Strengthening the urban health system for the extreme poor

Urban health is becoming increasingly important in Bangladesh due to the explosive growth in the population and the concentration of those living in urban slums. By 2030, more than 60% of the population will be living in urban areas.  Although Bangladesh has made remarkable progress in achieving health and nutrition Millennium Development Goals, nearly one fifth of the urban population still live below the poverty line. Poor access to basic amenities and health services has hampered progress towards meeting the Sustainable Development Goal of “Universal Health Coverage” and contributes to poor health outcomes of people living in poverty.

The Urban Health Systems Strengthening Project (UHSSP) was a component of the Urban Health Programme (UHP), funded by UK Aid. The purpose of the programme was to improve access to maternal, newborn and reproductive health services for the urban poor.

Implemented by Options and PHD Bangladesh, the project created a more harmonised and supportive environment for urban health. We focused on improving coordination between government departments, better information management, increasing access for the poor and building the capacity of stakeholders within the health system. The project worked in three pilot cities of Dinajpur, Jessore and Mymensingh; and at the central level with the Ministry of Health and Family Welfare; and the Ministry of Local Government.

Bringing together government stakeholders for better coordination

Previously, the responsibility of urban health fell between the central and local governments and there was very little coordination. Our interventions brought together key stakeholders to agree on how to address the needs of the urban poor. Effective local government coordination and governance structures were created in the three pilot municipalities. This transformed the understanding of urban health. There was markedly better communication between stakeholders and this resulted in joint planning, mapping, and improved distribution and delivery of urban health services.

The Mayors and Health and Family Planning Managers of the three municipalities are now confident and fully empowered to oversee health in the cities.

“Before UHSSP, we never thought collectively or planned anything together – let alone working together. It is unbelievable the way we now work together in the Municipal Health Coordination Committees and Ward Health Committees. And it has been possible because of the interest and commitment of our three Mayors.” 

– Mr. Wahiduzzaman, Sanitary Inspector, Jessore Municipality

Improving Management Information Systems for better services

Information systems are crucial to gather essential health data to inform the planning and delivery of health services. The national Health Management Information System (HMIS) in Bangladesh was not able to capture complete health information at the municipality level, therefore making it very difficult for effective planning within the local government.  UHSSP created the urban health atlas, city health profiles and a municipality health dashboard, adapting and integrating the data into the national HMIS software (DHIS2).

For the first time, municipality level data was integrated into the national system resulting in complete health service data.

Municipality coordination committees and health managers are now able to review the reports generated and use the information for better decision making and planning service delivery. The use of the evidence has resulted in the review of area demarcations, client referral systems, and better location of clinics. Service delivery arrangements have been reorganised including establishing new, and relocating existing, EPI centres to make them more efficient.

Due to efficient planning, there are now 50% more EPI centres in Jessore and 22% more satellite clinics in Mymensingh.

Enabling access to services for the extreme poor

The availability and access to primary health care services in Bangladesh varies significantly between the poor and non-poor. The extreme poor are not able to access key health services and suffer poor health outcomes as a result. There is currently no national policy on identifying the extreme poor and what they are entitled to, service delivery is patchy and inconsistent, leaving the most vulnerable behind.

The NGOs serving the poor were uncoordinated and had differing systems and criteria for identification and providing for the extreme poor. We developed a common understanding and approach to identifying and reaching the extreme poor. We introduced a common health care entitlement card (CHCEC) that enabled extremely poor people to access services by any government or non-government provider, at little or no cost, in the three pilot locations.

CHCECs were distributed to 6,887 families who received services free or at subsidised costs. This resulted in the number of women giving birth at home decreasing from 35.6% in 2016 to 14.7% in 2018.

“The entitlement card for the extreme poor and the management information system integration have been two un-imaginable achievements by the Municipal Health Coordination Committees. We must hold on to, and continue these at all cost.”

– Dr. Dilip Kumar Roy, Civil Surgeon, Jessore

Building skills to develop city health plans

Building the capacity of the government structures to oversee urban health is crucial for the long term sustainability. UHSSP supported the cities to develop a health vision and prepare annual and five-year City Health Plans.

This was the first time in Bangladesh that health plans were developed for urban areas. The plans are helping municipalities to effectively coordinate and use all available resources to implement, monitor and improve urban health services, particularly for the poor.

“I had given very little thought to this issue [of urban health] and had no clue as to how to go about it before the project came along”

– CEO, Mymensingh Municipality

As Bangladesh pushes forward in hopes of attaining ‘Middle Income’ status, it is critical to ensure coordinated investments in human development, especially when it comes to health. The challenge that lies ahead is to build on the momentum that NHSSP has created, and to continue to strengthen inclusive health systems, fostering improved coordination among health service providers at multiple levels, and maintaining quality and consistency of health services for those most in need.