Maliha Khan Majlish
Dhaka has accommodated approximately 23.9 million in its 306.4 km-square core. After 1972, sovereign Bangladesh started its journey with 1.7 million people, while standing in 2024, there has been an approximate 22 million increase in population since 1972, with an annual change of 3.13%. [2] Thus, it is impossible to keep the urban health in dark while dreaming about vision 41 and Digital Bangladesh. Division (HSD) is in charge of medical and health services policy as well as health-related matters while the promotion, preventive, curative, and rehabilitative aspects are included.
The Local Government Division (LGD) of the Ministry of Local Government, Rural Development and Cooperatives (MOLGRDC) is in charge of matters pertaining to the Local Government, including Local Government Institutions as city corporations and municipalities. Hence, the provision of urban health demands collaboration among Ministry of Health and Family Welfare (MoHFW), MOLGRDC and urban local government institutions (city corporations and municipalities) for ensuring the health of overpopulated cities. The primary causes of the growing urban population are migration from rural to urban areas, the geographical expansion of already- existing city areas through the merger of rural and urban areas, the inclusion of new areas as cities, rapid industrialization and technological advancement etc. Consecutively, the over burden in cities lead to increased demand of health services, constraint resources, centralization, environmental impact etc. creating vulnerable urban health condition.
No “Health for All” without Urban Health
In the era of sustainable development, Bangladesh marked 14,384 community clinics of FY 2022- 23, ensuring health coverage beside home for rural people. While urban health lacks this coverage network and screams for delivering health care facilities feasible specially for urban poor, the ministers might be interested installation of more CRHC and PHC in urban areas with the hope to ensure Health for All. In alignment with the state, under the LGD, the urban primary healthcare projects have taken the stewardship since 1998 and are currently on their 4th phase. Despite the fact, the community level interventions are initiated and regulated but the Partnership NGOs or Private Sector, lacking regulatory and frequent monitoring as well as resource constraints in Bangladesh. Moreover, the collaboration with ministry of health can be utilized in governance, assessment, monitoring, and evaluation as well as resource mobilization in ensuring health in urban areas. Currently, 45 partnership areas are stewarded by NGOs and private stakeholders covering 11 city corporations and 18 municipalities. The NGOs and private sector engagement should be frequently monitored and assessed to aid smooth running through community levels. Budget and resource mobilization can be stretched by the concerning ministries to ensure Universal Health Coverage at doorsteps of urban dwellers. The ministers can create a chain of command to decentralize the responsibilities from grassroots level maintaining a coordinated approach for both LGRD&Co and MoHFW by creating a committee or forum or best suited organization. The facility areas might be mapped out for relocation, services availability, assessment, and initiatives after assessing the need curve among the dwellers to outrage the sub-delivery of health services, preserving special concern to underserved and urban poor. Frequent reporting and monitoring systems from private stewardships should be maintained and assessed for provision of resource mobilization or fulfilment of other needs for effective and universal functioning. Collectively, the effective collaboration and communication among LGRD&Co and MoHFW is fundamental for moving towards Health at doorsteps for urban citizens. Moreover, acknowledging the overpopulation of cities, whether 45 facility areas can mitigate the health issues of city dwellers, can be a great topic to be discussed in a cup of tea.
Reformed Urban Health Strategies
Though the liberation flag was upheld in 1971, it took almost 42 years to understand the necessity of liberating the urban health from challenges. Whatever it is, there is a popular proverb, Better Late than NEVER! Despite taking 43 years to understand, it is the consolation for us that we are now thinking about urban health. From 1972 to 2014, city corporations and municipalities are in charge of offering the primary healthcare to city residents as per the Local Government (City Corporation) Act of 2009 and the Local Government (Municipalities) Act of 2009. Moreover, the Local Government Division (LGD) of Ministry of Local Government, Rural Development and Cooperatives (MoLGD&Co) took the initiative to prepare National Urban Health Strategy 2014 while Health Services Division (HSD) of Ministry of Health and Family Welfare (MoHFW) generated National Urban Health Strategy 2020 clearly emphasizing on effective collaborations between ministries. If the Urban health is designated to both Local Government and Health ministries, the strategies generated and published in segregation might be concerning. So, setting the strategies into one umbrella has become a crying need for identifying the laps-gaps of one moto: urban health.
A National Urban Policy
The government of Bangladesh has continuously given priority to urbanization in its national development plans since the 1stFive Year Plan (FYP) (1973-1978) inclusive of nearly all following FYPs till 8th FYP (2020-2025). The Urban Sector Policy was submitted for approval in 2014 after the initial draft was finished in 2006 and waiting for approval by the Cabinet which identifies the absence of an official policy as a major impediment to planned urban growth. The urban policy should be revised and approved for inclusion the consequences of Pandemic, Industrialization, and Development occurred in last five years in Bangladesh. Moreover, in alignment with the planning and mapping urban infrastructures, it is important to keep urban health in mind as well. So, drafting a policy might inevitably require collaboration and effective engagement of ministers of Health, Local Government, Housing and Public Works and other relevant ministries, stakeholders etc.
Revised Regulations and systems
The revisions of regulations or acts regarding urban health related issues should be prime concern aligning the current situations of urban health to moderate and facilitate the provision of services uninterruptedly. As Urban Health relies on the Public Private Partnership to conduct services, weak law enforcement with outdated regulations hinders and elongates the activities of urban services. In example, Any NGO or private health institution must apply for an operation license from DGHS in accordance with the Medical Practice and Private Clinics and Laboratories (Regulation) Ordinance of 1982. Like this, the Local Government (Municipality) Ordinance 2010 and the Local
Government (City Corporation) Act 2009 mandate that private and non-profit health service providers register with the municipality and renew their registration every year. Despite the regulation, these are hardly carried out and monitored. Revision of the regulation aligning with current demand and scenario analysis must be on the top of priority list for the concerning ministries.
The collaboration between LGRD&C and Health ministers for moderating the city corporations and municipalities is a crying need for meeting up the demand of health services of urban areas. A system or chain of operations can be created involving both health and LGD representatives at grassroots level to identify the challenges as well as aiding the city corporations and municipalities technically and financially. Moreover, frequent, and effective communication must be required from grassroots to ministries. Moreover, reporting and assessment should be conducted at regular intervals to effectively implement the health services.
Urban Health Surveys
The first Urban Health Survey was carried out in 2006 to determine the health issues and service usage of various city subpopulations, mostly for slums and non-slum areas inside City Corporations. The 2013 Urban Health Survey (UHS 2013) sought to ascertain how the health and service use profile of the urban population had changed since the 2006 survey, specifically focusing on mitigating the gaps between slum and non-slum groups. After the Pandemic Strikes, the 3rd Urban Health Survey 2021 implies several challenges such as teenage pregnancy, adolescent mother, less institutional deliveries etc. despite maximum coverage in the urban areas. Despite proudly flaunting 90% health facility coverage within the two kilometers, the challenges, and behaviors towards seeking health facilities implies questioning the quality of services rather than the quantity. Moreover, operating systems or separate regulatory services might be installed in urban facilities as red cards, garments workers, slum dwellers to deliver services free of charge for these special groups. Moreover, surveys should be conducted more frequently, as 2-3 years interval, incorporating technological advancements and promoting awareness and health among urban dwellers.
No Sustainable Development without Urban Heath
Urban Health is not only the concerning issues to health minister only, rather than the involvement of all ministries. The determinants of health issues as water, sanitation, and hygiene (WASH), climate etc. impose actively passive influence on health and disease burden. Climate pollution, Lack of education, mishandling of waste, lack of hygiene facilities and allocation of service facilities impose indirect but impactful hindrance in health services. So, a shout out to the fact that ensuring Universal Health Coverage is inevitable without ensuring the other components of SDGs as quality education, gender equality, clean water, and sanitation, reduce inequalities, sustainable cities and communities, climate action etc. In alignment to this, the efficient collaboration is required for sustainability of health services in urban areas among the respective ministries.
Healthcare services Quality or Quantity!
Beside accessibility across the country, the quality of the health services must be ensured and assessed. Moreover, inadequate and subpar public health facilities, especially in primary health care (PHC) and failing to address the healthcare requirements of the slum dwellers, working and floating/street population implies major challenges for urban health. So, rather than counting numbers of healthcare delivery centers, the quality of services of existing healthcare facilities must be ensured first. Standardized user fees amongst NGO/private providers, regular monitoring of healthcare facilities, efficient data handling system as well as establishment of formal referral systems might be effective for ensuring quality services. Additionally, proper geographical mapping of health centers, resource mobilization as human resources, financial, logistics etc. between local government bodies as CCs and Municipalities, promotion of availability of health services might be the concerning areas for the respective ministers to ensure and upgrade the quality of existing services.
Is the budget sufficient!
The health policy 2011 stretches 7% of total government expenditures relating to health, emphasizing on the rural people while neglecting the health needs of urban poor. Furthermore, in recent times, Population and Housing Census 2022 report claims that 18 lakh people as slum dwellers and 22,185 people as homeless/floating population. In this context, it is inevitable for the public stakeholders to think about the universal coverage leaving such vast population in dark. Moreover, urban local bodies as City Corporations and Municipalities have limited capacity to mobilize internal budgets as well as lack a dedicated budget for public health programs or health services. In this situation, the concerning ministers of both Health and LGD may engage in negotiations with the Ministries of Finance and Planning to secure a higher budget for health services and public health interventions, as well as separate revenue and development budgets, in city corporations and municipalities, respectively. Moreover, LGD may provide technical assistance to city corporations and municipalities in raising funds for these services, especially through negotiations with businesses that are situated within their borders.
A bridge between Health and LGD
The whole discussion concise to the point of effective collaboration between two concerning ministries to carry out the development in urban health sector at first hand. In this situation the ministers of both MoHFW and LGRD&Co might think of building a bridge to facilitate the collaboration, meetings, regulatory communications between two ministries. For efficient communication, a committee can be build involving both public and private stakeholders with the hope of mitigating one demand: Urban Health. As a warrior of Urban Health, Eminence, member secretary of Bangladesh Urban Health Network (BUHN) as well as other enthusiastic organizations will certainly be honored to engage in the communication process and being a part of sustainability journey of urban health.
The urban health should be a concern for the sustainable development warriors to health for all at every corner of Bangladesh. Though standing in 2024, it cannot be denied the development occurred for past several years, but constructed and effective management of urban health as well as efficient intervention is required. The aim towards equity and universal health coverage by 2030 screams for early interventions and initiatives and put in the delusion, If Not Now, When? There is always a saying, Better Late than Never!
The writer is a Senior Technical & Development Officer, Eminence, Associates for Social Development Project Associate, Bangladesh Urban Health Network (BUHN)
