Urban healthcare needs strategic shifts

Demographers are of the view that 50 percent of the population of Bangladesh will start living in urban localities by 2039. Presently, more than 28 percent of the population already do so.

All over the world, around 53 million people live in urban areas that might reach 79.5 million by 2028, with 400,000 migrating to the city annually.

With 200,000 individuals living per square mile in Dhaka city, Dhaka and Chittagong have come to become Bangladesh's fastest growing cities, while hosting 90 percent of the slum population of Bangladesh.

With 35 percent of Dhaka's urban population living in slums or shantytowns, they suffer from severe overcrowding, poor sanitation, and limited access to drinking water.

Although the country is on-track to reach Millennium Development Goals (MDG) on water, we are seriously off-track in achieving the goal of sanitation. In addition, big cities like Dhaka and Chittagong are marred with air, noise, and water pollution, creating a direct health hazard.

Housing in urban areas is characterised by overcrowding and poor ventilation, with inappropriate designing of open spaces like playgrounds for leisure and recreation. The situation is worse in slums both in terms of space and amenities.

Floating populations living in urban areas live under totally inhuman conditions, and receive no care from urban authorities. This arose from the unplanned growth of cities, misuse of land and water-bodies, and occupation of public thoroughfare by land-grabbers with the help of politicians.

Rapid urbanisation is inevitable. We have entered the urban millennium. Cities are always the driving force for socio-economic and cultural advances around the world. Cities act as the engines of growth and incubators of civilisation.

They are the crossroads of ideas, culture, great intellectual ferments, and innovation. And yet they are also the places of exploitation, disease, violence, crime, unemployment, and extreme poverty.

People are compelled to take shelter in cities and towns due to many push and pull factors. Economic migration, social conflicts, and climatic disasters are some major drivers.

The disease profile in cities is different. There is little influence of community in cities as observed in rural areas. The nature of poverty in urban areas is exhibits much the same. In rural areas, status and position of a person is upgraded based on their level of income and education, whereas in urban areas it is not so. There is serious discrimination of rights and privileges of persons living in cities and towns.

The economic, social, demographic, political, and structural differences between urban and rural prompt us to make separate strategic shift to address urban healthcare issues, since the whole country is going to be urbanised in near future.

National Health Policy of Bangladesh predominantly emphasises rural healthcare services, adequate use of infrastructure built, mobilisation of physicians and other service providers, supply of drugs and medicine, and related governance issues. Urban health care issues were not so emphasised in the National Health Policy. The Health Population Nutrition Sector Development Program has not mobilised special resources urban healthcare services.

The existing system of collaboration between Government and Non-Government Organisations through a model of private-public partnership approach is commendable, but might not be sustainable in the near future with half the population ending up living in  urban areas.

The high-profile non-communicable healthcare and serious epidemic-like problems of Ebola or SARS should, in a way, be left to the NGOs to address in the near future.

Besides, communicable diseases in the country are almost under control, whereas non-communicable diseases are spreading faster. That demands a huge cost to cure and care.

Diabetes, hypertension, gastroenterology, liver cirrhosis, cardio-vascular complications, HIV /AIDS, and RTI/STI are so endemic, the control of which requires specialised treatment through a complicated diagnostic process. Unfortunately, these diseases are spreading as the major killer.

To address the health care problems of cities with growing urbanisation, there is a need to move to strategic shifts like formulation of Urban Health Policy. Urban Health Policy must comprise strategic actions to alleviate food and nutrition insecurity, urban environmental risks, safe water, air pollution, open sewerage, along with measures to ensure social safety nets.

It can suggest integrated infrastructure under pluralistic governance with correct approaches towards solid waste disposal and medical waste management. The question of equity among the different strata of the urban population should also be addressed carefully to ensure basic amenities to slum-dwellers and the poor quintile of society.

Above all, the question of integrity and accountability should be the prime issue to be addressed in the Urban Health Policy.

Dhiraj Kumar Nath is a former adviser to the caretaker government.