Charting a Course Through the Jungle of Urban Healthcare Delivery in Bangladesh
By Alayne M. Adams, Senior Social Scientist, Health Systems and Population Studies Division, icddr,b
A pluralistic healthcare landscape is a defining feature of urban settings in low-income countries (LICs) and low- and middle-income countries (LMICs). Our recent census of health care facilities in seven cities in Bangladesh indicates that over 90% are managed by the private-sector. At the recent International Conference on Urban Health in San Francisco (April 1-4, 2016), we presented health facility mapping data from two city corporations. Heretofore uncharted, what emerged was a veritable jungle of services with little apparent logic. Geospatial explorers, we examined the distribution of health facilities against population density and the location of slum settlements with the aim of identifying patterns that might be useful in planning around the goal of universal health coverage.
We observed:
- A density of pharmacies and doctor’s chambers clustered in and around slums and public tertiary facilities,
- A concentration of smaller private sector clinics and diagnostic centres in affluent neighbourhoods open during evening hours and often staffed by public sector health care providers,
- A fairly even distribution of NGO run primary care facilities focused on Maternal and Child Healthcare (MNCH) in the vicinity of slums, supplemented by satellite clinics open a few hours a day, several days a week.
In short, geospatial analysis revealed an inherent logic in the coverage of facilities responsive to market niche and the convenience of urban providers and their clients.
Access to services in a pluralistic healthcare system
So what does this mean for the goal of universal health coverage premised on access to quality services that are affordable to all urban residents? Therein lies the rub. The public sector in urban Bangladesh is limited to the provision of tertiary level care, and a handful of marginally functional urban health dispensaries. According to the Municipality Act of 2009, local government is responsible for primary care, but lacking capacity, contracts out services to NGOs serving the poorest on a project basis. The void has been filled by the private sector. In Bangladesh, regulatory capacity is weak, and or dinances governing the operation of the private sector in health drafted in 1982, are routinely ignored. The pharmacy represents the first line of care for most Bangladeshis, especially the poor. Out of pocket expenditures constitute over 64% of national health spending, the majority of which is comprised of drugs and the costs of diagnostics and medical procedures such as c-sections – as much as 80% of deliveries in the private sector according to the latest 2014 Bangladesh Demographic and Health Survey.
For the urban poor, the situation is particularly dire when healthcare spending necessitates debt or the sale of household assets. Given the opportunity costs of illness, quick treatment is sought from drug shops or doctors’ with attached chambers, many of which are unqualified and under the ubiquitous influence of pharmaceutical representatives that peddle prescriptions. While NGOs have specialized in MNCH, the provision of general services for men, adolescents and the elderly, including the prevention and treatment of the growing epidemic of Non communicable diseases (NCDs), remains limited.
So what should be done, and where to start? These are issues that should be the focus of health systems research and urban health policy debate and reform.
Photo credit: icddr,b
Let’s discuss these issues at HSR2016!
The 4th 2016 HSG symposium in Vancouver will provide an opportunity to explore ways forward, and to identify implementation research strategies that experiment different approaches to engage the private sector around quality improvement and financial accessibility, and to test community-based and workplace NCD prevention efforts that involve the private sector by making these activities worthwhile in terms of returns on investment .
Participate in our session entitled: ‘Rapid urbanization and the private healthcare sector imperative: understanding motivations and entry points for enhancing health systems engagement and sustaining health gains in Bangladesh’. This session explores the implications of rapid urbanization on healthcare delivery in Bangladesh, and the role of the private sector. In seeking to more formally engage the private sector within the health system and around national health goals, understanding its motivations, strategies and challenges are a crucial first step. The session will be conducted in two parts, starting with short presentations, and followed by group work allowing the audience to engage in the discussion.
For any queries, feel free to contact me at aadams@icddrb.org.
