Maliha Khan Majlish:
Bangladesh’s burgeoning cities face a glaring governance gap in health. By law the Ministry of Health and Family Welfare (MoHFW) sets overall health policy, but the provision of primary care in urban areas has been assigned to the Local Government Division (LGD) of the Ministry of Local Government, Rural Development and Cooperatives. In practice this split has shown confusion. Rapid urbanization (urban population ~37% in 2020, rising to ~44% by 2030) has outstripped the capacity of either sector acting alone. An official review bluntly notes a “lack of effective coordination among MoHFW, LGD/MoLGRDC and city corporations/municipalities” on urban health. Local officials themselves admit they often do not understand the law or each other’s roles. As one commentator observes, neither city mayors nor health managers have ever reconciled “how the roles and responsibilities of the two ministries regarding health care in urban areas will be discharged”.
This institutional ambiguity leaves gaps and overlaps in services. Bangladesh’s urban system is highly pluralistic: MoHFW (through DGHS and DGFP) runs a network of city dispensaries, upazila health complexes and hospitals (maternal welfare centers, TB clinics, etc.), while LGD under the Urban Primary Health Care Services Delivery Project contracts NGOs to deliver basic care in most city corporations and municipalities. Many city corporations also maintain their own hospitals and maternity centers (e.g. Dhaka South City Hospital, Chittagong’s Momen Hospitals). In effect, patients may encounter two parallel systems: one led by the central health ministry and one managed by local government with no unified planning.
The consequences are stark. Public surveys show most urban residents still rely on private doctors or pharmacies (34% of visits) while government clinics capture only a small share of care. The national urban health strategy warns that city governments typically “don’t have a separate budget allocation for health services” and can’t raise local funds for clinics. Referrals between systems are largely ad hoc; the strategy explicitly notes a “lack of structured referral system” undermines continuity and patient rights. In slum and high-risk communities, the fragmented approach means prevention and immunization drive by MoHFW may not be coordinated with NGO-led maternal health outreach. An expert seminar on health reform recently urged a “hybrid urban healthcare model” and better MoH–Local Government coordination to close these gaps.
These gaps have concrete consequences. The World Bank notes that unclear mandates and duplication have “constrained efforts to improve health outcomes”, especially for the urban poor. For example, in Dhaka’s slums UNICEF found maternal and child mortality rates far exceed national averages, in part because neither the city government nor national health network fully cover slum settlements. Urban clinics often close or lack equipment because budgets aren’t synchronized. National NGOs have filled some gaps (through projects like Smiling Sun clinics under LGD’s UPHCP), but sustainability suffers when MoHFW and LGD remain unaligned. The National Urban Health Strategy also flags poor medical waste management and environmental health as gaps that involve both LGD (which controls city waste) and MoHFW (which enforces hygiene). In summary, key coordination shortfalls include unclear roles, separate budgets, weak joint governance bodies, and fragmented data – undermining primary health coverage in urban and peri-urban areas.
Experts and officials propose concrete fixes. The 2020 Urban Health Strategy recommends revitalizing the Ministry-level and local committees: meet the Urban Health Coordination Committee (chaired by MoHFW and LGD secretaries) quarterly instead of biannually and similarly increase Urban Health Working Group meetings to bi-monthly to set sustained momentum. It also calls for dedicated technical support to these committees to prepare meeting briefs, follow up on decisions, and update stakeholders. Such mechanisms already exist on paper – the key is enforcing them. At the city level, each corporation’s Standing Health and Sanitation Committees should be empowered (with expert advisers and government health officers as needed) to integrate LG and health ministry plans.
Budgetary reforms are also needed. The World Bank advocates separate health budget lines for local governments, as was done for education. For example, city corporations could have dedicated funds (and positions) for public health programs, supported by matching grants from MoHFW. In the short term, MoHFW could treat UPHCP clinics as a formal bridge, extending them until LGD budget lines are created. To clarify mandates, an inter-ministerial agreement (or legislation) should spell out that LGD’s urban facilities deliver PHC while MoHFW hospitals handle referrals, including a shared referral registry. Data systems should be unified: the health ministry’s MIS could accept inputs from city health posts, enabling MoHFW doctors to track patient outcomes across systems.
Global experience suggests these fixes are feasible. In Thailand, for instance, decentralization gave municipal councils health budgets and technical support units – but only after a decade of adjustment to avoid fragmented care. Bangladesh might likewise institute urban health boards co-chaired by health and LGD officials, mirroring rural Upazila Health Committees that coordinate village clinics. The recent WASH projects show city water planners partnering with MoHFW on hygiene campaigns, a model to expand. Importantly, any new coordination structure must be backed by clear accountability. As a health expert noted in 2025, “clear policies, dedicated budgets, better accountability, and cooperation between city corporations and local governments” are all required to make urban health sustainable.In sum, both major and minor coordination failures between the LGD and MoHFW from inactive joint committees to unaligned budgets – are well-documented. The fixes are similarly clear: enforce and empower the coordination bodies already envisioned, align planning and funding, and formalize data and referral linkages. Implementing these steps (with political commitment and donor support) could end the “fragmented governance arrangement” that currently constrains Bangladesh’s urban health and family welfare efforts.
[The writer is a Senior Technical & Development Officer, Eminence Associates for Social Development
&
Associate, Bangladesh Urban Health Network (BUIHN) ]
