulsory and common system of education is available for all (Article 17). Primary education became obligatory after the Compulsory Primary Education Act 1990. The government is currently in the process of introducing the Education Act 2013, which will apply to all government and non-government educational institutions in the country. This would be the ¿UVWDWWHPSWWREULQJWKHGLIIHUHQWSULPDU\HGXFDWLRQV\VWHPVXQGHUDFRPPRQOHJDOIUDPHZRUN and stronger oversight in the sector. 12. The government runs around half of all primary schools, while a vibrant non- JRYHUQPHQWVHFWRURSHUDWHVZLWKVXEVWDQWLDOJRYHUQPHQW¿QDQFLDOVXSSRUWDQGLQYROYHPHQW The government provides education to about 54 percent of the total enrolled primary school students, which are called government primary schools or GPS. Twenty one percent are the 5HJLVWHUHG1RQ*RYHUQPHQW3ULPDU\6FKRROV 51*36 ZKLFKZHUHGHFODUHG³QDWLRQDOL]HG´LQ January 2013. The rest are madrassas and other NGO-run schools. The government has different forms of involvement in all schools, including salary payments, regulation, curriculum decisions, and the provision of stipends and free textbooks, among others. The typology of primary schools DQGWKHQDWXUHRIJRYHUQPHQWLQYROYHPHQWDUHVXPPDUL]HGLQ7DEOH,QDGGLWLRQWRWKHRI¿FLDO statistics there are an estimated 10,000 more enrolled in “Reaching Out of School Children” schools, an innovative government program. Many of these schools target the poorest and most vulnerable children, who are also the least likely to attend and complete primary school (Sabur & Ahmed, 2010). 5 13. The governance issues in the schools are anecdotally different according to the type of school; however, the precise problems faced by each types of schools are not well established. The governance issues surrounding the RNGPs seem to feature more prominently than in government run schools. Their performance is generally not as good, even though they have fewer vacant teacher posts not as high. One main differentiating feature of RNGPSs from government schools is the stronger role played by local school managing committees (SMCs). 7KHVHFRPPLWWHHVDGPLQLVWHUWHDFKHUUHFUXLWPHQWZLWKWKHLQYROYHPHQWDQGDSSURYDORIWKHXSD]LOD HGXFDWLRQ RI¿FH XQOLNH *36V ZKLFK KDYH D PRUH FRPSOH[ UHFUXLWPHQW V\VWHP (VWDEOLVKHG privately or by communities, RNGPSs had received government recognition and registration, and consequently, some oversight and funding. In order to receive government registration, schools must meet certain criteria (including having a minimum number of enrolled students). Once registered, RNGPS teachers become eligible for 90 percent salary subvention (through the monthly pay order or MPO), a process that was reputed to have cumbersome administrative arrangements causing late salary payments. There was also anecdote of collusion between local SMCs and teachers to receive payments.6 Due to the Constitutional provision that mandates free primary education, the 51*36VZHUHQRWDOORZHGWRFKDUJHIHHVRUUHFHLYHDQ\³RI¿FLDO´FRQWULEXWLRQVIURPSDUHQWVRU others. 6 This anecdotal evidence was gathered through discussions with the education sector stakeholders in Bangladesh but no report or study of this issue was found in the public domain. 6 Table- 1.3: Government and Non-Government Primary Schools and Government Support, 20077 Type of Primary Enrollment % of Type of Government Funding School (‘000s) Total GPS Fully government funded. 9,484 54 Government provides basic pay of teachers and limited 3,573 21 allowances. Provides free stipends to 40 percent RNGPS of rural students and free textbooks to all students. Expected to receive full allowances as government is LQWKHSURFHVVRIQDWLRQDOL]DWLRQ Independent Teachers paid BDT 750 monthly. Provides free 850 5 ebtadayee stipends to 40 percent of rural students and free madrassas textbooks to all students. 5HFRJQL]HGQRQ Attached ebtadayee sections of higher madrassas. 1,146 7 government Alia Government provides basic pay of teachers and limited madrassas allowances. Provides free textbooks. 8QUHFRJQL]HG No government funding. n/a n/a madrassas Private schools No direct government funding. Free textbooks for 404 2 schools following national curriculum NGO schools No direct government funding. Free textbooks for 1,500 9 schools following national curriculum Community Teachers receive BDT 750 monthly. Provides free 426 2 schools stipends to 40 percent of rural students and free textbooks to all students. Government Alia Fully government funded. n/a n/a madrassas Total 17,383 100 Source: World Bank (2010b). 14. The responsibility for the provision of primary education rests with the Ministry of Primary and Mass Education. The objective of the Ministry is to ensure universal access in the formal and non-formal sectors for primary education only. MoPME has a comprehensive plan entitled the National Plan of Action II, and is currently implementing the Primary Education 7 Madrassas offer two types of education for children at the primary level: Aliya (the primary school section is called Ebtedayee or Ibtidaia), which are reformed and registered madrassas, and Quomi, which are unreformed/ and unregistered madrassas. Many madrassas, Quomi madrassas in particular, receive private donations from communities and Muslim individuals. NGO schools include BRAC-run schools a large provider which targets poor students who have dropped out of government-funded schools, ethnic minorities, students in rural areas who would not otherwise have education DFFHVVDQGVWXGHQWVZKRDUHYXOQHUDEOHPDUJLQDOL]HGRUH[FOXGHGGXHWRVSHFLDOQHHGVRURWKHUUHDVRQV%5$&VWXGHQWV are not charged any tuition or fees, and most of their learning materials are provided by the program. The table excludes numerous schools, including ROSC schools. 7 Development Program (PEDP) III using the Sector Wide Approach. The main objective of NPA II is to ensure universal access to primary education for all school-age children, to guarantee they receive and achieve quality education, and to ensure that the learning needs of both young persons and adults in both formal and non-formal sectors of basic education are achieved without any discrimination (MoPME, 2013a). 15. The government is currently in the process of nationalizing all RNGPSs, which is expected to improve the governance and oversight of these schools. 3ULRUWRWKHQDWLRQDOL]DWLRQ agenda, the government was responsible for providing teachers’ salaries of only MPO-listed 51*36 8QGHU WKH QDWLRQDOL]DWLRQ SURJUDP DOO 51*36 WHDFKHUV ZLOO EHFRPH JRYHUQPHQW HPSOR\HHV DQG WKH\ ZLOO UHFHLYH VDODULHV DQG EHQH¿WV DW SDU ZLWK WKHLU *36 FRXQWHUSDUWV DQG using the same administrative systems. The government will also become responsible for the management of the schools. This will reduce the number of MPO-paid teachers and the prevalence RI DQ\ JRYHUQDQFH FRQFHUQV DVVRFLDWHG ZLWK WKH 032 SURFHVV 7KH QDWLRQDOL]DWLRQ SURFHVV LV H[SHFWHGWREHXQGHUWDNHQRYHUWKUHHSKDVHV 032OLVWHG51*36KDYHEHHQQDWLRQDOL]HG already. 16. While the primary education sector receives prominence in the government’s policy and national strategic plans, the budget for MoPME is just 5.36 percent of the current FY budget. The revenue budget is 55 percent which is predominantly for salaries (95 percent); and 45 percent is the development budget (see Table-1.4). A breakdown of contributions to the PEDP 3 from government and development partners is provided in Annex 1. Table-1.4: MoPME Budget Share in Total Government Budget MoPME share of GoB Total GoB Budget MoPME Budget Budget (BDT billions) (BDT billions) (%) 2007-08 796.14 52.73 6.62 2008-09 999.62 53.31 5.33 2009-10 1,138.19 68.42 6.01 2010-11 1,321.70 79.93 6.05 2011-12 1,635.89 77.27 4.72 2012-13 1,917.38 94.53 4.93 2013-14 2,224.91 119.3 5.36 Source: Ministry of Finance, 2013. 8 2. Government Effectiveness in the Primary Education Sector 17. Overall, the literature on the primary education sector provides limited but important analyses of government effectiveness. Like ‘governance’, the term ‘government effectiveness’ can be interpreted in numerous ways. To break down the term, we present three aspects of government HIIHFWLYHQHVV SXEOLF ¿QDQFLDO PDQDJHPHQW KXPDQ UHVRXUFH PDQDJHPHQW DQG RUJDQL]DWLRQDO effectiveness. The Literature on Public Financial Management 18. Evidence from the literature suggests the following: a relatively low budget allocation to the sector; an under-funding for several key budget items; and good predictability in budget execution, especially on salaries, despite numerous delays and challenges. 7KH¿QGLQJV RIWKHUHYLHZRQSXEOLF¿QDQFLDOPDQDJHPHQWRXWFRPHVDQGV\VWHPVDUHVXPPDUL]HGLQ7DEOH 19. An analysis of budgets indicate that the government budget allocated for the primary education sector is low – around half that of other countries in the region as a portion of GNP (World Bank 2010b). The budget allocation to the sector is increasing though and reached almost BDT 12,000 crore in the 2013/14 budget (see Table-2.2). Given the sector outcomes are relatively good, the low spending in proportion to GDP is unexpected. Neither of these topics is well explored as research topics, but clearly the data showed that in 2005 at least, spending in proportion to national income was much lower in Bangladesh at 0.5 percent of GNP, than that of the average developing country at 1.8 percent of GNP (World Bank 2010b). Interestingly, in 2002, India and Nepal dedicated around 1.4 percent of GNP to primary education. CAMPE (2006) argues that the underfunding of primary education leads to two related outcomes: the need for increased private funding for education, particularly from individual families, and inequality in the provision of primary education. One alternative explanation might be that the budget process works well and that the use of the private funds available for education, lead to a rationale budget process and outcome that provides less from the public purse. Hossain & Osman (2007) broadly discuss the overall political value placed on the education sector as the main explanatory factor for the notable improvements in some education indicators, but their hypothesis fails to account for the relatively small portion of the budget spent on education, and primary education in particular. 20. Non-salary recurrent costs appear to be under-funded, with recent efforts to ensure DGHTXDWH¿QDQFLQJ )053 &$03( The PEDP III took steps to ensure that the VHFWRUIROORZVLWV07%)SODQZLWKDGHTXDWH¿QDQFLQJRYHUDOO+RZHYHUDOWKRXJKWKHUHSRUWLV outdated, a 2004 survey and focus group discussions indicated that operational expenditures were relatively underfunded. According to an analysis of the 2006/7 budget, personnel costs accounted for 98 percent of revenue spending in primary education, and non-salary expenditures were 20 percent of the total budget. Almost 80 percent of the budget was for stipends and textbooks, 9 leaving the regular running costs of the sector underfunded.8 7KLV ZDV FRQ¿UPHG E\ D VXUYH\ RIDQGGLVFXVVLRQVZLWK'LVWULFW3ULPDU\(GXFDWLRQ2I¿FHUV '3(2 8QLRQ(GXFDWLRQ2I¿FHUV 8(2 DQG'UDZLQJDQG'LVEXUVHPHQW2I¿FHUV ''2V±ORFDOOHYHORI¿FLDOVIURPWKH0LQLVWU\RI Finance) who indicated a lack of funding for operational expenses, such as travel and conveyance allowances, travel expenses and petrol, electricity and contingencies (FMRP, 2006, CAMPE, 7KH¿QGLQJVLQGLFDWHDODFNRIIXQGLQJIRUWKHRSHUDWLRQVDQGPDLQWHQDQFHRIWKHVFKRRO and an opaque allocation process. Table-2.1: Summary of the Literature on Public Financial Management Ministry Processes to Achieve Outcomes and their Outcomes Limitations Plan - - - Primary education budget is relatively low, compared to the region (World Bank, 2010b) Budget - - The distribution of the budget has become less pro- poor over time (World Bank, 2010b; World Bank, 2013b) - MoPME experiences good predictability in budget execution (MoPME, 2011a) - Budget execution at the local - Salary allotments are typically fully spent; but there level has numerous challenges is low execution of non-salary budgets at the local (FMRP, 2006) level (FMRP, 2006) - Accounts are consistent - Budget items showed mixed performance in Budget between MoF and MoPME execution (CAMPE, 2005; FMRP, 2006) Execution (FMRP, 2006) - Salary payments are delivered mostly on time - Record-keeping systems have (FMRP, 2006) improved at district level &ODXVVHQ $VDGX]]DPDQ - Stipend distribution is not pro-poor and sometimes 2013) misses full payments (FMRP, 2006) - Textbook distribution works down to the school level (FMRP, 2006) 21. Not only is the primary education budget allocation low, but some evidence also suggests the revenue budget is becoming less pro-poor, contrary to expectations. Analyses of the primary education budget shows that its distribution is not pro-poor and has become less so RYHUWLPH7KHUHVXOWVIURP:RUOG%DQN E DQG:RUOG%DQN E RIWKHEHQH¿WLQFLGHQFH analysis of sector spending are shown in Table- 2.3. While the poor represented 50 percent of the total population of school-aged children, they received only 47 percent of the total recurrent 8 The Ministry of Finance (MoF) website provides some information on budget allocation and expenditures in the primary education sector through GLIIHUHQW UHSRUWV 7KHVH LQFOXGH DQQXDO EXGJHW VWDWHPHQWV PRQWKO\ ¿VFDO UHSRUWV DQG$'3 XWLOL]DWLRQUHSRUWV7KRXJK WKHVH UHSRUWV SURYLGH UHFRUGV RI RYHUDOO ¿JXUHV DQG VWDWXV RI GHYHORSPHQW DQG non-development expenditures across the ministries, including MoPME, they lack a detailed breakdown of the budget expenditure items. 10 primary education expenditure in 2005 and this fell to 37 percent in 2010. This evidence deserves further investigation into the allocation of particular types of spending, such as the posting of teachers to poor and non-poor geographic regions, and the targeting of the stipend program (which, as discussed in Paragraph 27, is not well targeted to the poor). Table-2.2: Ministry of Primary and Mass Education, BDT crore Budget Revised Budget Actual 2013-14 2012-13 2012-13 2011-12 Non-Development 6,652 5,537 5,443 5,749 Development 5,278 3,916 4,382 2,408 Total 11,930 9,453 9,825 8,157 Source: Ministry of Finance, 2013-14 budget documents. Table-2.3: Incidence of Public Primary Revenue Expenditure (in percent) 2005 2010 Quintiles 1 24 27 2 23 23 3 21 20 4 18 17 5 14 13 Poor 47 37 Non-Poor 53 63 Male 52 49 Female 48 51 Rural 74 76 Urban 26 23 Sources: World Bank, 2010b; World Bank, 2013b. 22. Budget execution rates are high, and the budget is a relatively good predictor of expenditures. Findings from the Ministry’s own analysis, shown in Table-2.3, indicate that the variance between budget and execution ranges between 5 and 10 percent. The actual expenditure being in excess of the budget is probably explained by a supplementary budget, but the report does not provide an explanation. Detailed data on the government’s budget execution rates for more recent years is not publicly available.9 Also the spending under the Primary Education 9 The Ministry of Finance (MoF) website provides some information on budget allocation and expenditures in the SULPDU\ HGXFDWLRQ VHFWRU WKURXJK GLIIHUHQW UHSRUWV 7KHVH LQFOXGH DQQXDO EXGJHW VWDWHPHQWV PRQWKO\ ¿VFDO UHSRUWV DQG$'3 XWLOL]DWLRQUHSRUWV7KRXJK WKHVH UHSRUWV SURYLGH UHFRUGV RI RYHUDOO ¿JXUHV DQG VWDWXV RI GHYHORSPHQW DQG non-development expenditures across the ministries, including MoPME, they lack a detailed breakdown of the budget expenditure items. 11 Development indicates a high budget execution rate at 89 percent in FY11. At the local level, an DQDO\VLVRI0R30(UHFRUGVDQGHGXFDWLRQRI¿FHUHFRUGVVKRZH[HFXWLRQUDWHVWREHDOPRVW percent for salary expenditures, and slightly lower for non-salary expenditures (FMRP, 2006). $FFRUGLQJWRHGXFDWLRQRI¿FHUHFRUGV*36VVSHQGSHUFHQWRIVDODU\EXGJHWDQG SHUFHQW RIQRQVDODU\EXGJHW EXW8(2RI¿FHVVSHQG SHUFHQWDQGSHUFHQWRIVDODU\DQGQRQVDODU\ EXGJHWVUHVSHFWLYHO\2YHUDOOEXGJHWH[HFXWLRQUDWHVLQLQGLYLGXDOGLVWULFWVDQGXSD]LODVVKRZVRPH variation around this relatively high average. In some instances anomalies in budget execution may be due to poor record keeping (FMRP, 2006). However, this topic merits further work to explain these variations. Table-2.4: MoPME Budget Execution Rates for Fiscal Years 2009/10 2010/11 2011/12 Actual Budget Actual Budget Actual Budget Execution Execution Execution (BDT (BDT (BDT (BDT (BDT (BDT billion) Rate (%) Rate (%) Rate (%) billion) billion) billion) billion) billion) Revenue 37.49 41.38 110.37 48.55 51.53 106.13 54.42 57.49 105.64 Development 28.62 27.00 94.33 32.07 31.51 98.25 35.14 24.08 68.52 Total 66.11 68.38 103.43 80.62 83.04 103.00 89.56 81.57 91.07 Source: Ministry of Finance, 2013. Note: This table uses non-revised budget estimates. 23. The public expenditure tracking system has improved over time, as evidenced by the decline in discrepancies in salary expenditures (FMRP, 2006; Claussen & Asaduzzaman, 2012). The FMRP 2004 survey indicated a difference of 12 percent between reports of salary H[SHQGLWXUHVDWWKHXSD]LODHGXFDWLRQRI¿FHDQGWKRVHDWWKHVFKRRO7KH¿QGLQJZDVHYHQKLJKHU for RNGPS at 21 percent. For non-salary expenditures the discrepancies were lower at 18 percent DQG SHUFHQW UHVSHFWLYHO\ IRU *36 DQG 51*36 +RZHYHU D UHFHQW DQQXDO ¿GXFLDU\ UHYLHZ FRQGXFWHGE\GHYHORSPHQWSDUWQHUVFRQ¿UPVQRPDMRULVVXHVGHWHFWHGZLWKSD\UROODXGLWVEXWKDV raised this as a risky area (A. Qasem & Company, 2013). The FMRP survey also mentioned late VDODU\SD\PHQWVDVDVLJQL¿FDQWSUREOHPIRU51*36WHDFKHUV±RQO\SHUFHQWRIWHDFKHUVVD\ they received their payment on time. For GPS teachers on the other hand 90 percent did not have a problem with late payment. The agreement to place non-government primary school teachers onto the same terms and conditions and processes of payment as GPS teachers should solve this problem. Furthermore, the FMRP survey revealed problems with accounting at the district level, where by the district accounts show a difference of 23 percent and 27 percent for salary and non-salary payments respectively compared to the Ministry accounts. Since the FMRP survey, LPSURYHPHQWLQSXEOLFH[SHQGLWXUHWUDFNLQJKDVRFFXUUHGWKURXJKFRPSXWHUL]HGUHFRUGNHHSLQJ YLDWKH,QWHJUDWHG%XGJHWDQG$FFRXQWLQJ6\VWHPDWGLVWULFWDFFRXQWLQJRI¿FHV$FFRUGLQJWRD recent assessment, this initiative has improved account reconciliations between district accounting RI¿FHVDQG''2VWKRXJKVRPHLPSOHPHQWDWLRQFKDOOHQJHVUHPDLQ &ODXVVHQ $VDGX]]DPDQ 2013). The assessment further highlights improvements in the timeliness of payment processing for bills. 12 24. Fund release delays are one of the main factors behind the lower execution rates for non-salary expenditures, and informal payments to speed up the process was found to be a prevalent problem according to the 2004 survey (FMRP, 2006; Qasem & Company, 2013). Recent interviews with senior management of the National Academy for Primary Education 1$3( LGHQWL¿HGWKHGHOD\VLQIXQGUHFHLSWVIURP'3(DVWKHPDLQUHDVRQIRUGHOD\VLQVFKHGXOHG programs and for which, some school activities are often managed through exhausting their own reserves such as C-Ed program fees and dormitory fees (Qasem & Company, 2013). Districts and XSD]LODVW\SLFDOO\ZDLWHGWRPRQWKVDIWHUWKHVWDUWRIWKH¿VFDO\HDUWRUHFHLYHWKH¿UVWIXQG disbursement; while allotments for small repairs often did not arrive until 9 months had passed. 7ZRWKLUGV RI '3(2V DQG D TXDUWHU RI 8(2V UHSRUWHG GLI¿FXOWLHV LQ JHWWLQJ EXGJHW DOORWPHQWV from the DPE. Some respondents reported that the allotment letter did not arrive at all or contained errors when it did; and 27 percent of DPEOs and 7 percent of UEOs cited the need to make informal payments to receive the allotment letters from DPE, for the release of funds. In addition WRGHOD\VDQGSD\LQJIRUWKHDOORWPHQWOHWWHUWKHSURFHVVRIJHWWLQJELOOVSDLGDWWKHDFFRXQWVRI¿FH also causes problems. Half of UEOs reported unexplained delays and 38 percent of DPEOs and 48 SHUFHQWRI8(2VUHSRUWHGWKHQHHGWRPDNH³VSHHGSD\PHQWV´DWWKHDFFRXQWVRI¿FH SHUFHQWRI DPEOs and 48 percent of UEOs said they had not experienced this and 5 percent of DPEOs and 8 percent of UEOs said they didn’t know or refused to answer). 25. There is some evidence that the stipend program was affected in the past by delays and shortfalls in fund release, and also that stipends were not well targeted on the poor; however, there have since been improvements (FMRP, 2006; CAMPE, 2005; World Bank, 2013b).10 An FMRP survey found that some schools experienced a shortfall in allocations to the stipend program (received from the UEOs) which led to reduced stipend payments (nearly half of students did not receive their full stipend of BDT 300), suggesting that that the allotment and disbursement system for stipends not working well. Furthermore, CAMPE reports that, based on their survey evidence, the stipend is not pro-poor, but instead evenly distributed across income categories, while FMRP found 33 percent of stipend “cardholders” were from the richest two quintiles and a large number of poor families were excluded from the program. Several reforms of the stipend program subsequently took place in 2010 to improve targeting and the distribution process. World Bank (2013b) reports that there is current evidence suggesting that the stipend program is having an impact on its main objective, to increase the enrollment rate of all primary level school age children of poor families; and that stipends are likely to be given to the educationally inclined, moderately poor students. The changes to the distribution system brought about by the reforms, DQGZKHWKHURUQRWWKLVKDVLPSURYHGSUHGLFWDELOLW\RI¿QDQFLQJKDVQRW\HWEHHQUHVHDUFKHG7KH potential for corruption in stipend distribution is discussed in the next section.11 26. Survey results meanwhile point to a textbook distribution system that functions reasonably well to the school level, but with informal fees sometimes charged from parents (FMRP, 2006; CAMPE, 2005). Previous textbook surveys report some incidence of illegal textbook fees; the FMRP 2004 survey mentions that around 9 percent of class 5 students in GPSs said that they had to pay an average of BDT 10 to receive textbooks from their schools, while CAMPE (2005) estimates that 24 percent of primary students in GPSs paid an average of BDT 14 for the textbook. 10 Non-salary spending on stipends and textbooks in FY 2004-05 represented 78 percent and 15 percent of total non- salary spending. 11 According to the FMRP the distribution of textbooks to GPSs and RNGPSs was done well, and according to the rules. 13 Gaps in the Literature on Public Financial Management 7KH OLWHUDWXUH UHYLHZ GLG QRW ¿QG VHYHUDO DVSHFWV RI UHVHDUFK LQWR SXEOLF ¿QDQFLDO management, including: the planning process; school level budgeting and accounting for 6/,3 IXQGV DQG WKH GHWDLOV RI WKH ÀRZ RI IXQGV GHOD\V 7DEOH VXPPDUL]HV WKH JDSV SDUWLFXODUO\ RQ WKH SURFHVVHV WKHUH LV D QHHG WR VFUXWLQL]H ERWK WKH IRUPDO DQG DFWXDO SUDFWLFHV LQSODQQLQJEXGJHWLQJDQGEXGJHWH[HFXWLRQ7KHUHLVQRVWXG\WKDWH[WHQVLYHO\VFUXWLQL]HVWKH process of drafting plans and a review of either technical quality or process (such as stakeholder DQGSXEOLFFRQVXOWDWLRQVDQGWKHLQÀXHQFHRIGHYHORSPHQWSDUWQHUV DQGH[DPLQLQJWKHOLQNDJHV between the planning and budgeting process would also be useful to aid in the understanding of the relatively low budget allocation. Table-2.5: Gaps in the Literature on Public Financial Management Ministry Processes to Achieve Outcomes Outcomes and their Limitations - Plans formulated with adequate technical input and country ----------[Political Economy]---------- - Plans represent country needs Planning ownership - 3ODQVLQÀXHQFHEXGJHWV - Processes to align MoPME budgets to plans - Processes that determine the MoPME budget - Inadequate complementary Budgeting - Processes to determine within-budget inputs allocations for MoPME - Budget execution capacity of - Detailed information on MOPME, especially at the national spending, linked with Budget level performance Execution - Distribution systems for goods such - Stipend distribution to the stipends student level 28. Numerous factors that relate to budget execution capacity have not been studied, or are dated and deserve a fresh review. Issues such as capacity constraints, high staff turnover in ¿QDQFLDOPDQDJHPHQWDQGSURFXUHPHQWDQGWKHQXPHURXVSURFHVVHVIRUDSSURYDOZKLFKLPSHGH the PFM processes are not well covered. While there is some evidence, the effectiveness of the distribution systems for stipends especially under the new rules post 2010 should be re-examined. ,PSRUWDQWO\ D FOHDU GHVFULSWLRQ RI WKH RI¿FLDO DQG XQRI¿FLDO SURFHVV E\ ZKLFK VWLSHQGV DUH distributed would be useful. 29. An analysis of the political economy aspects of the governance issues could contribute substantially to understanding the effectiveness of PFM. In particular such an analysis should EHLQFOXGHGLQQHZUHVHDUFKLQWRWKHVORZÀRZRIIXQGVGHFLVLRQPDNLQJUHODWHGWRJRYHUQPHQW ¿QDQFHVDQGWKHSUHYDOHQFHRILQIRUPDOSD\PHQWVDVZHOODVWKHOLQNVEHWZHHQSODQVDQGEXGJHW DOORFDWLRQVDWWKHFHQWUDODQGGHFHQWUDOL]HGOHYHOV 14 The Literature on Human Resource Management 30. The literature on HRM covers a range of issues, including recruitment and promotion processes, training, and salary payments. The topics found in the literature are shown in Table-2.6. Issues related to absenteeism are dealt with in the next section on corruption. 31. In the past, a large number of vacancies in GPSs have been a problem in the sector (FMRP, 2006). According to the survey, the overall teacher vacancy rate in GPSs was 8 percent, while 28 percent of schools had at least one post vacant. Since then there has been a large recruitment GULYHWR¿OOWKHHVWLPDWHGYDFDQW*36WHDFKHUSRVWVLQ%DQJODGHVKDWWKDWWLPH12 It would be timely to review the success of that recruitment process and the prevalence of the vacant post issue currently. The vacant posts issue was not a problem for RNGPSs, where recruitment was ORFDOL]HGDWWKHOHYHORIWKHVFKRRO$SRWHQWLDOYDFDQWSRVWLVVXHWKHUHIRUHPD\HPHUJHIRUWKHVH schools under the new arrangements for RNGPS teachers who are being brought onto the same terms of service as the GPS teachers. Table-2.6: Summary of the Literature on Human Resource Management Ministry Processes to Achieve Outcomes Outcomes and their Limitations - The formal process of teacher recruitment - 7KHUHDUHDPRGHUDWHQXPEHURIXQ¿OOHGWHDFKHU includes checks and balances and is partly de- positions in primary schools (FMRP, 2006). concentrated (CAI, 2002) - Teachers are under-paid, relative to local labor - The salary payment system functions with some market (Asadullah, 2006) discrepancies but few delays (FMRP, 2006) - The education level of primary school teachers - Personnel registers and payroll information is quite high, especially in GPSs, though not in are manual, not updated and not available all districts (CAMPE, 2009) comprehensively (FMRP, 2006) - The vast majority of primary school teachers - The primary school teacher training system has have undergone training (World Bank, 2010b) the capacity to train the vast majority of teachers - Teacher knowledge of basic subjects is quite (CAMPE, 2005) low (FMRP, 2006) 32. The formal process for teacher recruitment includes numerous checks and balances (Creative Associates International, 2002). The recruitment process includes a departmental UHFUXLWPHQW WHVW DSSOLFDWLRQV WR WKH 'LVWULFW 3ULPDU\ (GXFDWLRQ 2I¿FHU D 7HDFKHU 5HFUXLWPHQW Examination leading to a list based on test results, an independent review of the test results GHOLQNHGIURPDSSOLFDQWQDPHVLQWHUYLHZVE\WKH'3(2DQGDSDQHOVHOHFWLRQDQG¿QDODSSURYDO by DPE.137KHSURFHVVSULRULWL]HVWKHVHOHFWLRQRIWHDFKHUVZKRDUHIURPWKHVDPHXSD]LODDVWKH 12 Anecdotal evidence suggests that the urban bias of teachers contributes to vacancy rates (World Bank, 2013). Once WHDFKHUVDUHDSSRLQWHGDWWKHXSD]LODWKH\VHHNDSSRLQWPHQWWRDWRZQVFKRRORUWRDVFKRROZKHUHWKHUHLVJRRGDFFHVV E\SXEOLFWUDQVSRUW7KLVLVSDUWLFXODUO\WUXHIRUIHPDOHWHDFKHUVZKR¿QGLWGLI¿FXOWWRJHWDFFRPPRGDWLRQLQWKHYLOODJH With the appointment of 60 percent female teachers, this problem is further aggravated (World Bank, 2013). 13 $W *36V WKH *RYHUQPHQW LQWURGXFHG UHIRUPV LQ WR HQVXUH WHDFKHU TXDOL¿FDWLRQV LQFOXGLQJ UHTXLUHPHQWV WKDW 75 percent of marks in the recruitment process are to be based on an anonymous test (which reduces the incidence of cheating, unless others are brought in to take the test), and 25 percent of marks are to be allocated for the viva (oral exam). The appointment of teachers to Registered Non-Governmental Schools, at both primary and secondary levels, IROORZVDGLIIHUHQWPRGDOLW\DQGLVGHFHQWUDOL]HGWRWKHVFKRROOHYHO&$, DOVRGHVFULEHVWKDWWKHSURFHVVIRU RNGPSs lacks clear guidelines. 15 school vacancy. A variety of policies have also been implemented to support female employment as primary school teachers. The lengthy and relatively expensive process that has been put in place VLQFH PD\LQSDUWH[SODLQWKHFKDOOHQJHRIDOVRKDYLQJVXI¿FLHQWÀH[LELOLW\LQWKHV\VWHPWR ¿OOYDFDQFLHVDVWKH\DULVH:KHWKHUWKHVHFKHFNVDQGEDODQFHVDUHIXOO\LPSOHPHQWHGKDVQRWEHHQ documented, there is anecdotal evidence that is discussed in the following corruption section. Meanwhile, the process for promotion of teachers to head teacher positions is not available in the public domain. A 2004 survey found that two-thirds of head teacher appointments were based primarily on seniority (CAMPE, 2005) and that this promotion is about the only opportunity available to primary school teachers (CAI, 2002) to advance. 33. Evidence suggests that the level of educational attainment of GPS teachers is quite high, although this is not true for all districts and does not necessarily lead to high quality teaching (CAMPE, 2009; World Bank, 2013b). According to an original analysis based on the annual school census (Table- 2.7), over 60 percent of GPS teachers have a bachelors or master’s degree, and over 50 percent of all primary school teachers have those degrees. Up until recently, WKH PLQLPXP UHTXLUHPHQW ZDV D VHFRQGDU\ VFKRRO FHUWL¿FDWH ZKLFK KDV LQFUHDVHG WR D KLJKHU VHFRQGDU\FHUWL¿FDWH$VGLVWULFWVGULYHWKHUHFUXLWPHQWSURFHVVDQGSULRULWL]HORFDOWHDFKHUVPDQ\ GLVWULFWVKDYHIDFHGGLI¿FXOWLHVLQPHHWLQJWKHHGXFDWLRQDOVWDQGDUGVPHDQLQJWKDWWKHRYHUDOOWUHQGV IRXQGKHUHGRQRWUHÀHFWWKHUHDOLW\LQDOOGLVWULFWV$GGLWLRQDOO\DFFRUGLQJWRVXUYH\HYLGHQFHWKH correlation between the general education levels of teachers with student performance is quite weak, therefore the high levels of teacher education may not matter for improving the overall education of students (World Bank, 2013b). This is supported by the evidence from FMRP (2006), which found that on questions on math, reading and non-verbal reasoning, teachers answered MXVWSHUFHQWRIWKHTXHVWLRQVFRUUHFWO\7KH&$03(¿QGVWKDWW\SLFDOO\WHDFKHUVLQ*36VDQG RNGPSs have not received pre-service professional training to equip them with using learning DLG PDWHULDOV DQG FRQGXFW FODVVURRP VHVVLRQV IXUWKHU DGGLQJ WR WKH ¿QGLQJ WKDW WHDFKHUV PD\ be educated but not trained how to teach. The World Bank (2010b) reports that while the Non- *RYHUQPHQW7HDFKHUV¶5HJLVWUDWLRQ &HUWL¿FDWLRQ$XWKRULW\ 175&$ KDGWHVWHGRYHU candidates since 2005, approximately one third received accreditation. Table-2.7: Various Characteristics of Primary School Teachers, Percent Secondary Higher Secondary Bachelors Masters GPS 12.29 27.20 37.63 22.88 RNGPS 36.69 44.00 17.20 2.12 Others 14.89 33.28 32.58 19.24 Total 17.21 32.31 32.35 18.12 Source: Authors’ calculations based on Annual School Census, 2011. 34. Evidence indicates that teachers are generally not well paid (Asadullah, 2006). Until WKHQDWLRQDOL]DWLRQRIWKH51*36LQWKHUHZDVDVXEVWDQWLDOGLIIHUHQWLDOEHWZHHQ*36DQG RNGPS salaries. GPS teachers received a mean monthly payment of BDT 5,843, and RNGPS teachers BDT 2,002 in 2004 (FMRP, 2006). The decision to place RNGPS teachers on the GPS pay scale should eliminate the differential. The most detailed analysis of whether teachers are 16 UHODWLYHO\XQGHUSDLGLVRYHUDGHFDGHROG$VDGXOODK DQDO\]HVWKH+RXVHKROG,QFRPHDQG Expenditure Survey data from 2000. The report concludes that primary school teachers are under paid, as they do not earn a salary equivalent to their local market value; this correlates with the ¿QGLQJVWKDWWKH\DUHUHODWLYHO\ZHOOHGXFDWHG7KHZRUVWRIIDFFRUGLQJWRWKHVWXG\ZHUH51*36 IHPDOH WHDFKHUV OLYLQJ LQ XUEDQ DUHDV$ TXDOLWDWLYH UHSRUW IURP &$03( FRQ¿UPV WKDW teachers generally take on additional employment due to low pay (including private tutorial work) and that this employment can interfere with their work as teachers, which could even lead them to appoint proxy teachers. 35. Government teachers are paid on time, but not necessarily in full (FMRP, 2006). Nine out of every ten GPS teachers received their salary on time, whereas the same is true for only one-quarter of RNGPS teachers. 30 percent of late payments to GPS teachers were delayed by four weeks or more. Given the recent absorption of RNGPS teachers into the GPS system, the problems experienced by these teachers are likely to diminish. Data suggest that the intended salary payments and the actual payments received have discrepancies. There was a difference of 12 percent and 21 percent for GPS and RNGPS teachers respectively, between UEO and school pay records. 36. The World Bank (2013b) observes there are weaknesses in the Monthly Pay Order – WKHJRYHUQPHQW¿QDQFLDOFRQWULEXWLRQWRWHDFKHUVZRUNLQJLQQRQJRYHUQPHQWVFKRROV The Monthly Pay Order (MPO) is a salary support provided by the government to teachers of a variety of non-government schools, including community schools, ebtedayee madrassas and formerly 51*36V 7KH 032UHFLSLHQW SULPDU\ WHDFKHUV UHFHLYH ORZHU VDODULHV DQG EHQH¿W DOORZDQFHV than their government counterparts. In order to be eligible for MPO support, non-government schools must meet several quality standards that relate to school facilities, management, student population and exam performance of the school. World Bank (2013) observes that these criteria are not always strictly followed, because political considerations and biased evaluation processes often direct government subvention to non-government schools. The report further highlights that the criteria required for MPO enlistment remain unfavorable to some of the most disadvantaged schools (e.g. schools in remote areas), despite these school having greater need for government subsidy. 37. The studies that cover access to training for GPS and RNGPS teachers, shows that access does not seem to be a problem but quality of training could be (Nilson, 2003; CAI, 2005; CAMPE, 2005; World Bank, 2013b). According to a CAMPE survey conducted from 2003 to 2004, teachers have good access to training opportunities. Over 80 percent of GPS primary school WHDFKHUV DQG SHUFHQW RI 51*6 KDYH FRPSOHWHG WKHLU &HUWL¿FDWH LQ (GXFDWLRQ 7KH SULPDU\ education sector has 54 teacher training institutes, which are guided by the National Academy for 3ULPDU\(GXFDWLRQ7KH$FDGHP\GHYHORSVWKHFXUULFXOXPIRUWKH&HUWL¿FDWHLQ(GXFDWLRQSURJUDP DQGWUDLQVWKHHGXFDWRUVLQWKHWUDLQLQJLQVWLWXWHVDQGWKH¿HOGRI¿FHUV&$, FODLPVWKDWLWLV DIDLUO\ZHDNRUJDQL]DWLRQEXWWKLVUHTXLUHVIXUWKHUUHYLHZJLYHQWKHDJHRIWKHUHSRUW7KHUHSRUW DOVRFLWHVKLJKYDFDQFLHVLQWHDFKHUWUDLQLQJLQVWLWXWHVDQGWKDWWKHWUDLQHUVODFNTXDOL¿FDWLRQVIRU proper training, but the evidence base for these statements is not presented. There are other training programs available, run by the Institute for Educational Development under BRAC University, as ZHOODVRWKHU1*2V DQGWKHJRYHUQPHQWUXQV8SD]LOD5HVRXUFH&HQWHUVLQHYHU\XSD]LOD)XUWKHU training opportunities are few; though there are 10 state-supported universities, only the Institute 17 of Education and Research at the University of Dhaka and the Open University of Bangladesh offer education science as a discipline. While MoPME had instituted an innovative in-service training, qualitative interviews suggested that the training had not met expectations (CAMPE, 2005). Improved teacher training in Bangladesh is suggested to be important for better learning outcomes (World Bank, 2013b; Nilsson, 2003). Gaps in the Literature on Human Resource Management 38. Further study of the issues of vacant posts and informal recruitment practices, as well as the quality of teacher training would be helpful. 7DEOHVXPPDUL]HVWKHVKRUWIDOOV in the literature. Within the human resource management processes, a comparison of the formal and informal processes involved would be particularly useful, as would the political economy around the different recruitment processes for the GPS and RNGPS and how the recent changes to RNGPS teacher terms of service are affected by these dynamics. There is a lot of anecdotal evidence14 that expresses concern about the recruitment and promotion procedures and whether they are subject to interference; which does not seem to have a solid evidence base and should be explored further. The survey work on vacancies is also out of date and a follow up study would be timely, as would an investigation into the geographical differences in vacancies and pupil to teacher ratios. In 2010, the average pupil teacher ratio was high but reasonable at 46.6 students per teacher in GPSs (BANBEIS, 2013). But if these schools are still operating a double shift system, as was common when the FMRP report was completed, these ratios could be much lower in terms of teacher to student ratios in any given class. In the training institutes it would be good to investigate the quality concerns found in the earlier reports. Table-2.8: Gaps in the Literature on Human Resource Management Ministry Processes to Achieve Outcomes Outcomes and their Limitations - Formal and actual HR Processes, 6WDI¿QJOHYHOVXI¿FLHQF\E\VFKRRORU such as recruitment area Economy Political - Teacher training processes and their -7HDFKHUVWDI¿QJLQUHPRWHDUHDV quality - Impact on teacher quality from training - Actual progression along salary scale - Teacher pay scale 39. Additional analyses are needed regarding the appropriateness of teacher pay and EHQH¿WVDQGWKHLPSDFWWKLVLVKDYLQJLQWKHFODVVURRPThe research based on the HIES 2000 FRXOGEHXSGDWHGXVLQJWKH+,(6GDWDWRFRPSDUHWHDFKHUSD\DQGEHQH¿WVUHODWLYHWRWKH local labor market. An analysis should examine the relationship between the shortfall in teacher salary relative to the local market and the quality of student performance in schools. Similarly, an analysis of the actual progression of pay increases over the career of a teacher would also be useful. 14 See World Bank, 2013b; CAMPE, 2005; CAI, 2002. 18 40. Various types of political economy studies analyzing the interests of actors in HRM topics would be useful. 7KHUROHRIWHDFKHUDVVRFLDWLRQVLQLQÀXHQFLQJSD\VHHPVFOHDUJLYHQWKH UHFHQWGHFLVLRQWRPDLQVWUHDP51*36WHDFKHUVEXWWKHVHG\QDPLFVKDYHQRWEHHQDQDO\]HGLQ the literature. Similarly, there are strong interests involved in the teacher recruitment, transfers, promotion, payment and stationing decisions, so research here would contribute greatly to understanding the present HRM systems. The Literature on Organizational Effectiveness 41. The impact of the distinct organization of the education sector, which splits responsibility across two ministries, is generally not studied in the literature. The Ministry of Primary and Mass Education (MoPME) is responsible for primary education (except for religious streams) and non-formal education; while the Ministry of Education (MoE) is responsible for secondary and higher education, technical and vocational education training and religious education streams. The two directorates, Directorate of Primary Education (DPE) under MoPME and Directorate of Secondary and Higher Education (DSHE) under MoE, are mainly responsible for the management, administration and delivery of public education services under their respective Ministries (Table-2.9). 7KHUDWLRQDOHIRUDVHSDUDWHPLQLVWU\IRUSULPDU\HGXFDWLRQ±ZKLFKZDV¿UVWHQDFWHGLQ ±ZDV SURPSWHG E\ WKH GHVLUH WR SODFH SROLWLFDO VLJQL¿FDQFH RQ WKH *R%¶V SULPDU\ HGXFDWLRQ JRDOV DV well as to increase accountability leading to better management of and focused attention on the substantial PEDP consortium funds under the SWAp (Thornton & Thornton, 2012). Three entities whose work relates to the primary education sector, BANBEIS, NCTB and MEB, are found under WKHMXULVGLFWLRQ0R(ZLWKQRUHSRUWLQJOLQHVWR0R30('HVSLWHWKHRUJDQL]DWLRQDOFRPSOH[LW\WKHUH is little research into the challenges or effectiveness of the arrangement (See Table-2.10). Table-2.9: Departments and Entities under MoPME and MoE Ministry of Primary & Mass Ministry of Education Education - Directorate of Primary Education - Directorate General of Secondary & Higher Education - Compulsory Primary Education - Bangladesh Bureau of Educational Information & Implementation Unit Statistics (BANBEIS) - National Curriculum & Textbook Board (NCTB) - National Academy for Primary - Madrassa Education Board (MEB) Education - Directorate of Technical Education - Bureau of Non-formal Education - University Grant Commission - National Academy for Education Management - Bangladesh Education Engineering Department - Directorate of Inspection & Audit Ministry of Education - Bangladesh National Commission of UNESCO - Madrassa Teacher’s Training Institute - Bangladesh Technical Education Board - 1RQ*RYHUQPHQW7HDFKHUV¶5HJLVWUDWLRQ &HUWL¿FDWLRQ Authority - National Academy for Computer Training & Research - Boards of Intermediate and Secondary Education 19 :RUOG %DQN LQGLFDWHG WKDW ODFN RI D XQLTXH VFKRRO LGHQWL¿HU DQG SRRU FR ordination between DPE and BANBEIS undermined monitoring and evaluation of the public education system. World Bank found the Monitoring and Evaluation (M&E) Division under the DPE and BANBEIS under MoE are both responsible for collecting, compiling and disseminating primary and secondary education data respectively. The lack of coordination and information sharing between the two was a major short-coming in the monitoring and evaluation process of WKHSXEOLFHGXFDWLRQV\VWHP$PDMRUIUXVWUDWLRQZDVWKHGLIIHUHQWVFKRROLGHQWL¿FDWLRQQXPEHULQJ systems used (World Bank, 2010b).15 Table-2.10: A Summary of the Literature on Organizational Effectiveness Ministry Processes to Achieve Outcomes Outcomes and their Limitations - MoPME and MoE are divided, meaning that BANBEIS does not report to MoPME (World Bank, 2010b) - SWAp shows success in unifying - The Sector-Wide Approach implementation under PEDP II DPs and MoPME, and increasing faced implementation challenges, such as lack of capacity and policy coherence (ADB, 2008) LQHI¿FLHQWGHFLVLRQPDNLQJ $'% $KPHG 43. Two assessments examine the implementation of the SWAp under PEDP II, describing successes such as increased coordination and policy coherence, and implementation challenges such as capacity and timely decision-making (ADB, 2008; Ahmed, 2011). The education sector SURJUDP 3('3,, ZDVWKH¿UVWWRFRRUGLQDWHGHYHORSPHQWSDUWQHUVXSSRUWWKURXJKD6HFWRU:LGH $SSURDFK 6:$S $ SURFHVV LQWHQGHG WR KDUPRQL]H SODQQLQJ DQG PDQDJHPHQW SURFHVVHV IRU JUHDWHUHI¿FLHQF\DQGLQFOXVLYHQHVVLQWKHV\VWHP$'% WKURXJKDWHFKQLFDODVVHVVPHQWDQG key informant interviews, observed that coordination among development partners was improved ZLWKWKH6:$S$KPHG DUJXHGWKDW3('3,,KDGOLPLWHGRSSRUWXQLW\WRKDUPRQL]HVXSSRUW DVLWH[FOXGHGLPSRUWDQWVHUYLFHSURYLGHUVZKRZHUHQHLWKHU*36VQRU51*36V7KHVWXG\¿QGV that implementation has been greatly hampered due to the intensive planning and budget execution DFWLYLWLHVUHTXLUHGZKLFKDUHEH\RQGWKHFDSDFLWLHVRIWKHJRYHUQPHQW,QDGGLWLRQWKHLOOGH¿QHG roles and responsibilities of the development partners had led to uncoordinated business procedures. Gaps in the Literature on Organizational Effectiveness 44. The literature on organizational effectiveness is generally thin, and the fragmentation of the numerous entities involved and the reporting lines should be further examined. Table 2.10 presents a summary of the gaps in research. The literature at times mentions several problems related to the lack of coordination between DPE and the agencies, such as the effective monitoring and evaluation of the sector, particularly as relates to BANBEIS.16 World Bank (2013b) observes there are also challenges regarding coordination in primary and secondary stipend programs, SXEOLF H[DPLQDWLRQV DQG DVVHVVPHQW SUDFWLFHV +RZHYHU ZH ¿QG D PRUH FRPSUHKHQVLYH DQG 15 MoPME (2013a) also mentions that the successful implementation of NPA II faces a critical challenge with BANBEIS outside its administrative control, but does not explain the institutional challenges in detail. 16 :RUOG%DQN EULHÀ\PHQWLRQVWKDWDQQXDOVXUYH\VXQGHU'3(H[FOXGH(EWHGD\HHPDGUDVVDVLQGLFDWLQJDZHDNQHVV in the Directorate’s ability to provide accurate and reliable information on the performance of the primary education sector. 20 compelling analysis is needed in identifying the challenges that arise from the fragmentation and the consequences for the sector outcomes. Table-2.11: Gaps in the Literature on Organizational Effectiveness Ministry Processes to Achieve Outcomes and their Outcomes Limitations Political Economy - Transition rates from primary - MoPME separation from MoE to secondary school - &HQWUDOL]HGGHFLVLRQPDNLQJLQ0R30(DQG - Effective monitoring of PRYHVWRZDUGJUHDWHUGHFHQWUDOL]DWLRQ school performance - 0RQLWRULQJDQGRYHUVLJKWE\XSD]LODDQGGLVWULFW - Greater autonomy at school RI¿FHV level and accountability to local decision makers 45. Furthermore the issue of decentralization in the sector is a large and predominantly unexplored topic that requires more analysis if the PEDP III goal for greater decentralization is to be implemented. %RWKWKH3('3,,DQG3('3,,,IRFXVRQGHFHQWUDOL]DWLRQDWXSD]LODDQG VFKRROOHYHOVEXWOLWWOHSURJUHVVKDVEHHQPDGHRQWKLVIURQW³'HFHQWUDOL]H´UHPDLQVDSRSXODU recommendation in the literature without a substantial body of evidence regarding the superior activities at the local level versus other levels (Haq and Islam, 2005; Chaudhury et al., 2006; World Bank, 2013b). Research should focus on the potential advantages and disadvantages of GHFHQWUDOL]DWLRQSRWHQWLDOPRGHOVDQGSROLWLFDOHFRQRP\DVSHFWV 21 3. Control of Corruption in the Primary Education Sector The Literature on Corruption and Control Measures 5HVHDUFKRQWKHFRQWURORIFRUUXSWLRQLVQRWRULRXVO\GLI¿FXOWEXWRYHUDGR]HQVWXGLHV in the primary education sector in Bangladesh have attempted to measure the incidence of corruption and/or analyze the systems to control it. The challenge in researching this topic stems from its illegal and covert nature. In this section, we describe the current state of the research on the systems to address corruption, including rules for public procurement, auditing, oversight IXQFWLRQVDQGWUDQVSDUHQF\7KHOLWHUDWXUHSULPDULO\IRFXVHVRQWKHWRSLFRI¿QDQFLDODQGIDFLOLW\ management at the local level, with some studies touching on absenteeism (or human resource management “corruption”). Table 3.1 provides a summary of this literature. Table-3.1: Summary of the Literature on Corruption & Control Measures Area Primary Control Measures Form of Corruption Procurement - - - National auditing faces - Schools charge a variety GLI¿FXOWLHVEXWZLWKUHFHQW of “illegal” fees (FMRP, reform efforts. 2006; TIB, 2010; Choe et Financial and - /RFDODXGLWLQJLVVXI¿FLHQWO\ al., 2011, Chowdhury et Facility Management frequent (FMRP, 2006) al., 2012) - Oversight visits of schools - 2I¿FLDOVPDNHVSHHG should be more frequent payments to get bills (CAMPE, 2005; FMRP, 2006) passed (FMRP, 2006) - 2YHUDOOXQDXWKRUL]HG teacher absenteeism is low (Chaudhury et al., 2004; FMRP, 2006) - The incidence of ghost - Oversight visits of schools Human Resource teachers is low (FMRP, should be more frequent Management 2006) (CAMPE, 2005; FMRP, 2006) - Teachers often make informal payments for WKHLU¿UVWSRVWLQJEXWQRW for salary payment (FMRP, 2006) Regulation - - 22 47. At the facility level, three surveys provide evidence that families pay illegal fees for textbooks or enrollment (FMRP, 2006; TIB, 2010; Choe et al., 2011). Previous surveys provide evidence of illegal textbooks payments by primary school students (CAMPE, 2005; FMRP, 2006). Also, TIB reported 15 percent of households faced some form of corruption or irregularities in UHFHLYLQJVHUYLFHVLQWKHHGXFDWLRQVHFWRUDQGWKHVDPHSURSRUWLRQUHSRUWHGPDNLQJXQDXWKRUL]HG payments for admission or textbooks (These fees are technically illegal given the Constitutional mandate that public primary education is free for all). Furthermore, Choe et al. (2011) provide evidence that poorer households and households with female students are more likely to make such fees. The survey results are backed by anecdotal evidence according to SIDA (2008), that parents are angry at having to pay additional contributions for education be it contributions for electricity, cleaning, sports day, social events and other less explicit costs, and that these parents suspect malpractice. However, it is unclear that these informal fees are corruption, in the sense that they may not be taken for personal gain, but might have been used for the overall good of the school. 48. Two reports based on facility surveys show a low level of absenteeism and unauthorized teacher absences (Chaudhuryet al., 2004; FMRP, 2006). According to FMRP only 2 percent of *36DQGSHUFHQWRI51*36LQSRVWWHDFKHUVZHUHDEVHQWZLWKRXWDXWKRUL]DWLRQRQWKHGD\RIWKH survey. Sixteen percent and 11 percent of teachers were absent in GPS and RNGPS respectively. In an investigation of a sample of 100 government and government-aided primary schools, and based on unannounced visits, Chaudhury et al. found that 15.3 percent of teachers were absent, ZLWKSHUFHQWEHLQJXQDXWKRUL]HG:KLOHXQDXWKRUL]HGDEVHQWHHLVPLVQRWDFRQFHUQDXWKRUL]HG absences seem to be quite high, especially given the concerns noted in the literature in the previous section that classroom contact hours are low in Bangladesh. While the contributing factors for absenteeism are unclear, according to anecdotes from case studies (SIDA, 2008 and 2010), most students’ families observed that teacher absenteeism was due to poor supervision, especially in remote areas, and an absence of formal systems of complaints coupled with a fear of reprisals. CAI SURYLGHVDEULHIGHVFULSWLRQRIWKHRI¿FLDOUHVSRQVLELOLW\RIWKHKHDGWHDFKHUWRUHFRUGDQG report teacher absenteeism, as well as other oversight mechanisms that are not being enforced in schools, meaning that no penalty was implemented for absenteeism; they also partially blame the liberal leave regulations provided to teachers. 49. Ghost teachers–meaning teachers who are paid but no longer work at a school–do not represent a major concern, though corruption in teacher transfers does (FMRP, 2006). 7KH)053UHVHDUFKWHDPFRPSDUHGWKHOLVWRIVDODULHGWHDFKHUVDWWKH8(2RI¿FHZLWKWKRVHLQ SRVWIRUDODUJHVDPSOH¿QGLQJORZOHYHOVRIGLVFUHSDQF\ GLIIHUHQFHVDURVHDVDUHVXOWRISHUFHQW which had been transferred, 1 percent were on leave prepared for retirement and 1 percent no longer worked at the school. The survey found the vast majority of GPS teachers had transferred between schools at some point, and many of them paid bribes to execute the transfers. According to the survey transferring schools was far more common place for GPS teachers (81 percent of *36WHDFKHUVKDYHPRYHGEHWZHHQVFKRROV SHUFHQWRI¿FLDOO\WUDQVIHUUHG WKDQ51*36 RQO\ 22 percent moved schools) or AEM teachers (only 33 percent moved schools). Even though the majority of teachers are allowed to partake in the transfer decision, and it was the teacher who initiated the request for transfers in two-thirds of the cases, the survey shows that only 55 percent believe the transfer procedures to be fair, and 16 percent of those transferred admitted to paying speed payments of an average of BDT 7,000 to get these transfers. 23 50. Audits by the Comptroller and Auditor General observe that inconsistencies were IRXQG LQ WKH IRUHLJQ DLG¿QDQFHG H[SHQGLWXUHV EXW WKH 0LQLVWU\ KDV WDNHQ VWHSV WR DGGUHVV this challenge (MoPME, 2011). Though Foreign Aided Project Audit Directorate auditors have EHHQDVVLJQHGWRDXGLWSD\UROOVDVSHULQWHUQDWLRQDOVWDQGDUGVDUHFHQW¿GXFLDU\UHYLHZQRQHWKHOHVV HPSKDVL]HVWKDWKLJKULVNVUHPDLQIRUWKH0LQLVWU\LQWKLVDUHD $4DVHP &RPSDQ\ $ major problem with the external audit system is that reports are often incomplete and submitted quite late to Parliament, with huge backlogs of work. MoPME provides a response to issues raised in these external audits, though responding improvements are not documented. 51. At the local level, an FMRP survey indicates that auditing visits are generally FRQGXFWHGZLWKVXI¿FLHQWIUHTXHQF\ )053 )053UHSRUWVWKDWPRVW8(2RI¿FHVEXW YHU\IHZ'3(2RI¿FHVZHUHDXGLWHGIRUWKHLUUHYHQXHEXGJHWZKLOHPRVW8(2DQG'3(2RI¿FHV ZHUHDXGLWHGIRUWKHLUGHYHORSPHQWEXGJHWVIURP1LQHW\¿YHSHUFHQWRIDOO8(2RI¿FHV were audited for the revenue budget, with 3 percent having never received audit visits in the last \HDUV'3(2RI¿FHVKDYHKDGOHVVIUHTXHQWDXGLWYLVLWVZLWKRQHLQ¿YHEHLQJDXGLWHGIURP 2003-05, and 16 percent not having had any in the last 10 years. Development budgets are audited PRUHIUHTXHQWO\ZLWK SHUFHQWRIDOO'3(2RI¿FHVDQG SHUFHQWRI8(2RI¿FHVKDYLQJEHHQ audited in the last three years. ,QWHUPVRIRYHUVLJKWRISULPDU\VFKRROVVXUYH\HYLGHQFHLVFRQÀLFWLQJDVWRZKHWKHU AUEOs and UEOs visit schools frequently enough (FMRP, 2006; CAMPE, 2005). According to FMRP, GPSs and RNGPSs were visited on average approximately three times a year by an $VVLVWDQW8SD]LOD(GXFDWLRQ2I¿FHU $8(2 DQGRQFHD\HDUE\DQ8SD]LOD(GXFDWLRQ2I¿FHU 8(2 ZKLFKLVOHVVWKDQWKHRI¿FLDOVWDQGDUGVRI¿YHWLPHVSHU\HDU&$03(¿QGVGRXEOHWKH number of visits by oversight agents than the FMRP report (i.e. that AUEOs visit GPSs six times SHU\HDUDQG51*36V¿YHWLPHVRQDYHUDJH 17 17 The report further reports that AUEOs tend to visit nearby schools with much greater frequency, which, the report also DUJXHVPD\LQÀXHQFHWKHLUQXPEHURIVFKRODUVKLSZLQQHUV 24 Gaps in the Literature on the Control of Corruption Table-3.2: Gaps in the Literature on Corruption & Control Measures Area Primary Control Measures Form of Corruption - Corruption in procurement at Procurement - The procurement process national and local level Financial and - Content in auditing and oversight visits at the local level - Corruption in textbook and stipend facility distribution to students Political Economy management - Transparency at local level - Actual processes are meritocratic, - Favoritism in hiring, appointments, Human in recruitment, transfers, and transfers and promotions decisions Resource promotions Management - Integrity of the salary payment - Transparency of HR system - Accountability of government staff overseeing regulation of the private providers - Corruption in the regulation of Regulation private providers - Transparency in government regulation of the private sector 7KURXJKDQRYHUYLHZRIWKHOLWHUDWXUHRQFRQWURORIFRUUXSWLRQZHKDYHLGHQWL¿HGD number of areas for further research, many of which would provide a more robust evidence base to what is at present anecdotal evidence. Table-3.2 highlights that research should follow XSRQWKHVHWRSLFVHVSHFLDOO\LQWKHDUHDVRISURFXUHPHQWDQGUHJXODWLRQ2YHUDGR]HQVWXGLHV on the topic present anecdotal evidence, or make unsubstantiated claims, both of which require further research and therefore appear as gaps in the literature. Moreover, the research on processes VKRXOGIRFXVQRWMXVWRQWKHRI¿FLDOSURFHVVHVWRFRQWUROFRUUXSWLRQEXWVHHNWRFDSWXUHWKHDFWXDO practices involved. Finally, assessments of the transparency of the primary education sector are UHTXLUHGLQFOXGLQJWKHVWXG\RIKRZWRFRPPXQLFDWHFULWLFDOLQIRUPDWLRQWRFLWL]HQV 54. Focus groups discussions with local schools authorities bolster the view that the Local Government Engineering Department, which is largely responsible for the procurement of civil works for GPSs, suffers from resource mismanagement and poor work quality, topics that require more systematic analysis (CAMPE, 2005). :RUOG %DQN EULHÀ\ describes the system of procurement, observing that procurement of civil works is under the Local Government Engineering Department,18 and procurement of textbooks under the National Curriculum and Textbook Board. Also, while very limited funds are controlled at the school level, some procurement takes place, particularly via the SLIP funds; the integrity of these purchases is QRWVFUXWLQL]HG2YHUDOOSURFXUHPHQWV\VWHPVKDYHQRWEHHQDPDMRUWRSLFRIVWXG\IRU0R30( as such, it represents a gap in the literature on the governance of the sector. 18 These claims are further supported by a recent TIB survey that reports corruption, misuse of public resources and logistics and irregularities in KXPDQUHVRXUFHPDQDJHPHQWSURMHFWIRUPXODWLRQ¿QDQFLDODXGLWDQGRWKHUVLQ/*(' (TIB, 2013). 25 55. As for corruption at the facility level, anecdotal evidence from four studies suggests that a misallocation of stipends may be partly due to corruption in the awarding process (Mahmud, 2003; Tietjen, 2003; Hossain and Osman, 2007; SIDA, 2007). Survey evidence shows that the distribution of stipends is not pro-poor. Several studies (Mahmud, 2003; Tietjen, 2003; Hossain and Osman, 2007; SIDA, 2007) comment on the lack of transparency in stipend GLVWULEXWLRQDQGDUJXHWKDWWKHSURJUDPKDVEHHQLQÀXHQFHGE\SROLWLFLDQV+RVVDLQ VXJJHVWV that the extent to which parents and students are complicit in these practices that undermine program goals should be examined further. Based on anecdotal evidence, FMRP (2006) states that both the practice of registering ‘ghost’ students who do not actually attend school, and that of false FHUWL¿FDWLRQRIVWXGHQWHOLJLELOLW\IRUUHFHLYLQJWKHVWLSHQGVPD\DOVRUHSUHVHQWDSUREOHP$QRWKHU possible scenario based on anecdote is where school authorities and private bank staff conspire to require a student to make informal payments to receive an allocated stipend (Tietjen, 2003). Beyond these anecdotes, increased evidence is needed regarding the potential for corruption in the process, such as survey work on perceptions. Also, anecdotal evidence in SIDA suggests that hefty sums of money are sometimes paid as bribes to secure membership to the SMC. As an SMC PHPEHULWFDQEHHDV\WRGLVWRUWWKHVWLSHQGOLVWVDQGIDYRUIDPLOLHVDQGRULQÀXHQWLDOSHUVRQVRU WDNHEULEHVIRUSXWWLQJGRZQQDPHVRQWKHOLVW9DFDQWVSDFHVRQWKHVWLSHQGOLVWDUHQRW¿OOHGDQG the money is given through ‘ghost students’ and false names. It is not clear how valid these claims are, nor how prevalent. 56. Further study is needed regarding anecdotes that teachers seek extra fees for private tuition in an illegitimate manner, or that exam papers are sold. One potential method is where WKH\SXUSRVHO\PDGHKRPHZRUNGLI¿FXOWWRXQGHUVWDQGDQGSXQLVKHGFKLOGUHQZKRGLGQRWKDYH tutors so that their parents felt pressured to pay for private tuition (SIDA, 2008). Similarly, poorly performing students and their parents also reported that they do not get their exam papers back DQGGRQRWXQGHUVWDQGZK\WKH\IDLOHG$QRWKHUVWXG\DVVHUWVWKDW¿QDOH[DPLQDWLRQRUHQWUDQFH examination papers may be sold in advance to high-paying candidates or to favor particular students (Choe et al., 2011). 57. In human resource management, a study asserts that there is corruption in the recruitment of teachers in GPSs and in RNGPSs. Despite the perception that corruption in the system of recruiting teachers is systemic, Hossain and Osman (2007) observe, based on discussions ZLWKRI¿FLDOVDQGWHDFKHUVWKDWLWLVDOHVVFRPPRQSUREOHPLQWKHJRYHUQPHQWVFKRROVFRPSDUHGWR non-government schools. At GPSs, the government introduced reforms in 1997 to make the process more independent and robust. This means that bribes to the viva board do not guarantee a post, as WKH ¿QDO GHFLVLRQ GHSHQGV RQ WKH FRPELQHG VFRUH IURP WHVWV DQG LQWHUYLHZV +RZHYHU DPRQJVW RNGPSs, there are reports of SMC members “controlling” the recruitment process and accepting payment in exchange for posts in both primary and secondary schools (Hossain & Osman, 2007). $QRWKHUVWXG\FODLPVWKDWVFKRRORYHUVLJKWE\0R30(RI¿FLDOVLVRIWHQZHDNZKLOH the content of local audits has not been researched (CAI, 2004). &$, DVVHUWVWKDW RI¿FLDOV provide cookie cutter recommendations during school visits and maintain little contact with the community. Further analysis of the content of local oversight visits, and the precise focus of 0R30(RI¿FLDOVLQVFKRROVLVQHHGHGWRGHWHUPLQHZKHWKHUDQGKRZVXFKDFWLYLWLHVPD\EHPRUH effective. As for auditing, FMRP (2006) states that one of the limitations of the survey was not being able to determine the quality of the audit, but just the frequency, an area of further research. 26 59. No study has scrutinized corruption in the regulatory control of the variety of non- government schools, including NGO schools, private schools and madrassas, while research on RNGPS is limited. :KLOHWKHUHLVFRQÀLFWLQJHYLGHQFHDVWRKRZRIWHQ$8(2VDQG8(2VYLVLW RNGPS, there is no information on their focus during these visits. Precisely what their activities were, what documents they observed, who they spoke with and what activities followed are not GHWDLOHG0RUHRYHUWKHRYHUVLJKWRIWKHRWKHUQRQJRYHUQPHQWVFKRROVKDVQRWEHHQDQDO\]HG 60. The level of transparency of MoPME whether on its website, through documentation, or at the facility level, is not a common topic of analysis. Transparency is a cross-cutting issue that is relevant to each of corruption. Transparency at the facility level is not discussed in the literature, except, as mentioned above, transparency of stipends. At the national level, and mainly via an analysis of websites, World Bank (2011) examines six dimensions of transparency: annual EXGJHWGRFXPHQWDWLRQLQ\HDUEXGJHWH[HFXWLRQUHSRUWV\HDUHQG¿QDQFLDOVWDWHPHQWVH[WHUQDO audit reports, contract awards and resources available to primary service units. It makes the following observations19: x Aggregate MOPME budgets are available, but very limited access to detailed budgets x No transparency of in-year budget execution reports x $JJUHJDWH0230(\HDUHQG¿QDQFLDOVWDWHPHQWVDUHDYDLODEOHEXWGHWDLOHGVWDWHPHQWVDUH not x Various audits are not transparent x Extensive contract awards information not transparent x /DFNRIWUDQVSDUHQF\RIVFKRROOHYHO¿QDQFHV $WWKHVDPHWLPHDUHFHQWO\FRQGXFWHGVXUYH\E\1LHOVHQ VKRZVWKDWZKHQFLWL]HQVZHUH asked which types of information would be most useful in solving problems with the RTI Act, 7.8 SHUFHQWLGHQWL¿HGLQIRUPDWLRQRQHGXFDWLRQVHUYLFHVDVRQHRIWKHPRVWFRPPRQDQVZHUV0XFK more analysis is required regarding transparency of the numerous potential and actual areas of corruption mentioned above, and further initiatives in this regard. 61. Another cross-cutting topic that has not been studied is the legal system in cases of FRUUXSWLRQLHZKDWKDSSHQVZKHQDQRI¿FLDOKDVEHHQDFFXVHGRIFRUUXSWLRQLQYLRODWLRQRI the law. The Ministry is primarily charged with conducting the disciplinary proceedings; our team GLGQRW¿QGDQ\GRFXPHQWDWLRQRQWKLVWRSLF0HDQZKLOHWKHPDLQJRYHUQPHQWERG\UHVSRQVLEOHIRU effective, fair and speedy disciplinary proceedings against civil servants is the Bangladesh Public Service Commission. It does not execute disciplinary measures, but rather makes recommendations WRWKHUHOHYDQW0LQLVWU\RUJRYHUQPHQWERG\7KH3XEOLF6HUYLFH&RPPLVVLRQKDVEHHQFULWLFL]HG for its low level of independence and slow handing of many disciplinary measures (IGS, 2008). It is unclear whether this system provides an adequate disincentive for corruption among civil servants working in the primary education sector. 19 With the incorporation of PEDP 3 all these are made available, but limited to the 9 Development Partners who regularly assess these reports and give concurrence on their accuracy. 27 62. Furthermore, this literature provides almost no political economy analysis of the interests involved. Numerous topics are missing such as the interests involved in mis- procurement, a full understanding of the illegal fees that are sometimes applied in facilities, DPRQJVWRWKHUV7KLVOLWHUDWXUHGRHVQRWDQDO\]HKRZWKHVHLQWHUHVWVZRXOGSUHYHQWWKHSURSHU application of control of corruption measures. For instance, the full application of audits may EHGLI¿FXOWGXHWRSUHVVXUHVIURPWRSRI¿FLDOVZKRZDQWWRDYRLGH[SRVLQJDQ\HPEDUUDVVLQJ LQVWDQFHVRIIUDXG*RYHUQPHQWRI¿FLDOVPD\UHVLVWWUDQVSDUHQF\PHDVXUHVGXHWRWKHSRWHQWLDO accountability that would result. Proper government oversight of teachers is similarly an important determinant of absenteeism, but there is no analysis of why the current oversight system has broken down, and whether there is complicity in the absenteeism. 28 4. Voice and Accountability in the Primary Education Sector 63. Bangladesh has numerous experiences with voice and accountability initiatives in the primary education sector. The limited research on the topic has provided some important lessons, with many gaps remaining. The Literature on Voice and Accountability Table-4.1: Summary of Voice and Accountability in the Literature National Local Level Outcomes Level - Various local participatory bodies function relatively poorly o SMCs active, but with unclear role and little community 2I¿FLDO3URFHVVHV awareness (FMRP 2007; SIDA, for - 2008; CAMPE, 2009 & 2005; - Citizen World Bank, 2010) Participation o PTAs not active (CAMPE, 2005; FMRP, 2007, World Bank, 2010b) o UECs not active (CAMPE, 2005; FMRP, 2007) Participation Outside Gov’t - - - XQRI¿FLDO 64. The literature on voice and accountability in the primary education sector focuses primarily on these issues at the level of the school. Table-4.1 shows that the main subjects that are studied include School Management Committees (SMCs), as well as Parent Teacher $VVRFLDWLRQV 37$V DQG 8SD]LOD (GXFDWLRQ &RPPLWWHHV 8(&V HVSHFLDOO\ WKHLU OHYHO RI activity. Five studies present a variety of evidence regarding the composition and activities of SMCs (FMRP 2007; SIDA, 2008; CAMPE, 2009 & 2005; World Bank, 2010). There is a limited but growing literature on SMCs showing they are quite active, though with numerous challenges. SMCs are school-based decision making bodies responsible for school stipend distribution, the planning and execution of SLIP funds and general oversight of the school, among others; they are made up of eleven members, including the head teacher, local school patrons, parents, an MP appointee and others. Based on a survey in 2008, CAMPE (2009) provides an analysis of the membership of SMCs in various primary schools, including RNGPSs and madrassas showing that the participation of women is low, the majority of members have a secondary 29 school degree and SMCs hold meetings just over eight times per year on average. Through a review of meeting minutes, the study further revealed that the most commonly discussed topics in these meetings, are examinations and student absenteeism. CAMPE (2005) also notes that there is little awareness of the role and activities of SMCs among its members and the community at large, based on focus group discussions. Based on a qualitative study, FMRP (2007) observes that the performance of SMCs is quite varied, leading to differing effects on the quality of schooling. 65. Parent Teacher Associations and Upazila Education Committees are not very active at the local level (CAMPE, 2005; FMRP, 2007). There is a government requirement for all government schools and colleges to establish Parent Teacher Associations (PTAs). They should include approximately nine members, and are responsible for establishing school accountability and for involving parents in school management, among others. However, several studies, with survey evidence, observe that PTAs rarely meet (CAMPE, 2005; FMRP, 2007; World Bank, 2010b); FMRP (2007) and CAMPE (2005), based on a series of case studies, observe that there LVOLWWOHRYHUDOOLQYROYHPHQWRISDUHQWVLQVFKRROPDWWHUVZLWKDOPRVWQRLQIRUPDWLRQÀRZLQJWR SDUHQWV0HDQZKLOH&$03(VKRZVWKDWWKH8SD]LOD(GXFDWLRQ&RPPLWWHHJHQHUDOO\RQO\H[LVWV on paper, with meetings never taking place. Gaps in the Literature on Voice and Accountability Table-4.2: Gaps in the Literature on Voice and Accountability National Level Local Level Outcomes 2I¿FLDO3URFHVVHV - Other local for - Public participatory bodies Economy consultation on - Outcomes Political Citizen o SLIP plans or budgets Participation o ROSC Participation - Media - Media Outside Gov’t - /RFDO&62FLWL]HQ - Outcomes XQRI¿FLDO - CSO oversight oversight 66. The literature on voice and accountability requires much more research on a variety of topics. Table-4.2 shows that studies are lacking in voice and accountability at the national level, LQXQRI¿FLDOFKDQQHOVDWWKHORFDOOHYHODQGLQWKHRXWFRPHVRIVXFKSDUWLFLSDWLRQ 67. The literature only marginally covers voice and accountability mechanisms at the national level. Hossain and Osman (2007) only observe the role of Education Watch in critiquing the performance of the sector, as well as providing evidence and independent analysis. There is no mention of national level consultations in the literature, within either the primary education sector planning or the budget process. Moreover, the role of the media in overseeing the education sector is not a topic of research. 30 68. While there are small initiatives for local level planning and budgeting, most have not been examined. 6FKRRO /HYHO ,PSURYHPHQW 3ODQV UHSUHVHQW RQH VXFK LQLWLDWLYH WR ¿QDQFH SODQVFUHDWHGE\WKH60&DQGWKHODUJHUFRPPXQLW\,*6 D EULHÀ\GHVFULEHVUHVHDUFKRQ School Level Implementation Plan (SLIP) implementation, claiming that there have been some small contributions but great challenges remain such as disbursement of funds, capacity building and control of corruption. The Reaching Out of School Children program empowered the school FRPPLWWHHVZLWKVXEVWDQWLDOUHVSRQVLELOLWLHVDVZHOOZKLFKKDVQRWEHHQDQDO\]HGLQWKHOLWHUDWXUH 7KHXQRI¿FLDOPHFKDQLVPVRIYRLFHDQGDFFRXQWDELOLW\LQWKHSULPDU\HGXFDWLRQVHFWRU including local media and social accountability tools such as citizen report cards, also have not been studied. 6XFKVRFLDODFFRXQWDELOLW\WRROVKDYHEHHQXWLOL]HGE\WKH$I¿OLDWHG1HWZRUN for Social Accountability and Manusher Jonno Foundation, amongst others (World Bank, 2013b). 0RUHRYHU DV RXWOLQHG LQ +RVVDLQ FLWL]HQV PD\ FKRRVH WR HQJDJH LQ LQIRUPDO PHDQV RI accountability, i.e. ‘rude accountability’, whereby social pressures and bad reputation may provide teachers and SMC members with incentives toward good performance. 70. Additionally, this literature has not attempted to measure the outcomes of the various voice and accountability efforts. 5HVXOWVRIYRLFHDQGDFFRXQWDELOLW\PHFKDQLVPVDUHGLI¿FXOW WRGH¿QHDVDPXOWLWXGHRISRWHQWLDORXWFRPHVDUHSRVVLEOHVXFKDVLPSURYHGHI¿FLHQF\UHGXFHG leakages, better targeting of resources, increased communication of public needs, and greater FLWL]HQVDWLVIDFWLRQDPRQJVWRWKHUV7KHEHVWDYDLODEOHLVWKHIRFXVJURXSVXQGHU)053 ZKLFKFRQFOXGHVWKDWWKHUHLVOLWWOHWRQRLQIRUPDWLRQÀRZEHWZHHQSDUHQWVDQGVFKRROVVXJJHVWLQJ that local governance bodies are failing to promote parent participation. 71. Further political economy research is needed to better understand voice and accountability, especially given the prevalence of anecdotal evidence alluding to politicization of SMCs. CAMPE (2005), based on focus group discussions, observes that the greatest complaint DERXW60&VLVWKHLQÀXHQFHRIWKH03DQGKHDGWHDFKHULQWKH60&PHPEHUVHOHFWLRQSURFHVV )053 DUJXHV WKDW WKH SROLWLFL]DWLRQ RI 60&V PD\ EH HLWKHU GHVWUXFWLYH RU SURGXFWLYH for school outcomes, based on case studies of six primary schools. The productive outcome can arise if greater resources are available for schools with connections with politicians who make these resources available. Interests such as these may also explain the lackluster level of activity in other local participatory bodies. Also, such dynamics may also be equally relevant to social accountability initiatives, or even participation at the national level. 31 Table-5.2: Student Performance of GPS and RNGPS in 2012 (Average Scores Attained) Bangla Math Bangla Math Grade 3 Grade 5 Government Primary Schools 70 52 28 35 Registered Non-Government Primary 59 45 14 25 Schools Source: World Bank, 2013b. Gaps in the Literature on Regulatory Quality 74. The governance topic of regulation is the least well researched of the WGI categories. This is highlighted in Table-5.3. There is little documentation in the public domain on the UHODWLRQVKLSEHWZHHQ0R30(DQGWKHSULYDWH IRUSUR¿WDQGQRQIRUSUR¿WDQGUHOLJLRXV VFKRROV or the primary schools attached to secondary (or High Schools). Given the goal of the Ministry WR SURYLGH D TXDOLW\ RI HGXFDWLRQ WR DOO DQG WKH FLWL]HQV¶ HQWLWOHPHQWV LQ WKH &RQVWLWXWLRQ WKH regulatory oversight of nearly half of the service providers is a large gap in the literature. A review RIWKHUXOHVDQGUHTXLUHPHQWVIRUHVWDEOLVKLQJDVFKRROUHFHLYLQJJRYHUQPHQW¿QDQFLDOVXSSRUW charging fees, maintaining accounts and delivering above a certain standard is a logical place to start. Table-5.3: Gaps in the Literature on Regulatory Quality Ministry Processes to Achieve Outcomes Regulatory Outcomes And their Limitations - Quality of Government oversight of private - Consistent and systematic Economy Political providers measures of the quality of - Effectiveness of Government support for private education amongst all private providers providers 75. The lack of systematic data collection on student performance among all the non- government schools frustrates quantitative analysis on performance by type of school. The DPE conducted a series of national primary education survey in 2006, 2008 and 2011. According to DPE (2012), the designs of student performance surveys in 2006 and 2008 did not allow comparison across grades or over time; however the National Student Assessment 2011 was conducted so that performance could be monitored with future reports. The National Student Assessment 2011 survey however includes students from Grade 3 and Grade 5 of GPS and RNGPS only, excluding students from the variety of other non-government schools. Without consistent and comparable data, it is GLI¿FXOWWRGHWHUPLQHZKLFKW\SHVRIVFKRROVGRZHOODQGWRLQYHVWLJDWHZK\E\FRUUHODWLQJRWKHU IDFWRUV VXFK DV WKH TXDOLW\ RI WKH WHDFKHUV RU WKH DYHUDJH FODVVURRP VL]H 6XFK GDWD VKRXOG EH gathered consistently among all schools and made public to enable further research. 33 76. There are a number of important issues of regulatory policy that should be informed by further research. Internationally, governments often intervene to improve the quality of education in primary schools in several areas: 1. Setting teacher recruitment standards, including their education level, experience, or even the process of recruitment; 2. Ensuring the adoption of a national curriculum, including providing the materials used, the courses offered, the content of the course, etc.; 3. Setting standards for teaching methods, such as the use of materials, engagement with students; and 4. Establishing minimum requirements for opening new schools, such as the FRQGLWLRQRIWKHIDFLOLW\ODQGDQG¿QDQFHV 8QGHUVWDQGLQJ WKH H[WHQW RI ¿QDQFLDO RYHUVLJKW RI WKH UHVRXUFHV WKDW DUH XVHG LQ QRQ *36V ZRXOG DOVR EH DQ DUHD IRU LQYHVWLJDWLRQ LQWR WKH HI¿FLHQF\ DQG HTXLW\ RI WKHVH expenditures. 7KHPDLQDUHDVRIJRYHUQPHQW¿QDQFLDOFRQWULEXWLRQWRQRQJRYHUQPHQWVFKRROV include the payment of teacher salaries and the provision of stipends and textbooks. 78. Overall, there is scant literature on the effectiveness of Government regulation of the curriculum and teaching methods in non-government schools; no literature discusses the requirements Government places for opening a new school. The vast majority of primary schools DUHUHTXLUHGWRXVHWKHIUHH*RYHUQPHQWWH[WERRNVEXWWKHOLWHUDWXUHKDVQRWVFUXWLQL]HGZKHWKHU this ensures that a quality curriculum is followed in primary schools. The Government has tried WREULQJUHIRUPWRPDGUDVVDHGXFDWLRQRIIHULQJUHJLVWUDWLRQDGPLQLVWUDWLRQDQGJUHDWHU¿QDQFLDO incentives on the condition that they teach the same secular subjects as taught in government schools, but their level of success is not documented. Students of Aliya madrassa will also begin WRWDNHWKH6KRPDSRQLWHUPLQDOH[DPDWWKHHQGRIFODVV¿YHVLPLODUWRVWXGHQWVRI1*2VFKRROV (Sommers, 2012). There is similarly no literature on government oversight of teaching methods. Greater study of the regulation of curriculum, the quality of teaching and teaching methods in non-Government schools is necessary to understand whether current government initiatives are successful. 79. Government scrutiny of teacher recruitment in RNGPSs also merits further research. Although the SMCs in the RNGPSs have the responsibility of recruiting teachers, they still require WKHDSSURYDODQGSDUWLFLSDWLRQRIWKH8SD]LOD(GXFDWLRQ2I¿FH7KHUHIRUHWKH*RYHUQPHQWFRXOG voice objections in teacher selection at RNGP schools (Sommers, 2012); the extent to which this contributes to ensuring the selection of quality teachers has not been studied. 80. Available literature does not offer an analysis of the political economy of government regulation of non-government primary schools. 3URPLQHQWJURXSVVXFKDV+HID]DW DPDGUDVVD RUJDQL]DWLRQ DQG WHDFKHU DVVRFLDWLRQV LQ 51*36V VHHN WR LQÀXHQFH JRYHUQPHQW SROLF\ EXW this has not been a topic of substantial research to date. The regulation of madrassa education, and politics of that regulation, is similarly a topic requiring much more analysis. Singh (2006) mentions that madrassas are often related to religiously related parties, such as Islami Oikya Jote and Jamaat-e-Islami. As a result, regulation in this area could prove to be politically sensitive and require careful consideration. 34 6. Conclusion 81. The systematic review not only summarizes the literature to date, but also lays the foundation for research that is needed to inform efforts to improve service delivery in the primary education sector.'HVSLWHWKHFRQVLGHUDEOH¿QDQFLDOUHVRXUFHVLQYHVWHGLQWKHVHFWRUE\ the government and development partners, there are relatively few systematic and empirically rigorous studies on governance challenges, even though this is a well-known concern affecting performance in Bangladesh. 6HYHUDO LQWHUHVWLQJ ¿QGLQJV RQ WKH OLWHUDWXUH HPHUJH UHJDUGLQJ WKH JRYHUQDQFH RI primary education in Bangladesh: x First, according to annual school census data from 2011, primary school teachers overall have a high level of educational attainment, particularly in GPS but not in 51*367KLVDOVRGRHVQRWDSSO\WRDOOGLVWULFWVPDQ\RIZKLFKKDYHGLI¿FXOW\¿QGLQJ TXDOL¿HGWHDFKHUV$WWKHVDPHWLPHSULPDU\VFKRROWHDFKHUVDUHXQGHUSDLGUHODWLYH to the local labor market. The level of education for teachers is not correlated to student performance, suggesting that the challenge to attaining quality education lays elsewhere. x Second, despite the relatively small portion of the government budget devoted to primary education, Bangladesh has made great progress in the sector, particularly as relates to the gross primary enrollment rate and gender parity. This counter-intuitive outcome raises questions as to what Bangladesh is doing right, including the contribution from non-government primary schools and innovative approaches such as the Reaching Out of School Children program. x Third, there are concerns as to the degree to which primary education spending is pro-poor. Measures of the distribution of school stipends (which are again dated) suggest that they are not focused on the poor. Moreover, the incidence of revenue budget expenditures indicates that such spending is becoming less pro-poor over time. :KLOHGHFOLQLQJRYHUWLPHWKHXQRI¿FLDOIHHVVRPHWLPHVSDLGIRUVFKRROHQUROOPHQW are concerning. x )RXUWK LQ FRQWUDVW WR WKH SXEOLF KHDOWK VHFWRU XQRI¿FLDO DEVHQWHHLVP DSSHDUV WR EH quite low in the sector. Time on task, however, is still a major concern. 7KLVUHYLHZLGHQWL¿HVDODUJHQXPEHURIJDSVLQUHVHDUFKEXWVHYHUDOXQGHUVWXGLHG topics represent a prime focus of government plans for primary education. These gaps provide options for future topics to be researched further. For example, there is little evidence on the effectiveness of government’s role as a regulator of the non-government sector. The main JRYHUQPHQWGRFXPHQWVGH¿QLQJWKHSULRULWLHVLQFOXGHWKH6L[WK)LYH<HDU3ODQRI%DQJODGHVKWKH National Plan of Action II, and the PEDP III. Additionally, even if not represented in the planning and program documents, recent major changes in the primary education sector require informed analysis. 35 84. Limited research has focused on the role of government to oversee and support non- government primary schools. The Sixth Five Year Plan, the National Plan of Action II and PEDP ,,, HDFK HPSKDVL]H WKH LPSRUWDQFH RI SXEOLFSULYDWH SDUWQHUVKLSV LQ SULPDU\ HGXFDWLRQ ZKLFK includes a critical regulatory role for government. According to the Sixth Five Year Plan, such D UROH PD\ LQFOXGH VWDQGDUGV DFFUHGLWDWLRQ SURWHFWLQJ SXEOLF LQWHUHVWV LQ ¿QDQFLDO PDWWHUV DQG ensuring equity. These schools, including RNGPS, NGO schools, madrasas and private schools, DUHUHVSRQVLEOHIRUHGXFDWLQJDOPRVW¿IW\SHUFHQWRISULPDU\VFKRROSXSLOV$ODUJHSRUWLRQRIWKH government budget is spent aiding these schools through teacher salaries, schoolbooks and stipends; however, studies on the effectiveness of this spending, as well as the larger role of government in these schools, are not found. The use of the Monthly Pay Order is similarly critical within this topic, including the integrity of its distribution and use among non-government schools. Further UHVHDUFK PD\ FULWLFDOO\ DQDO\]H WKH UROH RI JRYHUQPHQW WR RYHUVHH WKHVH VFKRROV DQG LPSURYH their performance. At the same time, these schools are undergoing changes due to government QDWLRQDOL]DWLRQHIIRUWV6WXGLHVFDQDOVRH[DPLQHZKDWWKHVHFKDQJHVPHDQIRUWKHJRYHUQPHQWLQ WHUPVRI¿QDQFHVVWDI¿QJDQGRYHUVLJKW 85. Decentralization also appears as a major objective in the Sixth Five Year Plan, the National Plan of Action II and PEDP III; however, there is no comprehensive study demonstrating the challenges and opportunities for implementation. 'HFHQWUDOL]DWLRQ LV FRPSOH[SDUWLFXODUO\DVWKHWUDQVIHURIDGPLQLVWUDWLYHDQG¿QDQFLDOGHFLVLRQVWRWKHORFDOOHYHO may take many forms, and research into how this policy should be implemented should be done before developing more detailed implementation plans. While a number of studies on SMCs KDYH EHHQ FRPSOHWHG WKH\ KDYH QRW SURYLGHG VXI¿FLHQW LQIRUPDWLRQ DV WR ZKHWKHU WKHVH ORFDO ERGLHVKDYHVXI¿FLHQWFDSDFLW\DQGLQFHQWLYHVWRWDNHRQDGGLWLRQDO¿QDQFLDODQGDGPLQLVWUDWLYH responsibilities. Political economy may also be critically important for explaining the government UHVLVWDQFHWRH[WHQVLYHGHFHQWUDOL]DWLRQ 86. While the Sixth Five Year Plan emphasizes the need for a large increase in the government budget for primary education, current allocations are lagging behind, with a decline of 6.62 percent in 2007/08 to 5.36 percent in FY 2013/14 of government spending. Further research may inquire into the reasons behind the low budget dedicated for primary education, including the budgetary decision making process. 87. In-depth political economy research may also explain persistent problems in the primary education sector. Particularly important here are the areas in which the policies and regulations are technically sound, but they are not applied. Moreover, the issue of the continuing resistance of government to integrate MoE and MoPME, despite the technical rationale to do so, is another important topic for political economy. Other potential topics of research include the strong LQÀXHQFHRIRUJDQL]DWLRQVLQPDGUDVVDHGXFDWLRQWKHLQWHUHVWVWKDWVZD\WKHEXGJHWSURFHVVWKH UHQWVGHULYHGIURPORFDOH[SHQGLWXUHVDQGFRQWLQXHGUHVLVWDQFHWRGHFHQWUDOL]DWLRQ 88. This review faced a limitation due to the fact that many experts perceive information in the literature to be out of date due to changes initiated by MoPME; updated research is therefore needed. The review included research since 2000, but much of the data is out of date. We therefore hold many of the conclusions from the literature to be tentative, and recommend updates to the available literature. MoPME has undertaken a number of initiatives in order to 36 DGGUHVVPDQ\RIWKHJRYHUQDQFHFKDOOHQJHVLGHQWL¿HGLQWKLVUHYLHZ7KLVVXJJHVWVWKDWIXUWKHU efforts are needed to update the data and analyses in the literature. Furthermore, MoPME should advertise their initiatives to improve governance. 89. Improved knowledge management is necessary so that governance research may have an impact. A considerable amount of effort was required by the authors to compile the literature in this review. Moreover, different experts informed our research team of studies that were not publicly available, or that were lost in time. Greater attention is needed to made research both publicly available and easily searchable. Moreover, efforts are required to make research accessible for a variety of audiences, particularly online in an easily searchable format. There is also a need to better evaluate the effects of the research completed thus far. Based on such an HYDOXDWLRQ WKH UHVHDUFK FRPPXQLW\ FDQ EHWWHU FRPPXQLFDWH WKHLU ¿QGLQJV WR NH\ DXGLHQFHV WR ensure impact. 90. Finally, the quality of evidence in empirical research in governance is frequently weak. Often, statements are made without an empirical basis, and anecdotal evidence may be portrayed as facts. At times, the primary education governance literature does provide evidence of problems, but falls short of an analysis of the systems involved in addressing the problems, nor an explanation for why the systems may fail. For example, the primary education budget is relatively VPDOOEXWWKHOLWHUDWXUHKDVQRWDQDO\]HGWKHEXGJHWGHFLVLRQPDNLQJSURFHVVHVWKDWOHDGWRWKLV RXWFRPH0RUHRYHUOLWHUDWXUHVKRXOGGLVWLQJXLVKEHWZHHQWKHRI¿FLDOSURFHVVHV de jure) including the laws and regulations, as opposed to action (de facto VFUXWLQL]LQJWKHZD\WKDWRI¿FLDOVDQG various actors actually behave. An analysis of the budget system should inquire into both the RI¿FLDOSURFHVVRIFRQVWUXFWLQJWKHEXGJHWDQGDOVRWKHLQIRUPDODJUHHPHQWVWKDWDUHPDGHWKHXVH RIDQDO\WLFDOZRUNDQGWKHSROLWLFDOFRQVLGHUDWLRQVWKDWLQÀXHQFHWKHVHGHFLVLRQV5HIRUPHIIRUWV that do not take these informal processes into account are likely to fail. 37 Annexes Annex- 1: PEDP III Planned Contributions to the MoPME Budget (US$ Million) Total GoB Contributions Total DPs Contribution Total (US$ (US$ million) (%) (US$ million) (%) million) MoPME 3,170.95 2,748.75 86.61 422.2 13.31 Dev’t Budget MoPME 4,186.98 3,553.68 84.79 633.3 15.13 Revenue Budget Total 7,357.93 6,302.43 85.57 1,055.50 14.35 Source: MoPME, 2011. Annex-2: Mean Monthly Paid Salary for Teachers (BDT) GPS RNGPS Basic Allowance Total Basic Allowance Total By sanctioned revenue/ MPO post Head Teacher 4,096 2,334 6,430 1,564 449 2,063 Assistant Teacher 3,541 2,096 5,685 1,575 407 1,982 By Gender Male 4,073 2,337 6,429 1,587 422 2,026 Female 3,270 1,970 5,295 1,539 406 1,945 All sanctioned revenue/ 3,658 2,145 5,843 1,572 417 2,002 MPO posts Source: FMRP, 2006. 38 Bibliography A. Qasem & Company. 2013. Annual Fiduciary Review 2011-2012: Interim Report for PEDPIII. Bangladesh. Aboud, Frances E, Kamal Hossain, and Chloe O’ Gara. 2008. “The Succeed Project: Challenging Early School Failure in Bangladesh”. Research in Comparative and International Education. Vol 3, No 3. $KPHG0DQ]RRU6DPLU1DWKDQG.D]L6DOHK$KPHG /LWHUDF\LQ%DQJODGHVK±1HHGIRU a New Vision. Campaign for Popular Education (CAMPE). $KPHG0DQ]RRUThe Sector-wide Approach in Bangladesh, Primary Education: A Critical View. Institute of Education and Development. 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Bangladesh governance in the health sector : a systematic literature review
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