Where do the urban poor go to get health care services? Sure, there is no shortage of pharmacies, clinics, and hospitals in most of the urban and semi-urban areas of the country. But those come with a high price, often too high for the rickshaw-puller who drove you to your office today, the day labourer who works tirelessly in the construction of the building next door, the sanitation worker that keeps your neighbourhood street clean, or the household help whose early morning doorbell ring announces the arrival of the day.
There are also a number of secondary and tertiary level specialised hospitals and medical college hospitals in cities like Dhaka and Chittagong. Yet these are specialised hospitals where a regular person with a sizeable wallet has a hard time accessing, let alone the poor without the assurance of the next day’s square meal if s/he misses work due to illness.
Thanks to the government, the rural population, particularly the poor, can go to the community clinics at the village and ward levels for treatment of basis diseases, material health care, and referrals in diagnosis of more severe diseases.
This much needed intervention is supported by the National Health Policy 2011 that provisions the establishment of a community clinic for every 6,000 citizens.
But if you are unfortunate enough to be an urban poor living in a slum, squatter, or simply on the pavement, there is no community clinic to attend to for your aliment. It’s because there are no community clinics in urban areas. Thus, unless you have money, often a good amount, there are not many places you can go to save you from the suffering.
The existing scenario in urban health in Bangladesh is unfortunate considering the National Health Policy 2011 has well-articulated objectives of providing primary and emergency health care for every citizen and expansion of quality health care based on equality irrespective of location.
The country also has a National Urban Health Strategy 2014 that aims to create “an environment where urban people, especially the poor, will have equitable access to utilise public and private sector health services.”
The gap in urban public health service is also glaring considering Bangladesh’s remarkable performance in health indicators. The country has achieved remarkable results in MDGs in reducing under five mortality rate and maternal mortality rate, while it leads neighbouring countries India and Pakistan in lower child mortality rate and higher immunisation coverage.
Despite the challenges in decentralisation, financial and human resources, and out of pocket payment, Bangladesh’s impressive results in coverage through delivery in primary health care facilities has prompted WHO to term it as an example of effective low-cost service delivery.
But the explosion of urban population in the last couple of decades has caught Bangladesh off-guard.
With declining employment in the agriculture sector, increasing landlessness and natural disasters, people are drawn to the glimmer of opportunities that the cities offer. The majority of the urban poor resort to living in the ever-growing unauthorised slums. The poorest among them, unable to afford Tk1,500 to Tk3,000 that renting a room entails, settle in the squatters and even right on the streets under the open sky.
The urban poor migrating from the rural areas find themselves unwelcome in their own country. Life in underdeveloped slums, squatters, and pavements means living without access to basic services. The poorest among them, who do not have a holding number for address, cannot even get their national identity cards or birth certificates due to its specific requirements in the application forms.
The urban poor’s low access to health services are starting to have a dent on the national health indicators. According to Bangladesh Demographic and Health Survey and Bangladesh Urban Health Survey 2013 data, infant mortality rate in urban poor areas is 49 per thousand, as opposed to 43 in rural areas, while malnutrition rate is 49.6% as opposed to 42.7% in rural areas.
The urban-rural disparities in health are not going to be resolved automatically, and are only likely to increase. At current rate, the country is projected to transition as an urban majority country by 2040. With as many as 62% of the urban population dwelling in the poverty of slums in 2009, it would not surprise anyone if the number of urban poor multiplies concurrently in the future. The pressure on urban health service delivery mechanism, thus, will be insurmountable.
So what can be done to prevent this foreseeable enormous crisis? Some simple yet resolute and immediate steps can go a long way.
The urban poor migrating from the rural areas find themselves unwelcome in their own country
The absence of an effective primary public health care service in urban areas essentially boils down to a policy and institutional quagmire between the two ministries, Ministry of Local Government, Rural Development, and Cooperatives (MoLGRD&C), and the Ministry of Health and Family Welfare (MoHFW).
While the MoLGRD&C are responsible for providing the primary health services in the urban areas through the City Corporations and Municipalities, the MoHFW is assigned to provide this service in rest of the non-urban areas of the country.
The problem arises as the city corporations are yet to be equipped with the budget, institutional capacity, human resources, and autonomy to deliver the services that primary healthcare demands.
There is also no effective coordination taking place between the two key ministries to handle the massive challenge in urban health.
NGOs and private providers ie, NGO Health Service Delivery Project (NHSDP), the Urban Primary Health Care Services Delivery Project (UPHCSDP), Marie Stopes Clinics, and BRAC Manoshi project fill in some of the gap in urban primary health. Yet, their scope and coverage are limited. Unless a strong government institutional mechanism is established, it is difficult to envision the urban poor’s equitable access to primary health care services any time soon.
Much of the problem can be sorted out through establishing a strong coordination mechanism between the two key ministries, which is yet to happen. We have to look only as far as the Urban Health Strategy for the necessary policy provision, which assigns “Urban Development Wing of the Local Government Division” under the MoLGRD&C to coordinate the strategy.
It also calls for a “high level coordination committee” combined of the two ministries to centrally implement the strategy.
At the same time, if the urban poor are to receive effective primary health care, the City Corporations need to be provided with adequate financial, technical, and human resources.
These central administrative institutions are also suitably positioned to coordinate the disperse activities of GO-NGO service providers, which can amount to a lot in filling the gap.
It is not that there is a shortage of commitment part of the government. In addition to the array of policies, the government’s strong political commitment in addressing hunger and under-nutrition has placed Bangladesh in the 14th among the developing countries and the second among Asian developing countries in the Hunger and Nutrition Commitment Index.
Now it is a matter of translating the commitment into action. Before the situation spins further beyond control with ever-increasing urban population, resolute measures for effective collaboration, coordination, and synergies between the MoLGRD&C and MoHFW to streamline the primary health services is a dire necessity.
It is easier said than done, but if the expectation-defying achievement in rural health are to be taken as any indication, then solving the urban health quandary should be, however formidable, an achievable feat.
The urban poor, as equal citizens of the country, deserve it.
Asif Imran Khan is Advocacy Coordinator, Concern Worldwide.