The urban poor are victims of widening health inequalities because of inadequate facilities and inaccessible health service delivery system in urban areas.
The urban poor population is growing rapidly and the health service delivery system is failing to address their vulnerability to different health problems of communicable diseases, non-communicable diseases, and malnutrition and micronutrient deficiencies, public health experts have noted.
Instances of exploitation, bad demeanour and lack of ethics in health service delivery to the illiterate and poor are also apparent in clinical and public health studies.
Because of inadequate public service provision in urban areas, many urban dwellers seek care from the informal private sectors, the studies show.
Officials of local government ministry, which is responsible for health services in urban areas, say that the available health facilities are not adequate enough to provide health services to the poor population, particularly the growing poor section.
A recent study of ICDDR,B that reviewed 61 studies on issues related to social justice, health, and human rights in urban Bangladesh, found that more than 70 per cent of the urban poor seek care from the informal private sector like pharmacies, drug sellers, and traditional healers as the first point of care as the health services for the urban poor was not accessible.
It pointed to the lack of coordination between the ministries in the field of health service provision, coverage, and referral and said those problems posed critical challenges to ensuring quality and accessible healthcare for the urban poor.
The study also pointed to widening inequalities in health indicators between the urban poor and other urban people.
Another study by researchers of Bangabandhu Sheikh Mujib Medical University and Japanese universities found that the urban poor were vulnerable to different non-communicable diseases and they had adequate risk factors associated with non-communicable diseases.
Public health experts find the current health system of Bangladesh complex, involving several government ministries, the private sector, non-government organisations, and development partners, each playing an important role.
The ministry of health is responsible for formulating health policy and regulation and for ensuring all citizens have access to comprehensive healthcare and although rural health provision is mainly the responsibility of the health ministry, the urban health system is governed by the local government ministry, they say.
The health service delivery system in Bangladesh have different setups, the rural areas have community clinics, union health centres, upazila hospitals and district hospitals but no such tiered health services are available in the urban areas, they point out.
The urban areas have tertiary hospitals or institutes, run by health ministry but the primary healthcare is provided by the local government ministry under Urban Primary Health care Services Delivery Project.
The project runs 47 primary health care centres and 10 maternity centres across Dhaka city for the urban people, especially the poor.
But due to insufficient human and financial resources of urban local bodies, the local government ministry has been providing primary health care services in urban areas through an Asian Development Bank-supported project that contracts out the services to NGOs.
Health centres have only one doctor and four paramedics while the maternity centres have seven doctors.
The health centres and maternity centres offer only primary healthcare services like family planning, maternal and some neonatal services.
During visits on Tuesday and Wednesday, the health centres and maternity centres at Goran and Moghbazar were seen with a few patients with minor ailments like cough, cold and fever.
Some pregnant women were found at the maternity centres but they said they did not rely on the maternity centres as those were not well-equipped.
‘I will go to other public hospitals if I see any complications in my sisters’ delivery,’ said Akhi Begum at Goran Maternity Centre on Tuesday.
Masuda Begum, manager of Nayatola Health Centre and Maternity Centre at Moghbazar, said they offered reproductive health services like normal delivery and some caesarean delivery at their maternity centre and provide immunisation, family planning services, pre-natal and anti-natal services at the health centres.
She said that most of those availing the service were lower and lower-middle-class people and admitted that the services were not adequate.
The ICDDR,B study titled ‘Right to health and social justice in Bangladesh: ethical dilemmas and obligations of state and non-state actors to ensure health for urban poor’, published in June 2018, said, ‘The essential package of services offered is largely focused on maternal, neonatal, and child health, with limited capacity for the prevention and control of emerging and re-emerging diseases or for providing specialised care for men, adolescents, and the elderly’.
Also, few urban primary healthcare services are offered at convenient times for the working population, and there are no referral linkages from primary healthcare centres to public secondary and tertiary healthcare facilities, as those are governed by the health ministry, it says.
Urban health expert and ICDDR,B associate scientist Sohana Shafique says that Bangladesh is witnessing a three per cent growth in urbanisation annually while urban slum settlements are growing at the rate of seven per cent per year.
If the current trends continue, she says, the number of urban population will exceed rural population although the health services for the urban poor are not increasing widening the inequalities in health services delivery.
The widening inequalities between urban poor and other urban people are evident in the urban health statistics of different studies and surveys.
About 45 per cent of the births in urban areas are attended by skilled birth attendants while the rate is 15 per cent for urban slum areas, the studies show.
The birth registration rate is 53 per cent in urban areas compared to 28 per cent in the urban slums while improved sanitation facilities are available to 54 per cent of urban people compared to nine per cent in the urban slum.
The initial breastfeeding rate is 50 per cent in the urban areas but 35 per cent in urban slums.
The under-five mortality rate is 53 per 1,000 in the urban areas compared to 95 per 1,000 in urban slums.
The nutrition status also shows inequalities with 50 per cent urban slum children suffering from stunting compared to 33 per cent in the non-slum areas.
At least 19 per cent for urban slum children grows weaker due to malnutrition compared to 16 per cent of the non-slum children.
Slum children in the urban areas in Bangladesh are also suffering from stunted growth, a trend several studies have related to malnutrition.
The studies say that the slum children are suffering from stunting and other malnutrition-related complications such as thinness and underweight, higher than national prevalence.
The stunting prevalence of the under-five children in slums is around 45 per cent against about 35 per cent for the non-slum and national level, the studies have found.
A Plan of Action for Nutrition, announced by the government in December 2017, says, ‘A half of the under-five children in slums are stunted, which is around one-third for non-slum and other urban areas’.
Other studies done by local and international organisations corroborate the government’s findings of stunted growth of slum children.
A study, State of Food Security and Nutrition in Bangladesh, done by National Nutrition Services in 2015, finds that the prevalence of stunting among the under-five children of Dhaka slum was much higher (45 per cent) compared to other areas of Bangladesh.
Bangladesh’s national stunting prevalence of under-five children is 35 per cent, it says.
Another study of the UN World Food Programme on ‘Food Insecurity and Under-nutrition in Urban Slums in Bangladesh’, released in early 2016, reveals that an alarming 44 per cent of slum children experience stunted growth and nearly one in five (16 per cent) are too thin for their height.
Health experts have blamed a lack of intervention by the authorities concerned for the stunted growth of the slum children.
They say that the slum dwellers have less access to nutrient foods and improved water and sanitation facilities which are responsible for the stunted growth, thinness and underweight of the slum children.
Another reason for stunted growth is the lack of exclusive breastfeeding, they note.
The WFP study also says that the slum households in Dhaka (50 per cent) and nearly two-thirds of slum households in Barisal (63 per cent) consume less than 2,122 kcal per capita per day.
It also shows that slum households derive 63 per cent of their energy from cereals, chiefly rice.
The National Nutrition Services study finds that the proportion of exclusive breastfeeding is comparatively low (25 per cent) in Dhaka slums than in other areas, with the overall exclusive breastfeeding rate falling to 47 per cent.
The absence of basic amenities in low-income settlements in urban areas, together with unsanitary environments and overcrowding, creates a vicious cycle of infections, malnutrition, and poor health, says the ICDDR,B study.
Citing a report ‘State of the World’s Mothers 2015’, it says that the urban slum is one of the worst places to be a mother in.
‘Not surprisingly, health indicators are not only far worse in urban slums than in non-slum urban areas, but are well below the national average,’ the study commented.
While under-five mortality rate is 46 (per 1000 live births) at the national level, the rate is 57 among residents in urban slums, it says.
Similarly, neonatal and infant mortality rates in urban slum settlements are double those in non-poor urban areas.
Although there are official provisions for antenatal care, skilled birth attendance, and full childhood vaccine coverage from the PHC services, service coverage remains low in urban slums.
In the past decade, many infectious diseases have re-emerged in urban areas and are more widespread in urban than in rural areas.
Overweight and obesity — risk factors for non-communicable diseases (NCDs) —are also increasing over time even among urban poor women.
Hypertension, diabetes mellitus, cancer, and other NCDs are also more common in urban poor communities.
The ICDDR,B study says that because of inadequate public service provision in urban areas, many urban dwellers seek care from the formal and informal private sectors, which are rapidly increasing in size and importance.
More than 70 per cent of the urban poor seek care from the informal private sector like pharmacies, drug sellers, and traditional healers as the first point of care, it says.
Unregulated over-the-counter drug selling by untrained informal providers is of obvious concern as is the high cost of formal private sector care, differentially impacting the poorer segment of the population and leading to high out-of-pocket expenditures, the study finds.
Unnecessary diagnostic tests and caesarean sections are also common and impose a substantial economic burden on the poor. High out-of-pocket expenditures for these items may be catastrophic for slum dwellers and poor households, leading to deeper impoverishment, it notes.
The study says that different other studies in similar settings show that the poorest households are the most heavily burdened and often resort to borrowing and selling assets to meet expenses, in the absence of provisions for financial and social protection that would mitigate these impacts.
It says that a lack of trust or communication between healthcare providers and patients is another source of stress and anxiety for the urban poor.
Due to low educational status and social position, the urban poor are often unable to voice their concerns or understand medical advice. Being unaware of their right to respectful and timely quality care, many of the urban poor are incapable of asserting themselves or demanding quality and fairness.
Programme managers working under the Urban Primary Health care Services Delivery Project said that the project itself suffered from different setbacks and failed to meet the need of the urban poor people.
Expired in March 2018, the project was extended for one year, but the allocation remained stalled, they said.
The employees working under the project remained unpaid for the last nine months.
The project director, Abdul Hakim Majumder, said the existing health services were not adequate, but they were trying to offer the best services with limited resources.
‘We have 57 health centres and 10 maternity centres against the demand for at least 400 health centres and 50 maternity centres,’ said Abdul Hakim, also joint secretary of local government ministry.
According to the Bangladesh Bureau of Statistics, there are 22.32 lakh dwellers in slums in the country and 10 per cent of them are below five years of age. Independent researchers, however, put the figure much higher as they estimate about 40 lakh people living in Dhaka slums only.
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