Health Care Facilities in the Urban Areas and Way Forward
One of the major social and demographic changes that Bangladesh is going through are rapid urbanization (at an estimated rate of 6%), expanding industrialization, rising incomes and increase in non-communicable diseases. Currently, about 27% of total population of Bangladesh lives in urban areas. Population growth rate in urban areas (2.7%) is more than the national population growth rate (about 1.4%). Dhaka, the largest city itself accounts for 40% of total urban people. The other five divisional cities account for 29% while 309 municipality towns have 31% of total urban population. Rapid and incessant growth of migrants in urban slum areas of large cities is creating continuous pressure on urban health care services.
Urban health care services are the responsibility of the Ministry of Local Government, Rural Development and Cooperatives (MOLGRDC). The Municipal Administration Ordinance of 1960, the Pourashova Ordinance of 1977, the City Corporation Ordinance of 1983 and the Local Government (Pourashova) Act 2009, undoubtedly allocated the provision of preventive health and limited curative care as a responsibility of city corporations and municipalities. But, the public-sector health services were not greatly assisted with requirements as there were limitations in resources and manpower. Private health care providers are the main resources for providing remedial care, including tertiary and expertise services to the urban people, but they seldom provide preventive and promotional health services. On the other hand, MOHFW is tasked with setting technical standards, packaging services, strategies and policies of the country’s health sector.
A distinctive picture of availability of different facilities and services for secondary and tertiary level health care is being seen in the urban areas, while primary health care facilities and services for the urban population at large and, specifically for the urban poor are insufficient. With the implementation of two urban primary health care projects (UPHCPs) since 1998, services have been provided by the city corporations and municipalities through contracted NGOs under MOLGRDC in the project’s areas. The project provides free services to 22% (as per household survey 2007) of the total population of the project areas.
The non-project urban areas are being served by the health facilities of MOHFW. To reach the urban poor, there are around 4000 satellite centers in total. Moreover, 35 urban dispensaries under the DGHS are providing outdoor patient services including EPI and maternal and child health (MCH) to the urban population. These urban dispensaries will be equipped with necessary facilities to use as the outlet centers of the tertiary hospitals. Various NGOs provide critical services as well as some special services (52 HIV/AIDS clinics) through 158 PHC centers, 34 comprehensive centers, 56 DOTS centers, 47 VCT centers. In conclusion, to fill up the needs of the fast growing urban population, various urban primary health care services that are being provided are yet largely inadequate.
In order to take up the mutual authorized responsibility on a sustainably effective manner, there is a need to establish a stable harmonized structure between the two Ministries. MOHFW will join to deal with this challenge through a counseling process with MOLGRDC, city corporations and concerned stakeholders in order to jointly assess, map, project, and plan HPN services in urban areas. The emphasis on urban health will be a new (and very singular) element compared to HPSP and HNPSP. It will involve MOHFW inaugurating new ways to work with its partners, notably MOLGRDC, NGOs and others.
The UPHCP of MOLGRDC and NGOs have lots of experiences in providing urban primary health care (UPHC) services through contracted NGOs. There have been striking achievements in terms of coverage, monitored quality of services and monitored exemption schemes for the poorest. These will continue, but side by side MOHFW will seek to extend the coverage of PHC services in the particular urban areas which are not covered by the UPHCP. In order to make the population being ensured with better health care, services in the urban dispensaries under the DGHS will be enhanced by inaugurating an effective referral system in the facilities. MOHFW also provides health services through secondary and tertiary hospitals that will continue to be reinforced in terms of coverage, quality and equity of service delivery in response to demand.
Priority interventions will include development of an urban health strategy with time-bound action plan in collaboration with MOLGRDC. The focal person for urban health in MOHFW will take the initiative for formulating the strategy in consultation with relevant stakeholders. Commissioning a study to determine how the two Ministries can jointly assess, map, coordinate, plan and work together to provide quality HPN services for the urban population will also be a concern of priority interventions. It will include establishing a permanent institutional arrangement and governance mechanism to integrate relevant ministries, agencies and institutions with a promised responsibility to urban health. It will also promote ways to expand or upgrade urban dispensaries for effective and eminent PHC services (including services for reproductive health, nutrition and health education). It will also incorporate an adequate referral system between the various urban dispensaries and the second and third level hospitals which will explore feasibility of introducing General Physician (GP) system. Development and utilization of urban HIS for effective management of urban health care will also be a concern of priority interventions. Thus, it will enhance capacity development of the various service providers under MOHFW and MOLGRDC. Determining the role and accountability of different NGOs and the private sectors in the delivery of urban health care services, and formalizing relationships through PPPs for diversifying delivery strategies health services will also be considered by priority interventions.
Author: Professor Shah Monir Hossain
Former Director General of DGHS, MoHFW and