88234
BANGLADESH: GOVERNANCE IN SECTORS
           Working Paper




 Bangladesh Governance in the Health Sector:
       A Systematic Literature Review




                                               i
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     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¿QDQFLDOPDQDJHPHQW3)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¿QDQFLDOPDQDJHPHQWSODQEXGJHWDQGEXGJHWH[HFXWLRQ
Government
                 x +XPDQUHVRXUFHPDQDJHPHQWVWDI¿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:HOIDUH0R+):RI¿FLDOVWR
           KLJKHUOHYHORQHVQRWDEOHZDVWKH¿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
      DQGGHYHORSPHQWSDUWQHUV0DUWLQH]: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
      GHFLVLRQV0DKPXG7KRPDV$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$QGDOHHEHWDO6LGGLTXH	
.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¿FLDOSURFHVVHVde 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\DQGPLGVLQ
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¿QLWLRQ³JRYHUQDQFHLVWKHWUDGLWLRQV
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¿QDQFLDOPDQDJHPHQWSODQQLQJEXGJHWLQJDQG
                                       budget execution)
    Government Effectiveness        x +XPDQUHVRXUFHPDQDJHPHQWVWDI¿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\FDUH7DEOH

                 7DEOH2XWSDWLHQW([SHULHQFHVZLWK3XEOLF+HDOWK6HUYLFHVLQ
                                                                                  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
ELOOLRQLQ6DDG3URWHFWLRQLVTXLWHVWURQJRQ0DUFKWKH*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\:HOIDUH0R+):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%'7RU86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
    UDWHVLQWKHUHYHQXHEXGJHWUHPDLQTXLWHKLJKDERYHSHUFHQWIRUHDFK\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 $QQH[7KH RI¿FLDO EXGJHW IXQG
release process goes through several stages, which may affect regular and timely release of funds
DFURVVGLIIHUHQWPLQLVWU\OHYHOV:RUOG%DQNHWDO3UREOHPVLQFROOHFWLQJIXQGXWLOL]DWLRQ
VWDWHPHQWVIURP''2VIRUVXEPLVVLRQWRFHQWUDOOHYHOZDVLGHQWL¿HGDVRQHRIWKHLVVXHVLQIXQG
UHOHDVHGHOD\VLQWKH¿QDOTXDUWHU6HH$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]LODOHYHO0R+):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\OLQHLWHPDOVRJLYHQWKHLPSRUWDQFHRI
     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
                   7DEOH9DFDQF\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


           )LJXUH0DSRI+XPDQ5HVRXUFH9DFDQF\5DWHDW'LVWULFW/HYHOLQ3HUFHQW




     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\UROOZKLFKLQFOXGHVPHGLFDORI¿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

             7DEOH6XPPDU\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¿FXOWLHV0DUWLQH]

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
     OHQVKLJKOLJKWVWKHVWUHQJWKRIJRYHUQPHQWEXUHDXFUDFLHVWRUHVLVWUHIRUPHIIRUWV6XQGHZDOO
     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 DWWDLQHG0DUWLQH]+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\HDUG'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
     OHYHOVWDIIKRZHYHUWKHLQFLGHQFHDQGWKHDPRXQWRILOOHJDOIHHVSDLGDSSHDUVWREHGHFOLQLQJ
     (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+&VSHUFHQW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        5DWHChaudhury&
                                              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\GHSDUWPHQWDQGQRWZHOOUHVRXUFHGDVDUHVSRQVHDSULYDWH¿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]DWLRQ7KRPDV%+:

                                        - 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
     FKDOOHQJHV7KRPDV 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\VWHP0,6+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\IHZWLPHVDQGD1DWLRQDO+HDOWK6HUYLFH8VHUV¶)RUXPSURSRVHG
XQGHU+1363EXWQHYHULPSOHPHQWHGDQG¿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%'7ELOOLRQLQ6DDG          
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$QGDOHHEHWDO6LGGLTXH
	.KDQGDNHU Andaleeb et al. (2007) conducted a survey on patient satisfaction across two
SXEOLFKRVSLWDOVDQGWKUHHSULYDWHKRVSLWDOVLQ'KDNDFLW\¿QGLQJWKDWDYHUDJHVDWLVIDFWLRQVFRUHV




                                                                                                                    29
     RIDQGRXWRID¿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\RIGUXJV6LGGLTXH
     	.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
     UHJLVWHULQJPHPEHUVWKHUHSRUWFLWHVNH\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\LQFOXGHDGHTXDWHVSDFHDQGKHDOWK\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2UGLQDQFHWKHUHLVDSHQDOW\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:HOIDUH0R+):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¿FLDOSURFHVVHVde 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\DQGPLGVLQRWKHUZRUGVDW
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             SUHSDUDWLRQLGHQWL¿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¿VFDOIUDPHZRUNPHGLXPWHUP
     )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
      )LJXUH3K\VLFLDQ9DFDQF\5DWHLQ3HUFHQWDQG0053HU/LYH%LUWKV




Source: DGHS Database, 2013.




                                                                                    43
              )LJXUH1XUVH9DFDQF\5DWHLQ3HUFHQWDQG0053HU/LYH%LUWKV




     Source: DGHS Database, 2011.




44
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                                                                                                        49
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            Service Provision.




50
    BANGLADESH: GOVERNANCE IN SECTORS
               Working Paper




Bangladesh Governance in the Primary Education Sector:
            A Systematic Literature Review




                                                         i
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     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¿QDQFLDOPDQDJHPHQWSODQEXGJHWDQGEXGJHWH[HFXWLRQ
Government       x +XPDQUHVRXUFHPDQDJHPHQWVWDI¿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¿FLDOSURFHVVHVde 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/,3IXQGVDQGWKHGHWDLOVRIWKHÀRZRIIXQGVGHOD\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\KDVWDNHQVWHSVWRDGGUHVVWKLVFKDOOHQJH0R30(
      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\VWHPDWLFDSSURDFKWRUHVHDUFKEXLOGLQJRQHDUOLHUVWXGLHV¿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¿QLWLRQ³JRYHUQDQFHLVWKHWUDGLWLRQVDQGLQVWLWXWLRQV
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¿QDQFLDOPDQDJHPHQWSODQQLQJEXGJHWLQJDQGEXGJHW
                                   execution, auditing, reporting)
    Government
                                x +XPDQUHVRXUFHPDQDJHPHQWVWDI¿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;
GHPRFUDWLFSUDFWLFHVDWWKHORFDOOHYHOWUDQVSDUHQF\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,QWHUQDWLRQDOQRUPVUHTXLUHFRQWDFWKRXUVEXWRI¿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\6FKRROV51*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[SHFWHGWREHXQGHUWDNHQRYHUWKUHHSKDVHV032OLVWHG51*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%DQNEDQG:RUOG%DQNE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\EXGJHWDQGSHUFHQW
     RIQRQVDODU\EXGJHWEXW8(2RI¿FHVVSHQGSHUFHQWDQGSHUFHQWRIVDODU\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¿FHSHUFHQWRI
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
     VLQFHPD\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*2VDQGWKHJRYHUQPHQWUXQV8SD]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
     SURJUDP3('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
*36WHDFKHUVKDYHPRYHGEHWZHHQVFKRROVSHUFHQWRI¿FLDOO\WUDQVIHUUHGWKDQ51*36RQO\
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\ZLWKSHUFHQWRIDOO'3(2RI¿FHVDQGSHUFHQWRI8(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\,*6D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(DQGWKHSULYDWHIRUSUR¿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]DWDPDGUDVVD
     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¿FLDOSURFHVVHVde 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
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