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Health Nutrition and Population Sector Program (HNPSP)
Tribal HNP Plan (THNPP)
Executive Summary

1. Background
Tribal groups in Bangladesh have their own set of languages, social structures, cultures and economic activities. They are at varying level economic and education development. They also live in sparsely populated and difficult to access terrains such as forests and hilly regions. Any development activity or provision of services needs to take into account these socio-cultural, economic, as well as spatial aspects. For HNP services to be effective in areas inhabited by tribal groups or to reach HNP services to tribal people, a concerted effort has to be made. Key issue here is how to make HNP services socially and linguistically sensitive, so that ethnic groups, such as tribal people, access and utilize the services provided by government. Discussion with tribal people, representatives of tribal groups and experts reveal that tribal depend on native medicine men or tribal healers for health care services. Access to nearest health facility, attitude of providers, language difficulties, and health seeking behaviour of tribal people largely limits effective utilization of HNP services. There is a general consensus to recognize the need for providing culturally and linguistically sensitive services in tribal area.

2. Activities under HNPSP
For this purpose a Tribal HNP Plan (THNPP) is suggested here to provide the interface for effective implementation of HNP programme in tribal areas and for tribal people. THNPP would systematically operationalise a plan to make HNP services culturally and linguistically sensitive to tribal needs. The components of THNPP are identifying areas (unions) with 25 per cent tribal population; empowering tribal people to plan for their HNP services and participate in stakeholder committees at District, Upazila and Union Level; give a choice for establishing village level health centres; training of fieldworkers for providing services at these centres or hiring of qualified doctors; training of providers operating at District, Upazila, Union, and CCs to be sensitive to the needs and expectations of tribal people in that area; developing and implementing a BCC strategy for providers (to bring about attitudinal change) and users (to encourage them to seek appropriate care); an effective monitoring and evaluation process to ensure completion of all these activities with desired outputs and outcomes.
Absence of reliable data on proportion of tribal population at union level, ethnographic studies as well as non-availability of disaggregated data for tribal (surveys and MIS) is the obstacle for operationalising the THNPP. Therefore, MOHFW would hire agencies to obtain these information through systematic ethnographic studies, with components of socio-demographic, health, and nutrition for operationalising the tribal HNP plan.

3. Implementation and institutional arrangement:
National: Secretary, MOHFW will be responsible for implementation and monitoring of Tribal HNP plan (THNPP). Secretary, together with steering committee (will be formed) shall review the progress of implementation of THNPP during its quarterly meetings. Line Directors (LD) of respective activities (ESP, BCC, HRD etc.) will include relevant tribal plan activities in their operational plan (OP), implement and monitor by compiling report with inputs from unions, upazila and district levels; and send report to steering committee. Annual Program Review (APR) will review the progress of THNPP.
District and Upazila: Management committees at District, Upazila, and union level would be responsible for monitoring the progress of Tribal HNP Plan. Chairperson of these committees would include in their monthly meeting agendas activities implemented under Tribal HNP plan and review the progress at union level.

4. Monitoring and evaluation
Sampling design of evaluation studies would include tribal districts/unions on a representative basis. During the implementation of HNPSP THNNP would monitor increased knowledge HNP services, importance of seeking HNP services for well being of women, children, aged and men, and communities' involvement in managing HNP services at local level. Community monitoring at village health centre, CCs, UHFWCs, and UHC, a key issue of tribal plan, would strengthen inputs to M&E by helping to capture information that would have gone unrecorded due to socio-cultural barriers and gender discrimination faced by communities, especially vulnerable groups. These data would demonstrate the extent to which tribal people have participated in and benefited through the implementation of tribal plan.
For the purpose of evolving an effective M&E a consultative workshop would be held for finalizing indicators for M&E on obtaining ethnographic information on various tribal groups, their needs, as well as identification of unions with 25 per cent of tribal population. A baseline survey using a cluster sampling procedure would establish the values on these identified indicators and same would be measured annually to track the progress of THNNP activities as well as impact of HNPSP. Annual independent evaluation would be carried out to assess the progress of implementation as well as outcome. The following indicators would be monitored:

5. Budget: Estimated budget for six years during HNPSP (2005-2010) is Taka 155 million (about US$ 2.58 Million).

Tribal Assessment

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ENVIRONMENTAL

Health Nutrition and Population Sector Program (HNPSP)
Environmental Assessment
Executive Summary

There are a number of environmental issues/impacts associated with the HNPSP, which have been identified. The health care waste management (HCWM) being the most significant issue, while there are other issues that also need attention due to the important impacts they may have depending on the prevailing circumstances. These issues are clean water supply and sanitation, construction related environmental issues and use of hazardous insecticides/pesticides associated with the health sector.
This report is mainly concerned with the review and mitigation of the impact of the current lack of proper HCWM in Bangladesh. The use of hazardous insecticides in the HCFs is to be managed using procedures for handling and use of such insecticides, training of workers etc. developed for the vector borne disease control program. Construction waste management problem is to be tackled by proper o observance of the national construction codes of practices to minimize environmental impacts. The problem of lack of safe water supply in the HCFs especially in view of wide spread Arsenic contamination of groundwater in Bangladesh, is to be addressed through the provision of improved water supply by linking with the ongoing schemes of GoB to this end. The issue of improper sanitation is similar to that of HCWM management as both pose the risk of spreading infection. This issue is to be considered and addressed during planning of HCWM activities at the HCF level.
This report attempts at a fairly comprehensive look at the environmental aspects of HCWM in Bangladesh. The present status of the HCWM including legislative and regulatory aspects have been reviewed and gaps in the system have been identified. These factors are broadly classified as inadequate legal provisions, inadequate institutional accountability, low awareness and capacity at facility level, resource constraints and lack of clarity on acceptable technical solutions. Strategy and its implementation including institutional and policy framework to tackle these gaps have been proposed. A phased investment and operation plan for five years during the period FY05-06 to FY09-10 at an estimated approximate cost of BDT 257 million (about US$4.5 million) has been proposed. The program is to be executed by the line director in the DGHS office under MOHFW.