National Research University Higher School of Economics

Health Care Access Challenges among Poor In-Migrants in

Dhaka City Corporation, Bangladesh

Presentation by
Md Reza Habib
Master Programme in Population and Development,
Institute of Demography, Faculty of Social Science.

Moscow, 21 April, 2018

Introduction & Background
(A)
● In 1974, only 9% of Bangladeshi population lived in urban areas,
by 2014, this proportion reached 28% (UNFPA, 2016).

● About 67.4% of the total rural-urban migrants settled in Dhaka

(30%), Gazipur and Narayanganj districts (UNFPA, 2016).

● Poor in-migrants settle in the slum areas (Hossain & Khan, 2012) and
the highest percentage of slums population lives in Dhaka city
as around 29% (Census of Slum, 2014).

● 72% of slum dwellers and 58% of non-slum dwellers, in Dhaka

City Corporation, reported that their birth place were in rural
areas (Urban Health Survey, 2006).
Introduction & Background
(B)
● Most of the “floating people” (72.5 in urban and 27.5% in rural) live in Dhaka city (Socio-
Economic and Demographic Report, BBS, 2015).

● In-migration leads to shortage of health care services and increases competition among
dwellers for getting better services.

● Unlike the non-slum dwellers, the dwellers of the slums lack of access to health services
– a slum generally lacks access to public health services.

● Bangladesh has proven great progress in achieving MDG 4 and MDG 5. The country still
does not have a comprehensive health policy (Islam, A. & Biswas T. 2014).
 
Problem Statement
● 3% of the(A)
Gross Domestic Product (GDP) is spent on health services and the total health
expenditure in the country is about US$ 31 per capita, 67% is being out-of-pocket (OOP)
expenses (WB & WHO, 2014).

● In the year of 2013, the health care deliveries were 36.7% and 65.1% in slum and non-
slum area accordingly (Urban Health Survey, 2013).

● For the last 15 years, the Local Government Division has been providing primary health-
care services to poor urban dwellers, but it has been unable to meet their needs and
demands adequately (Afsana & Wahid 2013).

● The Ministry of Health and Family Welfare is providing secondary and tertiary health care
services in urban areas but the outcomes are less satisfactory (Afsana & Wahid 2013).
Problem Statement
(B)
● The total fertility rate is 2.0 in slum and 1.7 non-slum areas of Dhaka city (Bangladesh Urban
Health Survey, 2013; 62).

● Increase their vulnerability to communicable, non-communicable diseases and death.

● Mortality rate of infant (49) and under five years’ children (57) in slums are higher than in
rural are as 40 and 49 (BUHS, 2013 & BDHS, 2014).

● Antenatal care (72%), skilled birth attendance (37%), and Postnatal care (34%) are low in
urban slums, compared to non-slum are as 90%, 68% & 60% (BUHS, 2013).
Main Objective

● The aim of the study was to explore and describe the healthcare access
challenges among poor in-migrants in Dhaka City Corporation.
Theoretical Framework
Supply- sides barriers

Geographical
Availability Affordability Acceptability
Accessibility

Demand- side
barriers

Source: Adapted from Peters et al. (2008) Poverty and access to health care in developing countries
and Ensor and Cooper (2004) Overcoming barriers to health service access: influencing the demand
side
Data & Methodology
● The data obtained from Bangladesh urban health survey 2006 & 2013, conducted by NIPORT,
ICDDR,B & Measure Evaluation and supported by USAID and DFID. In addition, district census
of Dhaka Zila, 2011 conducted by Bangladesh Bureau of Statistics.

● A retrospective explorative cross-sectional analysis was. Percentages and content analysis of

the variables related to urban in-migration were presented.

● The findings have been written based on the comparative analysis with different variables in
different year.
Urban in-Migration & Reasons of In-migration in Dhaka
City
Urban In-migration in Dhaka City Corporation Reasons of In-migration in Dhaka City Corporation-2006
(2006-13)
1.05
Other
90 0.45
2.55
Becauseof river erosion
80 1.4
70 For familial 37.3
reasons 10.95
60 For 18.4
0.45
marriage
50
For children’s
0.45
40 education 0
30 For own0.4
1.75
education
20 For more work/ 5.95
service/transfer 24.1
10
Looking 33.9
0 for work 60.9
0 10 20 30 40 50 60 70
Born in slum ofDhaka city Corporation
Born in other cities Male Female

Sources: Bangladesh Health Survey- 2006 and 2013

Urban Health Care System
Urban Primary Health Care
System

Local Government
NGO Private MHFW
Department

BRAC
UPHCSDP • Hospitals/clinics • DGHS
SSFP • Qualified private • DGFP
practitioners
MSCS • Relevant
NGO • Pharmacy/ Medicine Operational Plan
Other
sellers
NGOs • Drug
• Unqualified providers Administration

Sources: ICDDR,B, 2016

Supply-side Barriers: Geographic Accessibility

Location services in City Corporation Slum

0.20%
Private Facility 59%
40%

0.90%
NGO Facility 31%
50%

0.40%
Govt. Facility 54%
13%

0.20%
Any health facility 32%
68%

0% 10% 20% 30% 40% 50% 60% 70% 80%

< 1 Km 1 - 5+ Km DK Distance

Source: Bangladesh urban Health Survey, 2013

Supply-side barriers: Availability

● Unavailable health facilities-

No. of Govt. No. of Private No. of No. of bed at Govt. No. of bed at Govt.
Population In hospital/clinic hospital/clinic No. of bed at No. of bed Diagnostic Hospt / Clinic/ Hospt/ Clinic/nursing
Dhaka City /nursing /nursing Govt. at Private centre nursing home per home per 1000
Corporation home home facilities facilities 1000 inhabitants inhabitants
6970105 24 620 8719 16944 1040 1.25 2.43

** No. of hospital bed (0.6) per 1000 people, No. of Physician(.389) per 1000 & No. of Nurse (.213) per 1000 in BD (WB, 2011 & 2012)

● Unavailable health workers, staff absenteeism /vacant (14%), opening hours

No. of Doctor per 1000 No. of Doctor per No. of Nurse per No. of Nurse per No. of Technical No. of Technical
people at Govt. facility 1000 people at Non- 1000 people at 1000 people at Non- Staff per 1000 Staff per 1000
Govt. facility Govt. Facility Govt. Facility people at govt. people at Private
facility facility
0.56 0.87 0.44 0.46 0.10 0.17

Sources: Calculated the data from Census of Dhaka district, 2011

Supply-side barriers: Availability
● Unavailable drugs and health related stuffs-
● Waiting time for getting service
Problem lies with lack of effective supply
% of Recipents
chain management, lack of funds (or timely

4% <15 min. release of available funds) to pay for supplies

15-30m
19%
32% 30m- 1hr
1-2hr is also a serious problem. Shortage of
>2hr
15% Don’t know logistics in most public health care centers
14%
16%

Source: ICDDR,B, 2016

Supply-side barriers: Affordability
● High costs and prices of services - 66% of health care costs are out-of-pocket expenses
borne by individuals and families; Informal payment to mediator to get service from public
health facilities. (The Baseline Service Delivery Survey for HPSP conducted in 1999 found
that 22% of people make an extra payment to the workers when they visit government health
services and 27% pay an unofficial registration fee). cost of medicine, cost of consultation,
cost of hospitalization, cost incurred with respect to tests/investigations

● Private–public dual practices- Doctors of the public hospitals are referring patients to paid
treatment or paid operation in their own private clinics (Rahman & others, 2005)
Supply-side barriers: Acceptability

● Complexity of paying bill and service cost.- Most of the urban poor people are illiterate and they
have to face the complexity of paying bill and service cost.

● Less trust towards health service providers- The doctors are blamed for prescribing
unnecessary examination and diagnosis suggestion to the patients since they get commission
from the diagnosis centers (Rahman and others, 2005).
Demand-side barriers:
● Means of transportation and ambulance service-
% at Indoor % at outdoor

Source: ICDDR,B, 2016

150
MCWC
100 MCHTI

50 DH

0 MCH
MCH DH MCHTI MCWC
0 20 40 60 80 100 120 140
Rickshaw/van/cycle Ambulance/car/Micro bus Rickshaw/van/cycle Ambulance/car/Micro bus Auto/CNG/Motor cycle
Auto/CNG/Motor cycle Walking
Walking Train
Train

Almost 65% of the ambulances in these facilities are non-functional and lack of maintenance or fuel
money. Moreover, in many public hospitals the available ambulances are either inoperative or
being used by the physicians and other staff. ( Islam,A. & Biswas T. 2014:369).

● Less informed about the proper health care service providers or physicians.
Demand-side barriers:
● Own cultural preference, attitude and norms as well as social stigmas related health, Example:
home deliveries without skilled assistance, giving priority to husband decision, traditional or
religious faith healing practice.
(The DHS -Demographic and Health Survey data show that 44 per cent of women reported
difficulty in getting permission to go to a health provider as a constraint to health service
consumption. In addition, 49 per cent of women reported that finding someone to accompany them
was a problem)

● Cash flow is not available among urban poor people: Cash flow is not available among urban
poor people. Most of them are involved in day labour activities. Many slum dwellers are informal
daily labourers and have to look for an income, often outside of their community (Vijver, 2015). It
is also barrier to get emergency health care service.
Conclusion
 Not only should government and other assisting institutions/organizations to provide the health
care service, also should ensure the four dimensions like geographical accessibility, availability,
affordability and acceptability for poor urban migrants in health care.

 In addition, community based participation, regulatory approaches, available transportation

facilities in emergency cases, recruit more staffs in peripheral health service centers, culture
sensitive health service, proper monitoring and supervision are necessary to ensure the access
of poor urban migrants in Dhaka City Corporation
 o u f o r You r
Thank Y
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