Our growing cities and their healthcare challenges

Although the goal was set for 2016, in urban areas of Bangladesh we reached the target of bringing the total fertility rate (TFR) down to 2.0 births per woman by 2013.

This finding from the Bangladesh Urban Health Survey 2013 is but one of the corroborations for Bangladesh's claim to exemplary success in the health sector.

There was a fear that health indicators in urban settings might be lagging behind those in the rural areas, because of the built-in infrastructure and manpower mobilised in rural areas by the government. The findings of Bangladesh Urban Health Survey 2013 as disseminated on October 14, 2014 have not only dispelled these fears, but have given the government, the development partners and the NGOs working in the health and family welfare sector something to boast about.

The Survey however, emphasised that by 2039, Bangladesh would become an urban country, which means the majority of people would start living in urban areas. It estimated that around 79.5 million people would live in urban areas by that time, compared to the 53 million at present.

A United Nations estimate states that population of greater Dhaka city will grow from the present day 17 million to 27 million by 2030.

Bangladesh Urban Health Survey, 2013 was designed to obtain a broad health profile of the urban population in slums and non-slum areas of nine city corporations and other urban areas of Bangladesh. National Institute of Population Research and Training (NIPORT) pioneered the survey as lead agency while Measure Evaluation of USA and ICDDR,B provided technical support. ACPR, a research organisation, supported the mission in collecting data. NIPORT previously conducted an urban health survey in 2006.

The preliminary findings indicated a significant improvement in access to universal healthcare for urban citizens. The survey found that 95 percent of urban communities had healthcare facilities within two kilometers of where they lived and reported to have health workers within their reach, resulting in greater health awareness, pre-natal and post-natal care in particular. TFR is the lowest – 1.7 births per woman – in city corporation non-slum areas, and the highest – 2.0 births per woman – in slums and 1.9 births per woman in other urban areas. This indicates significant changes in demographic patterns, consistent with national goals and priorities.

The Contraceptive Prevalence Rate (CPR) is highest (70 percent) in urban slums and lowest in non-slums (65 percent) indicating that couples are highly likely to reach the goals of replacement level of fertility by 2016. In slums, under-5 mortality rate (U5MR) declined by 30 percent during last seven years whereas Infant Mortality Rate declined by 22 percent and child mortality and neonatal mortality declined substantially.

Of course, there has been no change observed in the incidence of teenage pregnancy over seven years in slums and non-slum areas. In case of access to electricity and use of mobile phone, universal access for the urban population was observed in all survey domains.

All these indicators speak of major improvements in urban health scenario that resulted from inclusive efforts and appropriate policy measures of government, development partners and non-government organisations combined.

But the survey also mentions that over half of the population will start living in urban areas by 2039. The size of the urban population has grown from 8 percent in 1974 to 28 percent. The urban population is also growing much faster, around 5 percent against the national growth rate of 1.35 percent. This is happening because of the push and pull factors compelling rapid migration from rural to urban areas.

The mushrooming 'cities'

The government too, is contributing to this trend, turning more growth centers and marketplaces into municipalities and expanding city corporations for political purposes.

Rural communities are becoming 'urban' overnight, with the pressure from city fathers. This is a very interesting phenomenon, perhaps unique to Bangladesh. There were hardly 80 municipalities in 1974, but this figure has now quadrupled to 321 municipalities with 11 city corporations.

In fact, all of this happened without any studies conducted and implications assessed or powers delegated to city corporations and municipalities. They are unable to mobilise their own resources or make reforms to holding tax or other non-tax revenues to make themselves sustainable and capable of keeping their cities clean and green.

The Local Government (City Corporation) Act, 2009 requires city corporations to cover 28 broad areas of activity including public health but gives them no power to change their organograms or take decisions on revenue or administrative matters, even though they are supposed to be autonomous bodies. Mayors of city corporations and municipalities are found loitering at the floor of LGD at the Secretariat for some grant-in-aid, thus registering their allegiance to the party in power and protecting them from fear of superseding their elected bodies.

The health and family welfare services in urban areas are supported mainly by development partners like USAID, ADB, DFID, SIDA, UNFPA etc.

In most cases the GoB's participation comprises of the sharing of land and the mobilisation of some manpower, that too on deputation. The health units of city corporations and municipalities merely play a supervisory role. NGOs and private sector agencies are the main providers of health services, with funding from development partners. Hardly any part of the revenue earned by urban local governments is spent in health sector services except perhaps some occasional anti-mosquito and cleanliness drive.

There is no visible planning to sustain the huge health care services expenditure although under the Urban Primary Health Care Services Delivery Project, a city corporation or a municipality has the provision of maintaining a primary health care sustainability fund at 1 percent of its revenue budget.

Overdependence on NGOs and DPs for urban health care might in the long run create a catastrophic situation; unless urban local bodies, with the support of GoB, undertake planned ideas and major interventions in sight right now.

The bifurcation of greater Dhaka city on political consideration is not a remedy to resolve issues of addressing urban welfare. There should be steps to restrict migration of rural population to cities by expanding facilities in rural areas as suggested by former president of India Mr. APJ Abul Kalam in a recent speech in Dhaka a few days back. We could also apply the experience of China in suburban townships, providing urban health care services as prime priority intervention followed by education.

If we are to hold on to our current global status in healthcare and make urban areas liveable for future generations, we must take the sustainability of urban health care services as a national priority issue.