Health policy planning for slum-dwellers
According to the latest census by the Bangladesh Bureau of Statistics (BBS), 2.23 million people are living in slums across the country and 1.06 million in Dhaka city.
The Global Livability Ranking 2019 has adorned Bangladesh capital Dhaka as the third least livable city in the world just after the war-torn Syrian capital Damascus and Lagos.
A ratio says that 18% of urban people are receiving minimum health care from the existing health facilities. The remaining 82% is mostly out of these facilities where the slum-dwellers are a major part.
Urbanization is a powerful engine for economic growth and socio-cultural development worldwide. But in Bangladesh, it is a matter of concern regarding health when urbanization is that swift. Article 25 of the Universal Declaration of Human Rights (UDHR) talks about universal standard living. Basic health service is a constitutional obligation for the government under Article 15 of the Constitution of the People's Republic of Bangladesh. Articles 15 and 18 of the National Health Policy 2000; 2008 (revised) also reflect the same.
Though Bangladesh has witnessed significant improvements over the last few decades in terms of health and population indicators, alarming disparities exist in the field of slum and non-slum dwellers considering health, nutrition, housing, water and sanitation. Overcrowd and poor living conditions are the common feature of the dwelling unit environment of the slum area. It is observed that more than 81 per cent of the respondent families are living in a single room with an average of five household members. Lack of ventilation, inadequate light, damp and dark house cause the dwellers living unhygienic. Enough supply of clean water is one of the prime requirements for hygienic living, though there is no supply of piped water. Inadequate supply of tube-wells, sanitation, and the drainage condition of the slum is making the status quo more complex. Thus creates a vicious cycle of infection, malnutrition and poor health.
Additionally, changing lifestyles, malnutrition, persistent social inequality, economic insecurity, and unstable social life have given rise to new health challenges- non-communicable diseases, substance misuse, and mental health.
Spread of infectious diseases like tuberculosis, hepatitis B, dengue fever, Pneumonia etc. have re-emerged in city slums.
The Local Government Act 2009 talks about preventive health and curative care for all underprivileged citizens. But, less attention is given regarding providing basic health care to slum-dwellers.
For the past 15 years, the Local Government Division has been responsible for providing primary health-care services to poor urban populations, but they don't have separate budget allocations for health services of slum-dwellers.
The Ministry of Local Government, Rural Development and Co-operatives (MoLGRC) Municipal Administration Ordinance 1960, the Pourashova Ordinance 1977, the City Corporation Ordinance 1983 all of them have specific provisions regarding preventive and curative health services provided by public sectors.
In spite of having laws, ambiguity concerning roles and responsibilities, the urban health system lacks effective planning and coordination among ministries. Outdated regulations and their patchy enforcement have led to fragmented health-service delivery for poor people.
Several non-government organizations are involved in primary care and maternity services for disadvantaged slum-dwellers. Marie Stopes, Smiling Sun Clinics, NHSDP, Manoshi Project under BRAC are some of the NGO's project which is working relentlessly to provide the proper health services to urban poor and slum-dwellers.
The private health care clinics are few and beyond the reach of slum-dwellers considering their social and financial capacity. Besides these, as because of long-work schedule, people of slums are unable to avail services at a convenient time as primary health-care clinics usually operate at daytime hours. Community mobilization to improve health services hardly exists. Moreover, unregulated over-the-counter drug-selling and seeking care from untrained itinerant doctors and low-quality unlicensed private clinics exacerbate the poor health of slum-dwellers. This situation eventually results in catastrophic health outcomes.
The existing UHC (Universal Health Coverage) policy has also talked about expanding access to primary health care services with a particular focus on economically marginalized people and slums, but there remain the barriers of implementation and the lack of greater demand. The need for funding protection has made a further movement of this policy quite uncertain. Raising social awareness is very crucial for preventive healthcare. Most of them even do not have any knowledge about simple healthcare issues.
There is no proper health policy planning for the slum people and pivotal steps are crying need.
The neighbouring country, India launched the National Urban Health Mission 2013 specifically focusing on the health emergency of listed and non-listed slums in India. The mission has provided community health volunteer like ASHA (Accredited Social Health Activist) where one ASHA will ensure health service covering 200-500 household in slums. The example of Nairobi can also be relevant who are providing individual training for the mothers under five-year-old children.
Brazil is using a master plan for upgrading slums management. Mumbai's community-built toilets are often cited in the literature as a remarkable example of community-driven action. Innovating programs to efficiently reach a large portion of slum-community focusing particular institutions such as school-based vaccination or outreach via religious institution can also be a path-finding opportunity.
Given the miserable health risks of slum-people, impact evaluations must take a holistic approach to the array of important policy-relevant outcomes to exacerbate the slum agonies. The Government together with individuals, NGOs and all the citizens can move from understanding to action and improve the lives of slum-people right now.
Afsana Ferdous Mimi is a student of law at University of Chittagong