Assessment of district performance in making

progress towards MDGs in Bangladesh

Carel de Rooy1 and Siping Wang2

Overview
Properly planned and conducted household surveys are the most reliable mechanism to assess
progress regarding achievement of Millennium Development Goals (MDGs) in countries
where the routine availability of development outcome or impact information is not readily
available. UNICEF has been supporting the Government of Bangladesh (GoB) since the year
2000 to undertake such surveys. Their results have been made available to GoB as well as
Development Partner institutions and organizations for planning, and prioritizing investment
and action. A sizeable share of data that has enabled the understanding of progress regarding
achievement of MDGs has come from these surveys.

Since the year 2000 three such surveys’ data have been made available (2000, 2003 and
2006)3. All these were undertaken with a household sample size of approximately 60,000 and
had a geographical resolution to the district level, allowing the comparison between the 64
districts of Bangladesh in each of these years. Approximately 20 indicators covering most
MDGs were used in each survey. Unfortunately somewhat different indicators were used
every time allowing for comparison over time of only approximately one third of the
indicators used.

This brief paper seeks to make a trend analysis over the 2000 to 2006 period using eight
indicators that could be compared over time.

Data for the analysis

The Child Risk Measure (CRM) is a composite index. It comprises 8 indicators which have
data by district for the years 2000, 2003 and 2006. The 8 indicators are:
• Infant mortality rate (IMR),
• Proportion of births not attended by skilled health personnel,
• Proportion of children 6-59 months without supplementation of vitamin A,
• Proportion of households without consuming iodized salt,
• Proportion of households without access to an improved water source,
• Proportion of households without access to an adequate sanitation facility,
• Proportion of primary school age children not attending school, and;
• Proportion of children under 5 without a birth registration.

1
UNICEF Representative, Bangladesh
2
Chief Planning, Monitoring and Evaluation Section, UNICEF Bangladesh
3
BBS and UNICEF, 2000: "Progotir Pathey 2000: Achieving the Goals for Children in Bangladesh", Dhaka,
Bangladesh;
BBS and UNICEF, 2003: "Progotir Pathey 2003: on the road to progress", Dhaka, Bangladesh
BBS and UNICEF, 2007: "Bangladesh Multiple Indicator Cluster Survey, 2006, Final Report, Dhaka,
Bangladesh, BBS and UNICEF

1 Assessment of district performance in making progress towards MDGs in Bangladesh

Source of data
Except for IMR, data for 7 indicators are from the MICS 2000, MICS 2003, and MICS 2006.
The data for IMR are from the Bangladesh Annual Vital Registration Sample Survey.

Methodology of computation
The index of each indicator for each district is calculated as a relative deviation from the
national average. A district with a negative value means that it has a comparatively lower risk
than a district with a positive value.

The CRM is the weighted average of the index of each of the 8 indicators. Each index is the
standard deviation of a given district value from the national average. The weight is
determined based on a conceptual framework (see the figure on the next page). The IMR is
given a weight of 4. The proportion of births not attended by skilled health personnel and
proportion of children 6-59 months without supplementation of vitamin A are given a weight
of 3. A weight of 2 is allocated to the following indicators: proportion of households without
consuming iodized salt; proportion of households without access to an improved water source;
proportion of households without access to an adequate sanitation facility; proportion of
primary school age children not attending school. The proportion of children under 5 without
a birth registration is given a weight of 1.

CRM maps
For the years 2000, 2003 and 2006 a color code was given to child risk related ranges for
each index. Red was allocated to represent districts where children are most at risk, here
represented by the value of a given index for districts being higher than the upper limit of the
standard deviation from the national average of that index. Blue was used to represent
districts where children are exposed to the relatively lowest risks, represented by index values
lower than the lower limit of standard deviation from the national average of that index.
Yellow represents districts where children are exposed to relatively medium risks and is
characteristic of index values between the lower limit and upper limits described above.

Maps depicting CRM trends

Additionally, color coding has been used to show evolution or changes over time in the CRM
ranking. This was done by showing the difference between data from 2003 and 2000; 2006
and 2003, as well as 2006 and 2000. Red represents a drop in CRM ranking. Pink depicts no
progress, at high risk in CRM rank. Yellow represents no progress at medium risk in CRM
rank. Blue shows districts that sustained a low risk CRM rank. Brown identifies those
districts that have evolved from high to medium risk in CRM rank. Green shows progress
from medium to low risk in CRM rank.

Rapid Assessment of District Performance Determinants

For further analysis UNICEF sought to understand through a rapid assessment (see Annex 1),
the most important positive determinants that might explain what makes districts such as
Jhenaidah, Munshigani, Meherpur, Dhaka, Narail and Khulna perform well, so that these can
be supported, promoted and enhanced elsewhere. Likewise it sought to be equally important
to acquire an understanding of the negative determinants that should be overcome, avoided
and neutralized to allow districts such as Bandarban, Cox’s Bazaar, Sherpur, Rangamati and
Jamalpur make accelerated progress towards MDGs.

2 Assessment of district performance in making progress towards MDGs in Bangladesh

The rapid assessment, undertaken by UNICEF field staff over a period of a three days,
revealed that for several indicators more favourable results emerged for the “Low
Performance Districts” (>10% difference):
• Pupil-teacher ratio
• Population-doctor ratio
• Population-health personnel ratio
• % population affected by major natural disasters
• Frequency of turn-over in key district level posts
• Per-capita expenditure of the MoHFW
• Average NGOs per district

Other indicators did not show any relevant difference between “Low Performance Districts”
and “High Performance Districts” (<10% difference):
• Average population per district
• Frequency of turn-over in key UNO level posts
• Frequency of turn-over in key Upazila level posts
• INGOs
• Bi-lateral donors
• Multi-lateral donors

The only indicators found that might explain the difference in performance between “Low
Performance Districts” and “High Performance Districts” were poverty and geographic
isolation:
• % of Poor population (20% higher in low performance districts)4
• % of Unions not seasonally accessible (two and one half more disfavourable for the
low performance districts)

Conclusion
When comparing data from 2000 with that of 2006, twelve districts substantially declined
while nine districts improved in their CRM ranking. Of the 9 originally classified in 2000 as
relatively high-risk districts 4 actually evolved into the medium risk category. In contrast
seven districts out of the 13 originally classified as relatively low-risk dropped into the
medium-risk category. Roughly 20% of the districts in the medium-risk category moved
either into the high-risk or low-risk categories.

Out of 15 variables assessed to attempt to explain the difference in performance between the
two categories of districts, only two variables emerged: poverty and geographic isolation.

4
World Bank, Bangladesh Bureau of Statistics and World Food Programme, 2009 : "Updating Poverty Maps of
Bangladesh: Key Findings, 2005", Dhaka, Bangladesh

3 Assessment of district performance in making progress towards MDGs in Bangladesh

The current drive of the MoHFW to promote the establishment of community clinics seems
very well placed in the context of the above related findings. If these clinics are:
• Well equipped;
• Provided with a regular supply of high quality medicines;
• Sustainably resourced with qualified human resources;
• Targeted upon the areas of the country that are seasonally not accessible and;
• Focused upon issues where inequity of access or outcome are greatest .......

this strategy could have an impact upon under-five, new-born and maternal mortality
reduction.

A recent study published in The Lancet5 implicitly suggested that economic determinants
have a lot of weight in explaining health outcomes in Bangladesh. This also implies that rapid
economic growth tends to shadow other determinants of health (and possibly other
development) outcomes. The above mentioned rapid assessment substantiates this finding.

In 2009 UNICEF supported the GoB through its Bangladesh Bureau of Statistics to conduct
yet another MICS. This time however 300,000 households were surveyed allowing for an
enhanced geographic resolution down to the upazila (sub-district) level. The results of this
survey will be launched in November 2009. They are potentially an important baseline for the
current government, both its administration and the country’s elected officials.

Similar surveys – with geographic resolution at sub-district level - will be conducted in 2012
and 2015 allowing the government to continuously assess progress towards the achievement
of MDGs. Subsequent ranking of districts will be made possible to recognize, acknowledge
and better understand those that have made most progress. Most importantly, this approach
will be replicated for sub-districts as well. This will, with other management tools emerging
for fine-tuning of social sector investment decisions6, facilitate the prioritization of
investment decisions by the Government of Bangladesh and its development partners alike. It
will also allow for the undertaking of remedial action for the least performing upazilas and
districts so that MDGs can be achieved with equity.

Finally, it is interesting to note that the rapid assessment suggests that over one third of the
population in both categories of districts assessed has been affected by major natural disasters.
This finding, although likely to be an over-estimation and therefore it requires substantiation,
however calls for a much more proactive approach to address emergencies. Instead of being
reactive the government, with support of its development partners, should enhance its
investment in resilience building to minimize impact of natural disasters and allow
communities and families to rapidly bounce back to normalcy one the critical phase of natural
disasters has passed.

5
“Effect of the Integrated Management of Childhood Illness strategy on childhood mortality and nutrition in a
rural area in Bangladesh: a cluster randomized trial” Shams E Arifeen et al. August 2009.
6
World Bank, WHO, UNFPA and UNICEF supported “Marginal Budgeting for Bottlenecks (MBB)”

4 Assessment of district performance in making progress towards MDGs in Bangladesh

Conceptual Framework of the Child Risk Measure

Infant Mortality Manifestation

Births not attended by

skilled health
personnel
Immediate factor
Vitamin A not
supplemented to
children 6-59 months

Households with no
access to an Households with no
improved drinking access to adequate
water source sanitation facility
Underlying factors

Households not School-age

using iodized children not
salt attending school

Process factor
Births not registered

The methodology of computation of the child risk measure (CRM), a composite index, is:
CRM = 4 * RD1 + 3 * (RD2 + RD3) + 2 * (RD4 + RD5 + RD6 + RD7) + RD8
where RDij is the relative deviation of the indicator Rij,
RDij = (Rij – ARi) / SDi,
i = 1, 2, … 8;
j = 1, 2, … 64

Rij is the indicator i for the district j;

• R1j: Infant mortality rate (IMR),
• R2j: Proportion of births not attended by skilled health personnel,
• R3j: Proportion of children 6-59 months without supplementation of vitamin A,
• R4j: Proportion of households without consuming iodized salt,
• R5j: Proportion of households without access to an improved water source,
• R6j: Proportion of households without access to an adequate sanitation facility,
• R7j: Proportion of primary school age children not attending school, and;
• R8j: Proportion of children under 5 without a birth registration.
64
ARi is the average of 64 districts for the indicator i, ARij = ∑ (Rij / 64)
j=1
64
SDi = standard deviation of districts for the indicator i. SDi = {∑[(Rij – ARi)2 / (64-1)] }1/2
j=1

5 Assessment of district performance in making progress towards MDGs in Bangladesh

 Annual Child Risk Measure (CRM)
Figure 1. CRM 2000 Figure 2. CRM 2003

Index
-18.4 - -9.5
Index
-15.4 - -9.6
-9.4 - 9.3
-9.5 - 9.5
9.4.- 18.0
9.6 - 24.3

Figure 3. CRM 2006

Index
-23.3 - -10.3

-10.2 - 10.2
10.3 - 24.3

6 Assessment of district performance in making progress towards MDGs in Bangladesh

 Trends in Child Risk Measure (CRM)

Figure 4. Change from 2000 to 2003 Figure 5. Change from 2003 to 2006

Figure 6. Change from 2000 to 2006

Code
Declined in CRM ranking
No progress, static at high risk of CRM rank
No progress, static at medium risk of CRM rank
Sustained at low risk of CRM rank
Improved from high to medium risk of CRM rank
Improved from medium to low risk of CRM rank

7 Assessment of district performance in making progress towards MDGs in Bangladesh

 Distribution of Districts According to the Child Risk Measure
2006

10 districts, 16% 10 districts, 16%

Low risk
Medium risk
High risk

44 Districts, 68%

25

20

15

10

-5

-10

-15

-20

-25

8 Assessment of district performance in making progress towards MDGs in Bangladesh

 Complete Data: Child Risk Measure Ranking
Annual Data Trend Data
Districts 2000 2003 2006 2003-2000 2006-2003 2006-2000
Cox''s Bazar 18.0 21.1 17.7
Bandarban 17.4 20.6 13.5
Sherpur 16.5 2.7 22.1
Rangamati 15.4 -4.6 18.1
Jamalpur 14.7 13.7 10.8
Brahmanbaria 14.5 9.4 4.6
Panchgarh 12.4 -0.5 -6.2
Sunamganj 11.9 24.3 7.1
Noakhali 10.8 6.8 5.0
Sylhet 9.2 -12.5 -0.8
Sirajganj 9.2 4.9 11.8
Netrokona 9.0 7.8 16.3
Kishoreganj 8.5 13.3 14.9
Khagrachhari 8.5 1.7 7.5
Bhola 8.0 2.8 7.1
Nilphamari 7.3 11.0 -1.7
Rangpur 7.2 7.5 -0.7
Sariatpur 6.1 10.8 6.7
Joypurhat 6.0 -12.8 -1.3
Kurigram 5.6 6.8 0.3
Baherhat 5.4 0.6 -2.0
Naogaon 5.4 -5.0 1.9
Pabna 5.3 6.2 5.0
Thakurgaon 4.6 12.2 7.0
Habiganj 3.7 10.5 16.8
Gopalganj 2.0 -6.7 -0.6
Manikganj 1.9 -11.0 1.6
Chittagong 0.9 -10.8 -1.8
Madaripur 0.6 0.9 -0.2
Moulvi Bazar 0.1 7.2 -6.0
Bogra -0.1 -6.1 -3.9
Narsingdi -0.2 3.2 -6.9
Mymensingh -0.5 9.2 17.1
Patuakali -0.6 6.7 6.5
Barisal -0.7 0.2 -13.9
Laxmipur -1.5 7.7 -1.4
Chandpur -2.0 -15.4 -6.7
Gaibandha -2.1 3.1 6.1
Nawabganj -2.3 -2.5 8.3
Lalmonirhat -4.1 4.7 2.0
Rajbari -4.4 -4.4 2.4
Comilla -4.7 -9.9 -11.5
Pirojpur -4.9 -9.6 -2.2
Faridpur -5.1 -6.5 -2.7
Satkhira -6.0 -2.5 5.3
Dinajpur -6.0 -3.1 3.2
Feni -6.2 -2.9 -16.7
Chaudanga -6.9 -5.9 -13.5
Natore -7.3 -4.4 -2.9
Tangail -8.5 4.6 7.4
Rajshahi -9.0 -11.3 -7.3
Jessore -10.0 -14.0 -9.0
Kushtia -10.2 -10.5 -9.5
Jhenaidah -10.2 -9.1 -13.9
Narayanganj -10.3 -6.9 -6.1
Meherpur -10.3 -13.0 -23.3
Gazipur -10.4 1.9 -3.1
Munshiganj -10.7 -14.6 -22.7
Dhaka -11.1 -15.1 -18.6
Khulna -14.0 -13.4 -13.3
Narail -14.4 -1.3 -12.9
Barguna -17.3 0.0 -6.4
Magura -17.9 -1.2 -8.6
Jhalkathi -18.4 3.3 3.9
Average 0.0 0.0 0.0
Stdev 9.3 9.5 10.2 Declined in CRM ranking
Lower limit -9.4 -9.5 -10.2
No progress, static at high risk of CRM rank
Upper limit 9.3 9.5 10.2
High Risk in CRM ranking No progress, static at medium risk of CRM rank

Sustained at low risk of CRM rank

Medium Risk in CRM ranking
Improved from high to medium risk of CRM rank
Low Risk in CRM ranking
Improved from medium to low risk of CRM rank

9 Assessment of district performance in making progress towards MDGs in Bangladesh

Acknowledgements
All UNICEF sections: Health & Nutrition, Water and Environmental Sanitation, Child
Protection, Education, Planning, Monitoring & Evaluation and Field Operations participated
in development of this brief paper. Field Operations were instrumental in very rapidly
collecting data for the Rapid Assessment of District Performance Indicators.

Annex 1. Questionnaire for Rapid Assessment of District

Performance Determinants

1. Basic Information:
Indicator Total
Total population of the district (2006) (source: DC/CS Office)
Number of Unions
Number of Unions seasonally not accessible by road or boat
Number of Primary Schools (include both Government and registered non-
Government schools)
Total number of primary school teachers (2000/2003/2006, absolute number
corresponding to year )
Total number of primary school students (2000/2003/2006, absolute number
corresponding to year )
Number of Health Facilities (hospitals and clinics, meaning: District
Hospital, UHCs, H&FWCs, Health Sub-centres)
Total number of doctors (2000/2003/2006, absolute number corresponding to
year)
Total number of medical assistants (2000/2003/2006, absolute number
corresponding to year)
Total number of nurses (2000/2003/2006, absolute number corresponding to
year)
Number of population affected by major natural disasters from 2000 to 2006
Names of major natural disasters from 2000 to 2006 ( Cyclone or Flood year
wise )

2. Governance
2.1 Frequency of turn-over of key government officials at district level
Key District Posts Number of persons on the Remarks
post from 2000 to 2006 (if any)
Deputy Commissioner
Civil Surgeon
District Primary Education Officer
Executive Engineer DPHE
Deputy Director Local Government
Deputy Director Social Service
Total

10 Assessment of district performance in making progress towards MDGs in Bangladesh

 2.2 Frequency of turn-over of key government officials at upazila level
Key Upazila Posts No of post in the district Number of Estimated number Remarks
persons on of months that posts (if any)
the posts remained vacant
from 2000 to between 2000 to
2006 2006
Total no. of Currently
posts in the occupied
district
Upazila Nirbahi Officers
Upazila Health and
Family Planning Officers
Upazila Primary
Education Officers
Sub Assistant Engineer,
DPHE
Upazila Social Service
Officers
Total

3. Financial resources
3.1 Annual allocations in thousands of Taka:
Sectors 2000 2001 2002 2003 2004 2005 2006
Health &
Nutrition
Education
WATSAN
Social Welfares
Local Government

3.2 Annual expenditure in thousands of Taka

Sectors 2000 2001 2002 2003 2004 2005 2006
Health &
Nutrition
Education
WATSAN
Social Welfares
Local Government

4. Development partners
Names of partners Local NGOs International Bilateral Multi-lateral
NGOs donors donors

11 Assessment of district performance in making progress towards MDGs in Bangladesh

Annex 2. Outcome of the Rapid Assessment of District Performance Determinants

% of
Population % of
living population Frequency Multi-
% of under % of unions Population- affected by Frequency of turn- Frequency Frequency latera
population national seasonally Pupil- Population health major of turn- over in the of turn-over of turn-over Per capita l
to total Total poverty not teacher doctor personnel natural over in DC district key in UNO in Upazila expenditure Bilateral dono
population population line accessible ratio ratio ratio disasters post posts posts key posts of MoHFW LNGOs INGPs donors rs
2000- 2000-
2006 2006 2005 2006 2006 2000-2006 2000-2006 2000-2005
Cox''s
Bazar 1.6 2,257,809 52 63 109 24,541 12,117 1.1 6 6 5 3 83.94 9 3 0 5
Bandarban 0.2 318,616 65 41 52 7,586 3,402 1.4 6 5 4 3 294.32 17 3 2 7
Jamalpur 1.6 2,234,166 54 88 77 26,597 9,009 8.4 10 7 7 4 90.43 773 4 2 9
Habiganj 1.3 1,880,380 47 39 68 22,385 11,083 8.5 6 5 5 3 91.59 4 1 1 0
Barguna 0.7 996,986 61 21 42 24,719 8,497 0.0 9 3 4 2 115.36 7 1 1 3
Panchgarh 0.7 948,572 56 0 157 27,102 10,236 0.0 7 7 6 3 105.05 9 1 0 0
Sunamganj 1.6 2,305,939 49 56 107 37,597 18,062 8.5 5 7 5 2 77.55 8 3 1 0
Barisal 2.0 2,855,780 60 26 63 36,302 12,692 4.7 6 5 5 3 254.44 9 1 2 3
Munshiganj 1.0 1,463,010 19 0 76 14,630 6,989 7.7 7 8 8 3 109.76 0 1 0 7
Narail 0.6 792,335 45 0 46 25,559 8,225 1.9 7 6 9 5 111.35 307 2 1 8

Low performance for children

High performance for children

%
% of Population Frequency Frequency Frequency
Average unions Population- affected Frequency of turn- of turn- of turn- Average
population seasonally Pupil- Population- health by major of turn- over in the over in over in Per capita LNGOs Multi-
per % Poor not teacher Doctor personnel natural over in DC district UNO Upazila expenditure per Bilateral lateral
district Population accessible ratio ratio ratio disasters post key posts posts key posts of MoHFW district INGPs donors donors
1,537,591 56 55 71 22,458 9,433 32 7 30 5 3 168.91 162 2 1 5
1,673,127 46 22 79 27,339 11,139 38 6 39 6 3 131.63 67 2 1 4

12 Assessment of district performance in making progress towards MDGs in Bangladesh