Detailed findings

ACCEPTABILITY

See effectiveness and reach column.

Data on care-seeking rates from CHWs only was unavailable for the team to review.

See FB-IMCI also.

FEASIBILITY

CB-IMCI implemented although MOHFW data showed coverage of only 51% by 2016 which KIs explained did not include NGO coverage. CB-IMCI was implemented nationally as at 2019 (Source: KIs)

FIDELITY

According to health facility survey data from 2014, although approximately 89% of surveyed community clinics had ORS for diarrhea treatment and 82% had amoxicillin for ARI treatment.

Infrequent supervision

EFFECTIVENESS/REACH

ORT coverage increased from 75% in 2004 to 83% by 2014.

By 2016, the proportion of deaths attributable to diarrhea, malnutrition and lower respiratory infections had decreased 95%, 86% and 83% respectively from 1990 figures.⁴ These drops in U5 deaths attributable to each condition reflected the effectiveness of CB-IMCI (given that incidence rates remained largely the same for diarrhea and fever for example) but may also be due to FB-IMCI.

As of 2016, MOHFW data showed that CB-IMCI had been rolled out in only about half of all subdistricts (249/490). However, KIs explained that this did not account for NGO coverage. Inclusive of this, KIs estimated that. CB-IMCI was implemented nationally in 2019 (Source: KIs).

IHME DECOMPOSITION RESULTS

ACCEPTABILITY

Findings from a study in 1993 showed that health workers were reluctant to prescribe ORT for treating diarrhea, which KIs explained might have resulted from a preference for intravenous therapy and the reluctance of mothers to use the ORT corners (separate areas where mothers could regularly feed their children ORT under the supervision of health workers)

See effectiveness and reach column.

FEASIBILITY

BRAC and Social Marketing Company’s ORT program, NORP (National Oral Rehydration Project), and CDD implemented with high coverage overall (although low at the beginning).

FIDELITY

Consistently high availability of ORS at health facilities and/or community clinics. According to health facility survey data from 2014, approximately 89% of surveyed community clinics had ORS and more than 80% of facilities had ORS. SPA 2000 data also showed that 88% of health facilities had ORS.³

EFFECTIVENESS/REACH

NORP’s coverage was limited with only 100/509 subdistricts having ORT corners.⁵

Initial monitoring of BRAC’s ORT program showed that although ORT knowledge was high, use remained low because men were not sufficiently engaged in the process and sugar was often not available in homes.

At the end of BRAC’s ORT programs, approximately 12 million mothers had been reached (an estimated 46% to 63% of women of reproductive age).⁵

A study conducted in 1993 found that more than 70% of mothers were able to correctly make ORT and ORT was used for managing approximately 60% of diarrheal cases. The study also found that drug sellers and village doctors frequently recommended the use of ORT and a high proportion (80%) of rural pharmacies had ORS available.⁶

Sales of Social Marketing Company’s brand of ORS increased from only 42,880 packets in 1983 to 16 million in 1992.

Minimal increase in the proportion of children with diarrhea who received ORS or recommended home fluids from 58% in 1992–1993 to 62% in 1996–1997 when the first phase of CDD ended. By

2004, after the integration of ORT into IMCI, it had increased to 75% and by 2014, coverage was as high as 83%.⁷

IHME DECOMPOSITION RESULTS

ACCEPTABILITY

Research conducted in 2012 found that health caregivers remained reluctant to treat diarrheal cases with zinc because the benefits of zinc (compared with ORS) were not as obvious.⁵ 

See effectiveness and reach column.

FEASIBILITY

Zinc program rolled out, although it achieved less than 50% coverage.

FIDELITY

 The full treatment (for 10 days) was not adequately emphasized to drug vendors as part of SUZY so they typically sold 2-3-day dosages, resulting in treatment ineffectiveness and discouraging successive use.

EFFECTIVENESS/REACH

Between 2006 and 2007, more than 5 million Baby Zinc blister packs were sold across the country, higher than the expected demand of 3 million.

According to Bangladesh DHS; in 2007, the proportion of children with diarrhea who received zinc supplements was 7%, increasing to 49% in 2014, although remaining below 50%.^8,9 

IHME DECOMPOSITION RESULTS

ACCEPTABILITY

See effectiveness/reach column

FEASIBILITY

Program rolled out and achieved high coverage in 2011 in both southeast and northeast. See effectiveness/reach column.

IRS implemented in targeted endemic areas and then hotspots.

FIDELITY

Not found.

EFFECTIVENESS/REACH

A study conducted between 2008 and 2011 found the proportion of households with at least one LLIN in the northeast increased from 22% (in 2008, 1 year after the program began) to 62% in 2011; whereas in the southeast, it increased from 60% in 2008 to 67% in 2011. The proportion of U5 children sleeping under an LLIN or other ITN was stable at 92% between 2008 and 2011 in the southeast and 87% in the northeast. The proportion of pregnant women sleeping under an LLIN or other ITN increased from 84% to 91% between 2008 and 2011 in the southeast, and from 77% to 83% in the northeast within the same time period.¹⁰

U5M attributable to malaria in Bangladesh declined from 0.02 deaths per 100,000 live births in 1990 and 2000 to 0.008/100,000 in 2016.⁴ This drop in U5M attributable to malaria may not be solely accounted for by ITNs but may also be due to other evidence-based interventions.

IHME DECOMPOSITION RESULTS¹

<1% of the reduction in under-five mortality attributed to ITNs and IRS

(Analysis of regional attribution in endemic areas not available.)

ACCEPTABILITY

In regard to the acceptability of PCV, a KI described Bangladesh as a “pro-vaccine country.” The KI also added that “if you come to a national immunization day in this country, you will see what a long queue [there is]. To get the vaccine, mothers are coming and waiting for hours on the queue to get the vaccine. There is hardly any country like this. So, Bangladesh has got magic, it’s a kind of magic, in fact honestly . . . our EPI is unbelievable.”

FEASIBILITY

PCV introduction delayed by a year from proposed introduction date.

PCV introduced in 2015.

FIDELITY

High staff turnover resulted in inadequately trained staff administering the PCV, and no formal supervision plan or documentation of supervisory visits for follow-up because supervisors were not regularly available to visit all sites.

EFFECTIVENESS/REACH

Coverage of PCV at 97% in 2016 and 2017 within 2 years of introduction.¹¹

Death rate among U5 children due to meningitis decreased from 7.3 deaths per 100,000 U5 population in 2000 to 4.4 in 2016. Also, in 2000, 470 U5 deaths per 100,000 population were attributable to lower respiratory infections, but by 2016, this decreased to 146.¹ While PCV contributed to these reductions in U5M, this was minimal given its introduction late in the study period.

Data on ARI incidence after 2015 (when PCV was introduced) was unavailable for the team to review.

IHME DECOMPOSITION RESULTS¹

 13.9% of the reduction in under-five mortality attributed to Hib, PCV, DTP3, and measles vaccines.

ACCEPTABILITY

In rural areas, strong stakeholder and community engagement led to high levels of Hib (as part of pentavalent vaccine) acceptance among service providers and communities.

In urban areas, poor community engagement resulted in lower knowledge among parents.

FEASIBILITY

Delayed 1 year due to delay in receipt of the vaccine introduction grant from Gavi, delaying development and printing of training and communication materials.

Hib was rolled out in Khulna District in January 2009 and nationally by July 2009.

In rural areas, cold chain and logistics for Hib vaccine (as part of pentavalent vaccine) were well planned and managed during the rollout and ongoing implementation.

FIDELITY

In rural areas, correct injection techniques, use of autodisable syringes, and proper filling of safety boxes were observed among service providers in rural areas, although the disposal of safety boxes was not correctly done in some health facilities.

EFFECTIVENESS/REACH

Hib3 immunization coverage among 1-year-olds in Bangladesh remained relatively stable at 93% in 2007 and 2011 and 91% in 2014, respectively.^9,12

According to IHME estimates, deaths due to meningitis decreased from 12 per 100,000 U5 children (in 2005 – just before Hib was introduced) to 4.4 in 2016, although the proportional contribution to U5M did not change (0.8% to 0.7%) and could have been due to PCV.⁴

IHME DECOMPOSITION RESULTS

ACCEPTABILITY

 See effectiveness and coverage data.

FEASIBILITY

An evaluation conducted in 2011 found that for the 2010 SIA, in some rural areas the numbers of refrigerators and cold boxes were inadequate.

2005, 2010, and 2014 SIAs achieved high coverage of 100% or higher – see effectiveness/reach column.

FIDELITY

Not found.

EFFECTIVENESS/REACH

Coverage of measles vaccine was high in 1993 at 69%; by 1999, it was 71%.¹³ 

The 2005–2006 SIA achieved high coverage (101%) with 36 million children receiving the measles vaccine – 1.5 million children were immunized during the first phase (2005) and 34.2 million during the second phase (2006).¹⁴

Following the implementation of the 2005-2006 measles SIA, the number of measles cases in Bangladesh dropped, from 25,934 in 2005 (during an outbreak) to 6,192 and 718 in 2006 and 2009, respectively.

The 2010 SIA achieved 100% coverage, with 18.1 million children vaccinated.

The 2014 SIA achieved 100% coverage, with 53 million children vaccinated.

According to DHS data, national measles vaccination coverage was high at 86% in 2014, although below the 90% target set by the government of Bangladesh for 2010.

According to a report published in 2017, between 2000 and 2016, confirmed measles incidence decreased from 34.2 to 6.1 per 1 million people, a decrease of 82%.¹⁴

U5M attributable to measles decreased.⁴

IHME DECOMPOSITION RESULTS

ACCEPTABILITY

Not found.

FEASIBILITY

Vitamin A supplementation implemented, but coverage remained at only about 2/3.

FIDELITY

Not found.

EFFECTIVENESS/REACH

Overall, vitamin A coverage in Bangladesh increased from the early 1990s, from 49% in 1993 to 67% in 1996, but remained at only about 2/3 coverage – 60% in 2011 and 62% in 2014.

IHME DECOMPOSITION RESULTS

ACCEPTABILITY

(Undetermined): Although low coverage data suggested low acceptability, this may have been due to the limited scale of both PMTCT and pediatric ART efforts in Bangladesh.

FEASIBILITY

In 2017, PMTCT was rolled out in only 3 national university hospitals.

FIDELITY

Research conducted in 2017 found that despite Bangladesh’s national policy guiding viral load testing and monitoring ART in HIV-positive clients (including in pregnancy and pediatric cases), the guidelines were not adhered to.¹⁵

EFFECTIVENESS/REACH

In 2007, only 33% of pregnant women living with HIV received ARV treatment as part of PMTCT; this proportion dropped to 14% in 2010 and 17% in 2017.^16,17

New cases of children (ages 0 to 14) with HIV remained at <100 between 2007 and 2015, but the proportion of children ages 0 to 14 diagnosed late (with CD4 <350 mm3) was more than 95% in 2017.¹⁶

Although early infant diagnosis increased, it remained low from 2% in 2010 to 10% in 2015.¹⁶

Data from 2017 (after the case study period ended) showed that only 31% of HIV-infected children ages 0 to 14 were receiving treatment.¹⁸ Although this was an increase from 2010 data (12%), it still remained low.

According to IHME estimates, while U5 deaths attributable to HIV/AIDS increased between 2000 and 2016, it remains low at 0.6 per 100,000 U5 children in 2016, an increase from levels in 2000 (0.05 per 100,000 U5 children).⁴

IHME DECOMPOSITION RESULTS¹

<1% of the reduction in under-five mortality attributed to PMTCT and ART.

ACCEPTABILITY

Data on acceptability not found.

FEASIBILITY

NNP implemented and reached national scale.

CMAM implementation as a component of CB-IMCI not yet accomplished in 2018, after the case study period ended.

FIDELITY

Government oversight and coordination of the BINP was suboptimal.

M&E oversight from the central level was limited because MIS was not developed for BINP.

EFFECTIVENESS/REACH

Evaluation showed a high level of participation in growth-monitoring sessions (75% to 95%) and nutrition education sessions (66%) in subdistricts where BINP was implemented.

The data on coverage and targeting of supplementary feeding for children showed low coverage, with only 21% of eligible children receiving supplementary feeding.

In BINP program areas, severe malnutrition dropped from 13% to 0.9% while moderate malnutrition dropped from 32% to 16% between 1995 and 2002 when BINP ended.

Prevalence of stunting, wasting, and underweight among children dropped during the implementation of the NNP, but remained high overall.

By 2005 (shortly after BINP ended and NNP began), U5 deaths attributable to malnutrition in Bangladesh had dropped from 193 deaths per 100,000 U5 children in 1990 to 54 in 2005. By 2016, it had dropped to 17.⁴

NNP reached national scale.

IHME DECOMPOSITION RESULTS¹

13% of the reduction in under-five mortality attributed to changes in rates of child growth failure.

ACCEPTABILITY

(Undetermined): Low coverage suggested low acceptability but may also be due to challenges.

FEASIBILITY

In 2011, 96% of the planned community health care providers had been recruited.¹⁹

In 2011, coverage of community-based skilled birth attendants was low (45.6%), with only 6,155 of the planned 13,500 recruited, which affected the performance of their roles.

FIDELITY

Inadequate supervision of attendants because too few midwives were trained, only 50 family welfare visitors trained by 2008, and challenges with scaling up the supervision training.

Health facility survey data from 2014 showed low readiness for providing ANC among health facilities and community clinics in Bangladesh, including guidelines and recently trained staff.

In 2014, many facilities did not have guidelines or trained providers.

EFFECTIVENESS/REACH

In 2004, shortly after the introduction of the community-based skilled birth attendant cadre, ANC1 coverage was at 56%; although it remained unchanged at 55% in 2011, it increased to 78% in 2014.^9,20

Assessment of ACCESS showed that in project subdistricts, ANC4+ coverage remained low, at 15%. ANC4+ coverage in both Mamoni districts – Sylhet and Habiganj – remained low also, at 8.2% and 8.7%, respectively ^21,22

ANC4+ attendance rates remained low, but increased from 17% in 2004 to 26% in 2011 and 31% in 2014.

Overall, the proportion of ANC sessions performed by CHWs remained low.

In 2008, Bangladesh achieved Maternal and Neonatal Tetanus Elimination status with less than 1 case per 1,000 live births per district year.²³

Bangladesh maintained a high rate of tetanus protection at birth at 88% in 2007 and 91% in 2011 (earlier data were unavailable for the team to review).

The proportion of women who had received at least two doses of tetanus toxoid vaccine was moderately high in 1999–2000 and 2004 at 64% but dropped steadily to 60% in 2007 and 47% in 2011.

U5M attributable to tetanus in Bangladesh declined by 99% between 1990 and 2016, and the rate of deaths caused by tetanus among newborns also dropped by 98%.

IHME DECOMPOSITION RESULTS¹

10% of the reduction in U5M attributed to reductions in low birth weight and short gestational age.

ACCEPTABILITY

Low acceptability due to lack of trust in community-based skilled birth attendants for delivery.

FEASIBILITY

Community-based skilled birth attendants recruited and trained, but achieved only low coverage (<50%).

Training coverage for higher-level skills only at 3%.

FIDELITY

Inadequate supervision because too few midwives were trained and only 50 family welfare visitors trained by 2008 and challenges with scaling up the supervision training. KIs reported poor quality.

According to 2014 health facility survey data, community clinics and upgraded family welfare centers showed low readiness for delivery.

EFFECTIVENESS/REACH

Assessment of ACCESS showed that in project subdistricts, skilled birth attendance remained low at 15%.²¹

Assessment of Mamoni showed that only 38% of deliveries were performed by community-based skilled birth attendants in project districts (Sylhet and Habiganj) during the project, but skilled birth attendance in Sylhet and Habiganj overall remained low at 25.8% and 19.4%, respectively.²²

In 2011, coverage of community-based skilled birth attendants was low (45.6%), with only 6,155 of the planned 13,500 recruited.

Overall, skilled birth attendance remained low in Bangladesh at only 42% in 2014 and few deliveries (less than 0.4% of all births) were carried out by community-based skilled birth attendants.^9,24

Increase in facility-based delivery, largely due to an increase in private-sector delivery rates.

IHME DECOMPOSITION RESULTS

ACCEPTABILITY

Research conducted in 2014 reported high levels of acceptability of the Helping Babies Breathe initiative.

 In response to a question about the acceptability of kangaroo mother care, a KI said: “It was easy for the health care providers to take it because evidence was there . . . So, they could easily take it.”

When asked about factors that contributed to acceptability of KMC by mothers, a KI said: “ . . . interestingly mothers were very much aware. When the awareness building program was done, they were very much aware for that because for their premature baby, they want to make him survive. And one of the culture I’ll tell you, for many years, actually if the baby is small or if it is a cold day, an elder person of the family does skin-to-skin contact or they cover the baby with them. From that, they [the mothers] saw that the elder person was doing like that. Not actual kangaroo mother care, but it is something similar. So, they took it.”

In 2009, Bangladesh’s recommendation to expand community-based treatment of neonatal sepsis, in case of referral failure, reflected data on its acceptability. Assessment of ProjAHNMo I showed that 71.4% of sepsis treatment was home-based, with 91.8% of women perceiving sepsis to be a serious complication.

FEASIBILITY

The Helping Babies Breathe initiative was introduced and scaled up to the national level.

CKMC not scaled up.

KMC rolled out, but not at the national level.

Chlorhexidine for cord care was rolled out, but available only in 32% of health facilities by 2016.

FIDELITY

Facilities’ readiness for providing neonatal resuscitation remained low in Bangladesh. Although 79.5% of district and subdistrict level facilities had a neonatal bag and mask, only 34.7% of union-level facilities and 22% of community clinics had these resuscitation materials.

Only 25% and 8% of staff in health facilities and community clinics, respectively, which provided normal delivery had at least one staff trained on neonatal resuscitation in the 24 months preceding the survey.

In 2014, poor skill retention and practice by skilled birth attendants.

In 2014, only 10% of community clinics and 8% of health facilities had staff trained in kangaroo mother care in the 24 months preceding the survey. Earlier data were unavailable for the team to review. While these data suggest low readiness of facilities, they also reflect the fact that KMC had not reached national scale as of 2014.

In 2014, a study found ongoing gaps in effective management of neonatal sepsis due to reasons such as poor quality of care.²⁵

EFFECTIVENESS/REACH

Deaths due to neonatal encephalopathy due to birth asphyxia decreased from 10,060/100,000 neonatal deaths in 2000 to 8,645 in 2015, although the relative proportion of deaths increased from 17% to 31% over that period.

The Helping Babies Breath initiative reached national scale in 2014.

Deaths due to neonatal preterm birth accounted for the highest percentage of neonatal deaths in 2000 (26% of all neonatal deaths) although by 2016, this percentage decreased to 16% of all neonatal deaths

For NNP, more than 75% of surveyed women initiated CKMC and 85% of the mothers with LBW babies continued until the postpartum period. Mothers who initiated usual skin-to-skin care reported more frequent breastfeeding, delayed newborn bathing, and slept with their babies more often.

In 2014 SPA, chlorhexidine for cord cleaning was available in only 32% of health facilities that provided normal delivery services in Bangladesh.

Deaths due to neonatal sepsis and other neonatal infections accounted for 2,580 per 100,000 neonatal deaths in 2000 (5% of all neonatal deaths) and by 2016, it declined to 1,466, although the relative proportion of neonatal deaths attributable remained the same at 5%.

Insufficient number of skilled providers in facilities.

IHME DECOMPOSITION RESULTS