SHARE Bangladesh - EU supports strengthening better policy pathways on health for urban poor

While Bangladesh is experiencing a steady economic growth over last couple of years, the persistence of health inequalities is also a serious concern with this growth scenario. Such inequalities have been one of challenges to achieve the targets of Universal Health Coverage (UHC) in the country, particularly in the urban contexts and for the urban poor. 

Bangladesh has a very good success in some areas of health sector programme such as Expanded Immunization Programme (EPI), Maternal, Neonatal and Child Health (MNCH). There are, however, challenges too because of some emerging factors e.g. epidemiological transition to non-communicable diseases, rapid urbanisation and increasing dominance of profit-making private healthcare providers in the very fragmented urban health systems. These challenges create barriers for the urban poor to get better access to health services. 

Strengthening Health, Applying Research Evidence (SHARE) is one of the EU projects in Bangladesh which is supporting urban poor people’s access to health services and those who suffering from Non-communicable Diseases (NCD’s).

Health Policy Dialogue (HPD) under the project’s Think Tank initiatives discusses about such challenges engaging relevant stakeholders including policy makers to discuss perspectives towards better policy formulation.

The 3^rd policy dialogue under the Think Tank was held on 22 September, 2018 entitled, “Urban Health and Universal Health Coverage in Bangladesh”, which was focused on existing challenges in urban health into achieving universal health coverage in Bangladesh. The discussants (including senior policy makers in Bangladesh) identified a range of issues as well as recommendations for better policies to support the health of urban poor. 

Professor Robaet Ferdous of the University of Dhaka moderated the event and welcomed all the participants reminding them of key issues such as inequalities in health services and good governance; lack of health literacy, problematic referral systems and coordination in health services especially for slum dwellers.

In the keynote presentation, Dr. Sohana Shafique, Assistant Scientist and Deputy Project Coordinator, Universal Health Coverage Programme at icddr,b and Dr. Md. Khalequzzaman, Assistant Professor, Department of Public Health and Informatics, Bangabandhu Sheikh Mujib Medical University (BSMMU) shared impact of rapid urbanization on public health in urban areas. Referring to different surveys and studies, they highlighted that in due to the epidemiological shift in Bangladesh currently 60% of the deaths is caused by non-communicable diseases (NCDs) and the burden is very high among urban poor as well. For example, in Dhaka slums, a recent study showed that the prevalence of hypertension was 20.7% in women and 18.6% in men and the prevalence of diabetes was 22.5% and 15.6% in men and women respectively, which is much higher than the estimated national prevalence. About 40% of people in urban slums were overweight and obese and 90% of the poor did not consume recommended amount of fruits and vegetables. The speakers also discussed the challenges in urban health systems and highlighted the importance of coordinated efforts across multiple sectors working in this field to achieve universal health coverage in Bangladesh.

Dr. Mushtuq Husain, Co-ordinator, Co-ordination and Support Center, DGHS, MoHFW, Government of Bangladesh discussed about rapid urbanisation and its health consequences arguing that slum dwellers are more vulnerable compared to rural and other urban residents. He emphasised that financial risk protection of the poor should be ensured for getting quality health services. “Though health sector of Bangladesh attained remarkable achievements but there are disparities”, Dr. Husain added. Ms. Doerte Bosse, first Counselor at the European Union Delegation in Bangladesh highlighted theimportance of social determinants of health and taking ‘Health in all polices’ approach in addressing urban health issues, for example housing, hygiene and safety. Mr. Saidul Karim Mintu, the Mayor of Jhinaidah Municipality (Local Government) said that health facilities like Community Clinic could be established in slum areas to serve urban poor. “The main duty of the municipality remains only to provide vaccination and succeeded in EPI coverage”, he urged to serve urban poor and provide comprehensive primary health services. 

Dr. Magduma Nargis, former Additional Secretary, MOHFW; also a former Project Director of Community Based Health Care (CBHC) project suggested to have a long term planning with clear vision to achieve UHC by 2032. The plan can include establishing Community Clinicsin the urban areas, especially in the slum settings engaging community participation. “People of all socio-economic classes should get the primary health care facilities across urban and rural. How it can be done?” she remarked. Dr. Mahbub Elahi Chowdhury, Scientist, UHC of icddr, b emphasized on governance and stewardship and collaboration between Ministry of Health and Family Welfare and City Coprorations for strengthening Urban Health Coordination Committee to improve Universal Health Coverage achievements. In this regard he said, “We need to rethink about the legal structure and whether there is any need to change the current structure.”

Dr. Quamrun Nahar, Senior Acting Director of HSPSD at icddr, b recommended that health facilities should also be availed by lower middle class people. She also emphasized on regulation of the private sector, as main healthcare providers in cities, and the important role of urban health committee in achieving UHC. Dr. Iqbal Anwar, Scientist and the Project Director of SHARE project discussed about responsibility of MOHFW for governance and stewardship and highlighted the fact that relying only on private health facilities is not enough to make health services available for all. He suggested adapting short and long term plans like establishing strategy for urban health immediately and increasing coordination between Ministry of Local Government, Rural Development and Co-operatives (MOLGRD&C) and Ministry of Health and Family Welfare (MOHFW) s to achieve UHC. 

Dr. Ashadul Islam, Secretary of MOHFW stressed on proper area mapping to appropriately serve the urban poor. He said that the government wants to allocate 3% of GDP for National Social Safety Programme and fund mobilization is needed. He also suggested for establishing Call Centre and Health Camps to reach the slum dwellers in an easier way. Professor Dr. TA Chowdhury, the Chairperson of Health Policy Dialogue (HPD) summarized the key recommendations, e.g; need for an integrated and multispectral approach; establishing referral linkages; enhancing preventive services in addition to curative service; emphasizing on social determinants of health; replicating Community Clinic in slum areas; community participation by engaging Community Support Groups; voucher system for urban slum dwellers etc. He emphasized the need for a greater partnership under the stewardship of the MOHFW and among MOLGRD&C, other relevant ministries, NGOs and the private sector with defined responsibilities to improve urban health in Bangladesh. “More focused discussions should be organized periodically with fruitful participation from all walks of life”, Prof. Chowdhury stated and concluded the session. 

The dialogue helped different individuals in health sector to engage, connect and interact with key decision makers; sensitized the policy makers into thinking better policy formulation on NCDs targeting the urban poor. It also brought MOHFW and MLGRD&C into same table to start working together in a coordinated and integrated way. As next steps it was decided that a policy brief would be formulated based on the discussions held and widely shared among stakeholders and the Think Tank members would share the recommendations will key policy makers in the country. 

For more information about the EU funded project activities: http://www.share4health.com/