Background

The sustainable development goals (SDGs) are universal in scope, and their call to leave no one behind puts the World’s most vulnerable and marginalized people – including children – at the top of the agenda. Thus, achieving the SDGs, and particularly those for children and women, will necessitate added efforts from all ministries, agencies and grassroot actors to improve effective coverage of basic social services like health, education, nutrition, child protection, drinking water, improved sanitation at all administrative levels in Bangladesh. Government along with various actors have been investing enormous resources to improve the human, social and economic capital of population, years over year.

In 2017, Government of Bangladesh had allocated 14 percent of the national budget on children issues and now committed to increase to at least 20 percent by 2020. Now, it’s significant to comprehend the status of accessibility, utilization, adequate coverage of services and effective coverage of quality services that meet people’s needs for the wellbeing as well as better utilization of committed resources by the duty-bearers.

Therefore, generating local level evidences for each of 64 districts on coverage of selected social services allows localizing SDGs and inform decision-making processes to accelerate SDGs in the country. In this process, identifying bottlenecks in the delivery of services permits focusing resources efficiently and enhance relevance and effectiveness of policies and implementation strategies. In this regard, an assessment on coverage of basic social services, a national household survey was conducted in 2016 (round-1), led by IMED, BBS and BIDS with technical and financial support by UNICEF. About 200,000 households of 2,012 MSVSB sample geographical areas spread all over the country was covered under the survey. The operational definition of effective coverage of select basic social services were defined and agreed upon. The results were brought out through dynamic dashboard to bring on the table information on coverage levels of selected GoB interventions for children and women along with information on reasons for not able to avail the services at the desired level.

Based on the lessons learnt from round-1 survey, IMED and BBS undertook another national household survey in November 2017 to assess the coverage of basic social services.

Introduction

Accelerating SDGs in Bangladesh from children’s perspective at local level means improvements in functioning of service points and efficient implementation of services. That’s why the achievement of the SDGs depend, more than ever, on the ability of local and divisional administrations including local governments to promote integrated, inclusive and sustainable local development. At various policy deliberations, emphasis was given to assess and improve coverage of basic social services. The utilization of evidence of effective coverage would significantly translate 2030 Agenda in the country. For this, mapping of key interventions around women and children are crucial.

The first 1,000 days start at conception and end at around 2 years of age of the child. During the early years of life an infant’s nutritional health critically depends on how the family, especially the caregivers, act. Parents must have knowledge of the changing food requirements of the child. Equally important are parents creating the cultural and psychological environment that influences the development of food habits, setting patterns for later years. Appropriate nutrition has a positive effect on the development of the children. Even though infants vary widely in their growth patterns, there is value in being familiar with typical patterns of growth and development. One of the preconditions for a healthy baby is antenatal care, – an essential part of pregnancy, which should start as soon as conception.

Having a healthy pregnancy is one of the best ways to promote a healthy birth. Antenatal care provides caregivers with an opportunity to explain the importance of proper nutrition during pregnancy and breastfeeding to expectant mothers. Delivery in health institutions are critical to deliver baby safe. Proper management of delivery assisted by skilled personnel’s and appropriate diets may help ending preventable deaths of new-borns and children under 5 years of age. As the child grows, other important services, practices and societal values and practices may affect his/her overall well-being, e.g. birth registration, early education, attending educational institutions, child discipline, marriage before legal age etc.

From July 2017, group of technical resource person including representatives from line ministries and other resource organizations have been consulted on the missing elements/interventions; accordingly proposed new modules in the national household survey. Accordingly, questionnaires of last round were also reviewed in a way that its outcome could be fed at national and subnational level for better planning to accelerate means of implementation of SDGs, appropriately initiate review of district performances and lead a process to empower all local stakeholders, aimed at making sustainable development more responsive, and therefore, relevant to local needs and aspirations.

There are several advantages and dimensions to the evidence generated in this assessment. The report powerfully displays gaps in effective coverage of social services as well as generate factsheets for national, divisions and districts. Further, this data is complemented by a holistic picture of how children, youth pregnant women and lactating mothers can access basic services, allowing for further analysis on how these patterns correlate with the key socio-demographic outcomes.

The report will be useful to the public and private sector’s duty-bearers, policymakers, development partners and researchers to understand the coverage and pockets of deprivation existent in the basic social services experienced in Bangladesh.

Objectives of the assessment

A range of public services provided by the government for its residents including healthcare, public housing, social care and social security, are known as social services. With its own resources and together with the development partners, government implements numerous social service projects. The success of these interventions depends on the effective coverage of the targeted beneficiaries. If an intervention fails to provide effective coverage, then the related population is deprived of the intended benefits.

To that end some fundamental issues in the management of social service arise: (a) Are the services reaching the people they should serve? (b) Have the services been effective in meeting the people’s needs? To that end, a nation-wide assessment was made on the efficacy of basic social services about breastfeeding, and complementary feeding of infants, iron and folic acid supplementation during pregnancy, maternal diet, management of illness, antenatal care, birth registration within 45 days of delivery, schooling for children aged between 6 and 14 years, comprehensive knowledge about HIV/AIDS, safe water supply and sanitation and hygiene.

The specific objectives of the assessment are to:

  • Assess barriers to equitable access of basic social services at national and divisional levels in Bangladesh; and to
  • Understand whether it generates actionable evidence helpful for decision makers to identify, prioritize and then solve barriers to utilization of basic social services across different tiers of the government.

Definitions

Operational definitions of select effective coverage of basic social services

Programme

Intervention

Level

Indicator

Numerator

Denominator

1. Nutrition

1.1. Early Initiation of Breastfeeding

1.1.1. Accessibility

Percentage of children 0-23 months whose caregivers have access to IYCF trained health worker within 30 minutes

Number of children 0-23 months whose caregivers have access to IYCF trained health worker within 30 minutes

Children 0-23 months

1.1.2. Utilization

Percentage of children 0-23 months whose caregivers received IYCF counselling during pregnancy

Number of children 0-23 months whose caregivers received IYCF counselling during pregnancy

Children 0-23 months

1.1.3. Adequate coverage

Percentage of children 0-23 months breastfed within 24 hours after birth

Number of children 0-23 months breastfed within 24 hours after birth

Children 0-23 months

1.1.4. Effective coverage

Percentage of children 0-23 months breastfed within first hour after birth

Number of children 0-23 months breastfed within first hour after birth

Children 0-23 months

1.2. Exclusive Breastfeeding

1.2.1. Accessibility

Percentage of children 0-5 months whose caregivers have access to IYCF trained health worker within 30 minutes

Number of children 0-5 months whose caregivers have access to IYCF trained health worker within 30 minutes

Number of caregivers of children 0-5 months

1.2.2. Utilization

Percentage of caregivers who know only breastmilk is the best for a baby eat/drink during the first 6 months of life.

Number of caregivers who know only breastmilk is the best for a baby eat/drink during the first 6 months of life.

Number of caregivers of children 0-5 months

1.2.3. Adequate coverage

Percentage of children 0-5 months who ever been breastfed and their caregivers know only breastmilk is the best for a baby eat/drink for during the first 6 months of life.

Number of children 0-5 months who ever breastfed.

Number of caregivers of children 0-5 months

1.2.4. Effective coverage

Percentage of children 0-5 months who exclusively breastfed and their caregivers know only breastmilk is the best for a baby eat/drink for during the first 6 months of life.

Number of children 0-5 months who are exclusively breastfed

Number of caregivers of children 0-5 months

1.3. Iodized Salt Consumption

1.3.1. Accessibility

Percentage of households, whose nearest market has retailer salt that is iodized

Number of households whose nearest market has retailer salt that is iodized

Number of total household

1.3.2. Utilization

Percentage of households who buy branded edible salts

Number of households who buy branded edible salts

Number of total household

1.3.3. Adequate coverage

Percentage of households consuming iodized salt (> 0ppm)

Number of households consuming iodized salt (> 0ppm)

Number of total household

1.3.4. Effective coverage

Percentage of households consuming adequately iodized salt (at least > 15 ppm)

Number of households consuming adequately iodized salt (at least > 15 ppm)

Number of total household

1.4. Complementary Feeding

1.4.1. Accessibility

Percentage of children 6-23 months whose caregivers have access to IYCF trained health workers within 30 minutes

Number of children 6-23 months whose caregivers have access to IYCF trained health workers within 30 minutes

Number of children 6-23 months

1.4.2. Utilization

Percentage of children 6-23 months whose caregivers received at least one promotion/ counselling session on complementary feeding in the past 3 months

Number of children 6-23 months whose caregivers received at least one promotion/ counselling session on complementary feeding in the past 3 months

Number of children 6-23 months

1.4.3. Adequate coverage

Percentage of breastfed children 6– 23 months with minimum acceptable meal frequency in the past 24 hours)

Number of breastfed children 6– 23 months with minimum acceptable meal frequency in the past 24 hours)

Number of children 6-23 months

1.4.4. Effective coverage

Percentage of breastfed children 6– 23 months with minimum acceptable meal frequency and diversity in the past 24 hours i.e. ‘minimum acceptable diet’

Number of breastfed children 6– 23 months with minimum acceptable meal frequency and diversity in the past 24 hours i.e. ‘minimum acceptable diet’

Number of children 6-23 months

1.5. Maternal Diet

1.5.1. Accessibility

Percentage of pregnant and lactating women (PLW) who have access to ANC/PNC service and trained health worker within 30 minutes

Number of pregnant and lactating women who have access to ANC/PNC service and trained health worker within 30 minutes

Number of Pregnant or Lactating Women

1.5.2. Utilization

Percentage PLWs who increased diet intake during pregnancy and lactation

Number PLWs who increased diet intake during pregnancy and lactation

Number of Pregnant or Lactating Women

1.5.3. Adequate coverage

Percentage of PLWs who increased diet intake during pregnancy and lactation and are consuming at least 5 food groups

Number of PLWs who increased diet intake during pregnancy and lactation and are consuming at least 5 food groups

Number of Pregnant or Lactating Women

1.5.4. Effective coverage

Percentage of pregnant/lactating women consuming an adequate diet (extra 1 fistful of food daily for pregnant women, 2 extra fistfuls of food daily for lactating women), from at least 5 food groups

Number of pregnant/lactating women consuming an adequate diet (extra 1 fistful of food daily for pregnant women, 2 extra fistfuls of food daily for lactating women), from at least 5 food groups

Number of Pregnant or Lactating Women

1.6. IFA

1.6.1. Accessibility

Percentage of pregnant women (PW) who delivered in last 6 months with access to FWC or CC providing IFA supplement within 30 minutes from home

Number of PW (delivered in last 6 months) with access to FWC or CC providing IFA supplement within 30 mins from home

Pregnant women (delivered last 6 months)

1.6.2. Utilization

Percentage of pregnant women (delivered in last six months) attended ANC and received IFA (initial contact irrespective of Number of tablet + at least 1 ANC visit)

Number of PW (delivered last 6 months) with Access to FWC or CC providing IFA supplement within 30 mins from home, made ANC visit (at least Once) and received IFA tablets

Pregnant women (delivered last 6 months)

1.6.3. Adequate coverage

Number of pregnant women (delivered in last six months) had received at least 100 IFA tablets from 4 ANCs

Number of PW received at least 100 IFA tablets from 4 ANCs from FWC or CC.

Pregnant women (delivered last 6 months)

1.6.4. Effective coverage

Percentage of pregnant women who also consumed 100 IFA tablets during pregnancy

Number of PW also consumed 100 IFA tablets of those got from 4 ANC from FWC or CC.

Pregnant women (delivered last 6 months)

2. Health

2.1. Institutional Delivery

2.1.1. Accessibility

Percentage of mothers who have access to health facility within 2 hours using any means of transport

Mothers who have access to health facility within 2 hours using any means of transport

Woman who gave birth last 11 months

2.1.2. Utilization

Percentage of mothers who have access to health facility within 2 hours using any means of transport and had at least one ANC visit during the last pregnancy

Mothers who have access to health facility within 2 hours using any means of transport and had at least one ANC visit during the last pregnancy

Woman who gave birth last 11 months

2.1.3. Adequate coverage

Percentage of mothers who have access to health facility within 2 hours using any means of transport and had four ANC visit during the last pregnancy and delivered in a health facility

Mothers who have access to health facility within 2 hours using any means of transport and had four ANC visit during the last pregnancy and delivered in a health facility

Woman who gave birth last 11 months

2.1.4. Effective coverage

Percentage of mothers who have access to health facility within 2 hours using any means of transport and had four ANC visit during the last pregnancy and delivered in a health facility and received medicine

Mothers who have access to health facility within 2 hours using any means of transport and had four ANC visit during the last pregnancy and delivered in a health facility and received medicine

Woman who gave birth last 11 months

2.2. Adolescent Health

2.2.1. Accessibility

Percentage of adolescent who can reach a health facility within 2 kilometres

Adolescent who can reach a health facility within 2 kilometres?

Adolescent age 10-19 Years

2.2.2. Utilization

Percentage of adolescents who can reach a facility within 2 kilometres and ever visited to receive health services

Adolescents who can reach a facility within 2 kilometres and ever visited to receive health services

Adolescent age 10-19 Years

2.2.3. Adequate coverage

Percentage of adolescents who can reach a facility within 2 kilometres and ever visited to receive health services and received the services according to expectation.

Adolescents who can reach a facility within 2 kilometres and ever visited to receive health services and receive the services according to expectation.

Adolescent age 10-19 Years

2.2.4. Effective coverage

Percentage of adolescents who can reach a facility within 2 kilometres and ever visited to receive health services and received the services according to expectation and satisfied with the service provider.

Number of adolescents who can reach a facility within 2 kilometres and ever visited to receive health services and received the services according to expectation and satisfied with the service provider.

Adolescent age 10-19 Years

4. Child Protection

4.1. Birth Registration

4.1.1. Accessibility

Percentage of parents know where and how or who can help them reporting birth and obtaining birth registration certificate.

Number of parents of children born in the last 1 year who know where and how or who can help them reporting and obtaining birth registration certificate

Parent of children born in last 1 year

4.1.2. Utilization

Percentage of parents applied for birth registration and obtained birth registration certificate for their children.

Number of children born in the last 1 year for whom birth registration has been applied for (including those who already have birth registration certificate)

Children born in last 1 year

4.1.3. Adequate coverage

Children are registered in BRIS and provided with birth registration certificate and seen.

Number of children born in the last 1 year registered in BRIS and provided with birth registration certificate

Children born in last 1 year

4.1.4. Effective coverage

Children are registered in BRIS and provided with birth registration certificate within 45 days of birth.

Number of children born in the last 1 year registered in BRIS and provided with birth registration certificate within 45 days of birth

Children born in last 1 year

5. WASH

5.1. Drinking Water

5.1.1. Accessibility

Proportion of households located within 150 meter of a functional water source from their home

Number of households located within 150 meters of a functional and improved water source from home

Total number of households

5.1.2. Utilization

Proportion of households collected water in last 2 days from a functional water point located within 150 meters from their home

Number of households using water from a functional and improved water point located within 150 m/492 ft from home during last 2 days

Total number of households

5.1.3. Adequate coverage

Proportion of households using at least 20 litters/person/day round the year from a functional water point located within 150 meters

Number of households using a minimum of 20 litters/ person/day round the year from a functional and improved water point located within 150 m/492 ft from home

Total number of households

5.1.4. Effective coverage

Proportion of households using at least 20 litters/person/day round the year from a water point within 150 meter and main water source is perceived as arsenic safe

Number of households using at least 20 litters/person/day round the year from a water point within 150 meter and main water source is perceived as arsenic safe.

Total number of households

5.2. Handwashing

5.2.1. Accessibility

Percentage of Mothers/caregivers of children under 5 who can indicate their knowledge of the critical times to wash hands with soap*; i) after defecation, ii) before preparing food, iii) before eating, iv) after cleaning a baby’s bottom, v) disposing of faeces vi) before feeding a child

Number of households with a child under 5 which have access to a latrine which have soap* available in the household and in which the mothers/caregivers can recite three of the five key handwashing times

Number of Households surveyed with a child under 5 and which have a latrine

5.2.2. Utilization

Percentage of households with soap* and water available inside the latrine or within 5m of the latrine

Number of households with a child under 5 with access to a latrine which have soap* available in the household, in which the mothers/caregivers can recite three of the five key handwashing times and which have water and soap* available inside or within 5m of the latrine

Number of Households surveyed with a child under 5 and which have a latrine

5.2.3. Adequate coverage

Percentage of observed latrine visits which were followed by handwashing with soap*

Number of observed latrine visits followed by handwashing with soap*Number of Households surveyed with a child under 5 and which have a latrine

Number of observed latrine-toilet visits

5.2.4. Effective coverage

Percentage of observed latrine visits which were followed by effective handwashing (with both hands, with soap* for at least 6 seconds)

Number of observed latrine visits followed by effective handwashing with soap*Number of Households surveyed with a child under 5 and which have a latrine

Number of observed latrine-toilet visits

5.3. Sanitation

5.3.1. Accessibility

Proportion of households which use an improved latrine within 20m of household

Households which use an improved latrine within 20m of household

Number of households surveyed

5.3.2. Utilization

Proportion of households which use an improved latrine within 20m of the household by all members of the household (over 5 years of age)

Households which use an improved latrine within 20m of the household by all members of the household (over 5 years of age)

Number of households surveyed

5.3.3. Adequate coverage

Proportion of households which use an improved latrine within 20m of the household and which is clean and can be used by all members of the household (over 5 years of age) all year round

Households which use an improved latrine within 20m of the household and which is clean and can be used by all members of the household (over 5 years of age) all year round

Number of households surveyed

5.3.4. Effective Coverage

Proportion of households which use an improved latrine which is within 20m of the household and which is clean and accessible by all members of the household (over 5 years of age) all year round, which has handwashing facilities (water and soap) available inside or within 5m of the latrine

Households which use an improved latrine which is within 20m of the household and which is clean and accessible by all members of the household (over 5 years of age) all year round, which has handwashing facilities (water and soap) available inside or within 5m of the latrine

Number of households surveyed

Methodology

The survey was designed to benchmark the status of basic social services and its coverage related to women and children available at the local level and accelerate achievements of SDGs 2, 3, 4, 5, 6, 11 and 16 by enhance understanding of the factors that contribute to nutrition, health, water and sanitation, child development and child protection. The major objectives were to provide a national, divisional and district level estimates of availability, access, utilization and effective coverage of some basic social services.

S.No.

Programme

Modules/Interventions/questionnaires

Linkages with SDGs 

1

Nutrition

1. Early initiation of breastfeeding (0-5 months)

2. Exclusive breastfeeding (0-5 months)

3. Complementary feeding (6-23 months)

4. Maternal diet (pregnant and lactating women)

5. Iodized salt (household)

6. Iron and Folic Acid (IFA) supplementation 

(pregnant and lactating women)

2

Health

7. Institutional delivery (pregnant women)

8. New-born care 

9. Adolescent health (10-19 years)

10. Comprehensive knowledge of HIV / AIDS (household)

3

Education

11. Attending educational institutions (5-14 years)

12. Early learning and stimulation (3-5 years)

4

Water, sanitation and hygiene

13. Drinking water

14. Handwashing

15. Sanitation

5

Child protection

16. Birth registration 

17. Violence against children (VAC)

18. Child marriage

A sample size large enough is required to derive estimates of different levels of coverage with acceptable statistical precision. To that end, the sample frame of the Sample Vital Registration System (SVRS) of the Bangladesh Bureau of Statistics (BBS)-that provides national, divisional and district level estimates on vital events of mortality, fertility, marriage, migration, disability and other indicators-have been used.

The survey employed 13 modules in the questionnaire to catch the levels of reach and utilization of different government intervention aimed at providing social services to children, mothers and households. In addition, five new modules were introduced to capture attitudes and perceptions on key issues like child marriage, violence against children. The questionnaire also gathered information on the age, sex and education among all usual household members, as well as the environmental circumstances of the household (water sources, sanitation etc.). Together, these modules provide extremely detailed information regarding maternal and child wellbeing related activities and experiences of respondent women.

Survey data were collected by the local female registrars of the SVRS of the BBS between November and December, 2017 after completion of a 3-day training. Data was gathered using Tablet PCs and sent to the main server via internet. Among others, the training familiarized them with the usage of Tablets. In each selected household, pregnant and lactating mothers were interviewed about breastfeeding, antenatal care, maternal diets, as well as health. Special measures were taken to reduce non-sampling errors.

As the size of the reference population is different, the sample size differs across different modules. The sample size of each of the 18 modules has been presented in Table

The district level household survey has been gathered from over 216,327 heads of households/mothers/caregivers by female registrars of BBS Sample Vital Registration System (SVRS) using tablets from 2,012 sample areas, each with about 100 and plus households. This data has been transferred directly to servers, reducing margins of manual data entry errors and results are available on web-based dashboard arranged thematically and geographically by division. Scaling-up and strengthening existing government systems, by adding an additional layer of information on the current SVRS system; maximizing its ‘value for money’ and contribution to the national monitoring and evaluation systems. This report also provides a new set of information that is otherwise unavailable in Bangladesh, particularly those that address the drivers and bottlenecks in the use of social services. These elements will inform actions at central and local level to provide improved services that will in turn lead to improved social outcomes.