Course:GEOG352/2020/Health Care Inequality in Dhaka

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Dhaka is the capital city of Bangladesh and is considered the 11th largest megacity in the world. In 2017 Dhaka had a population of approximately 18 million people, an urban growth rate of 4.4% a year, and a population density of 11 910 people per km^2 making it the most densely populated city (Bird, 2018). The increased growth is attributed to rural-urban migration. Urbanization has increased the economic growth of Bangladesh due to the increase in industrialization concentrated in Dhaka.  

However, rapid urbanization has also introduced a strain on the city's infrastructure and services, and increased congestion causing Dhaka to be ranked in the bottom 4 of the least livable cities (Abdullah, 2016). The challenges of 40% of the population situated in informal settlements, improper waste management systems, extreme traffic congestions, and high air pollution levels have consequently introduced new health concerns (Abdullah, 2016).

Despite the increasing urban population growth, healthcare policies and Non Governmental Organization (NGO) have focused their efforts on rural regions, regardless of the urban poor experiencing worse health outcomes than the rural population (Country Policy and Information, 2019). Limited resources and supplies, disproportionate ratio of healthcare services to the population, and increasing reports of malpractice are evident in public hospitals that are accessible to the city’s poor.

The wealth gap in the city is expanding, as the income held by the wealthiest citizens increases every year. The financially elite have the capabilities to access the expanding private healthcare system due to the high out of pocket payments (OPP). However, studies still show patients find physicians in foreign health care practices “more available, competent, and empathetic” compared to those in private hospitals (Country Policy and Information, 2019) As a result of this belief, outbound medical tourism has increased.

The United Nations Sustainable Development Goal 3 (SDG3) states equal “access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” which is not prevalent in Dhaka due to inequities across socioeconomic parameters (Goal 3 Sustainable Development Knowledge Platform, n.d).  

Dhaka Capital of Bangladesh

Overview

The introduction of Universal Health Coverage (UHC), by the WHO in 2010, brought a clear global shift of ideology regarding access to health services as a human right and States obligations to providing healthcare to its citizens. While the issue of global health has been an on-going concept, its narrative and goals have largely been dominated by countries from the Global North. Global initiatives led by international organizations funded and backed by powerful nations such as the United States, have historically defined and dictated development goals (Damaj, 2014). These multilateral efforts to secure health access for everyone have predominantly focused on economic growth as the central goal, with the health of populations being an incidental beneficent of growth. However, the exclusion of voices from the Global South has led to continued global health inequality and a North-South divide in the field of medical research and practice (Prince, 2012). Economic-driven institutions paid insufficient attention to contexts within healthcare in cities of the Global South live, as well as the more globally occurring issue of increasing income-inequalities affecting a population’s health.

In the 1980’s pressure from international financial institutions like the IMF and the World Bank led to the implementation of Structural Adjustment Programs (SAP’s) in many lower-income countries wanting to develop. As a result, countries who accepted these loans and the conditions of the programs, were forced to liberalize markets and privatize many social services such as education, including cutting state financial support for healthcare.Many of the world's existing universal healthcare models are variations of two models that emerged in the early 20th century in Germany and the United Kingdom. With Germany relying on household premiums and payroll taxes, using a multiple risk pool model to determine costs and premiums, they also rely on private healthcare providers in a two tiered system. While the U.K. uses a one risk pool model, relying on public taxes to fund the healthcare system. However, countries and cities of the Global South that experienced a cut of public health funding, have largely had to resort to relying on limited global health initiatives to fill the gaps in healthcare access (Irin, 2012).

Global health relief efforts have a tendency to favour non-government organizations, bypassing established government healthcare systems. This becomes troublesome in the larger scheme of granting universal access for populations, as an overwhelming amount of NGO presence can produce a number of exclusive enclaves providing some services to certain communities rather than focusing efforts on funding government public health facilities (Prince, 2012).Despite growing recognition of the detrimental consequences of Global North development programs and policies have been critiqued as being bandaid solutions and not addressing key social factors that are needed for sustainable growth (National Research Council, 2010) . For many cities, the temporary presence and reliance on NGO’s have had negative impacts and widened the gap in healthcare accessibility in the long run. Globally, those with less income have historically been excluded from healthcare systems by the costs of health related services, making the cost of health care disproportionately a burden held by the poor. Rapid urbanization in megacities have worsened pre-existing inequalities in access to healthcare services. Even though South and East Asia have been popular regions for health care innovation and investment opportunities, the divisions between formal and informal, and public and private sectors have exposed the greater issues of governance structures as well as greater health risks endured by those most frequently in need or at risk. In Dhaka alone there are nearly 4’000 NGOs that only provide basic health related services.

Case Study

Informal Health Care

Dhaka’s large income disparity causes the bulk of healthcare to be done by the public systems which are not equipped for the population.  In most locations Urban communities typically have better access to healthcare. The inverse is true within Dhaka among the Urban poor. “The issue is of particular urgency because the urban population is rapidly increasing: it is estimated that in 2011, of a national population of 150 million, 43 million (28 %) lived in urban areas, with 15 million (10 %) living in Dhaka; by 2025 it is projected that of 175 million people, 63 million (36 %) will live in urban areas with nearly 23 million (13%) in Dhaka” (Caldwell, 112).  The public options are underfunded and over utilized. Therefore, within impoverished neighbourhoods, informal healthcare systems have been created.  
Healthcare in urban slums is usually conducted in one’s home. Furthermore, informal healthcare products are largely sourced from informal sellers. Examples of informal sources can be drug-dealers and those who steal or loot the necessary materials.  Those who are or become informal care-givers largely do not have any training or education in medicine. The caregivers are also commonly “ever-married women”.  
A study done in Dhaka’s slums of Lalbagh and Mohakhali, interviewers asked individuals who they seek healthcare services from. “Of the 199 cases, in 124 (62%) a pharmacist was cited as a source; in 115 cases (58 %) they were the sole providers; seven respondents (4%) listed a traditional doctor as a source of treatment; nine (5 %) listed a homeopath; 27 (14%)” (Caldwell, 116). However, as informal healthcare products are usually acquired illegally, a larger study must be done to find statistically significant results.
The larger issue being seen within the study of healthcare is that “informal healthcare is often not included” (Ahmed et al,. 4).  Whilst “This growing population is persistently deprived of basic rights and services including healthcare, yet experience much greater health risks and exposures than non-slum populations (Ahmed et al,. 3).  As such, healthcare for the urban poor can not be understood and therefore assisted by public experts. Due to the absence and misunderstanding of Government, and that of “formal governance structures, slums and informal health care is largely managed by mastaan (local thugs) (Caldwell, 113).

Private Health Care Not Accessible

Under the industrial policy of 1986 the government of Bangladesh “adopted a liberalized business approach to develop the private sector” thus many hospitals and clinics were established. The private healthcare industry in Bangladesh “has grown to be one of the country's largest service-sector industries, both in terms of revenue and employment” (Rahman, 2018).  In the 1980s, there was an expansion in the medical services for the private sector due to a rise in disposable income. This caused the development of private hospitals and clinics which grew from private investment.
Recent reports estimate that “Bangladeshi people spend six times more at private hospitals than on public ones, contributing to the larger flow of revenue and resources in the private health care sector” (Rahman, 2018). Private health care facilities are more efficient, reliable and better quality thus they are more favoured among those who can afford them. This includes the upper-middle and upper socioeconomic classes almost exclusively (Rahman, 2018).
This sector of healthcare is inherently privatized, most private hospitals run primarily as a business with the goal to make money. As such, ethical boundaries have been rumoured to be broken, for example: “continue life support or keep patients in ICU/CCU even after death of the patient to charge more bills” (Rahman, 2018). Additionally, several private hospitals have begun “advertisements to increase their customer base without increasing the basic service quality”.  Therefore, ethical and practical standards come second to the hospital’s income.
Unlike other privatized medical systems such as the United States, may Bangladeshi citizens are not medically insured hence, “health expenditure in private health facilities is almost exclusively from OPP (93%)” (Joarder, 2019).  Dhaka is seeing more citizens using foreign healthcare services “despite the additional costs, travel, and lengthy visa procedures” (Siddiqui, 2007) due to the high cost and poor level of domestic private service. Foreign players take advantage of the increasing population and its rise in health care demand.  “According to the Export of Health Services survey conducted by the Directorate-General of Commercial Intelligence and Statistics of India, Bangladesh was the largest foreign user of India's health services exports in 2015-16” (Rahman, 2018).

Public Health Care Not Utilized

Public healthcare is highly subsidized by the government however only “2.64 percent of Dhaka’s gross domestic product (GDP) is spent on health” (Joarder, 2009).  Thus making Dhaka the lowest health financing country in the South Asian Region (Joarder, 2009). The use of the public healthcare system in Bangladesh is very low. “A survey by the Centre for International Epidemiological Training (CIET), Canada, showed that, in Bangladesh, 13% of treatment-seekers use government services (public healthcare)” (Siddiqui, 2007).  That said, the low use of Bangladesh’s public service is the consequence of underfunding.
When looking at the quality of healthcare institutions in Bangladesh, a study surveying patients found “the quality of service in private hospitals scored higher than that in public hospitals for nursing care, tangible hospital matters, i.e. cleanliness, supply of utilities, and availability of drugs (Siddiqui, 2007). Medical professionals are not supplied with the resources they require.  This has created a deep apathy among public medical professionals. As a result, “doctors and nurses are found to be unavailable, their attitudes and behaviour, waiting time, travel time, etc. contributed to the low use of public hospitals” (Siddiqui, 2007).
There are multiple barriers that the lower-middle classes have to endure when seeking to access the public healthcare system. A study was able to discover that lower- middle classes “lack awareness of the kind of publicly funded healthcare services available, deficiencies and inconsistencies in the quality of services, and lack of close proximity to the healthcare facility” (Ahmed, 2006). These are among the major reasons Dhaka’s lower and middle class suffer inaccessibility healthcare.
Public opinion also contributes to lower and middle classes’ perceived image of foreign funded public healthcare options. The lower and middle classes feel the “limited range of NGO services available do not meet their demands; a high service-charge for the healthcare services they sought; higher prices of drugs at the facility compared to the marketplace; a belief that the NGO clinics are primarily to serve the rich people, lack of experienced doctors at the centres; and  the perception that the facility and its services were more oriented to women and children, but not to males”(Ahmed 2006). It can be seen, Dhaka’s current binary formal healthcare system is currently designed to service the few while failing to properly service those who need it most.

Lessons Learned

The “Expanding Social Protection for Health towards Universal Coverage policy”, combines various policy documents and acknowledges the importance of bringing more funds to the health sector and combining resources, as concerted efforts are required to reach UHC (Joarder, 2019) in Bangladesh. Public health services have also explored sector-wide approaches rather than individual projects, creating a coordinated healthcare service (PRIMASYS -Bangladesh Case Study, 2020).  There has also been increased use of Telemedicine in primary health care facilities, thus reducing the out of pocket payments for specialist consulting (Prodhan, 2016).

There have been previously implemented strategies which have been proven to be effective towards healthcare accessibility but not quality such private pharmacies. They are utilized for the care and consultation of acute medical problems by slum dwellers due to the convenience, low costs, and accessibility compared to other low cost public healthcare options. However, the drug-sellers have limited education and are unregulated causing irrational use of drugs thus, training programmes should be made available if this method is implemented in other urban areas (Khan et al, 2012).

Public-Private partnership has proven to be very effective to increase accessibility and quality of healthcare. The clinics are funded by the government and Asian Development Bank under the Urban Primary Health Care Services program to provide primary health services to slum dwellers, squatters, and floaters. The service is provided by partner NGO’s in various urban slums and subsidized or free depending on income levels (Asian Development Bank, 2017).

Methods to bring health accessibility in Dhaka are novel but have proven to be effective. Therefore, these programs and policies can be adapted to a wide variety of local contexts, due to the collective initiative taken to address the social issue.

References

Abdullah, A. (2016). Rural-Urban Migration and Informal Sector of Dhaka City: Issues and Facts. Research Journal of Humanities and Social Sciences, 7(2), 101. DOI: 10.5958/2321-5828.2016.00017.6

Ahmed, S., Adams, A. M., Islam, R., Shaikh, M. H., & Panciera, R. (2019). Impact of traffic variability on geographic accessibility to 24/7 emergency healthcare for the urban poor: A GIS study in dhaka, bangladesh. PLoS One, 14(9) doi:http://dx.doi.org.ezproxy.library.ubc.ca/10.1371/journal.pone.0222488

Amon, J. The «Right to Know» or «Know Your Rights»? Human Rights and a People- Centered Approach to Health Policy. In When People Come First. Critical Studies in Global Health. Princeton: Princeton University Press, 2014.

Asian Development Bank. (2017, June 5). Urban Health Project Reaches Out to Dhaka's Poor. Retrieved from https://www.adb.org/results/urban-health-project-reaches-out-dhaka-s-poor

Bird, J., Li, Y., Rahman, H. Z., Rama Martín, & Venables, A. (2018). Toward great Dhaka: a new urban development paradigm eastward. Washington, DC: World Bank Group.

Caldwell, B., Rashid, S., & Murthy, S. (2014). The informal health sector and health care-seeking behaviour of mothers in urban Dhaka slums. Journal of Population Research, 31(2), 111-129. Retrieved March 13, 2020, from www.jstor.org/stable/43919943

Country Policy and Information Note Bangladesh: Medical and Healthcare issues. (2019). Home Office. Retrieved from https://www.justice.gov/eoir/page/file/1162571/download

Goal 3 Sustainable Development Knowledge Platform. (n.d.). Sustainable Development Goals Platform. Retrieved from https://sustainabledevelopment.un.org/sdg3

IRIN News, September 11 2012. Global South leads the way towards Universal Healthcare Coverage. Retrieved from http://www.thenewhumanitarian.org/report/96280/health-global-south-leads-way-towards-universal-healthcare-coverage

Jahan, N. A., Howlader, S. R., Sultana, N., Ishaq, F., Sikder, M. Z. H., & Rahman, T. (n.d.).  Health Care seeking Behaviour of Slum-Dwellers in Dhaka City. Institute of Health Economics, 1–66. Retrieved from  http://www.searo.who.int/bangladesh/publications/health_care_seeking_slum_dwellers.pdf

Khan, M., Grübner, O., & Krämer, A. (2012). Frequently used healthcare services in urban slums of Dhaka and adjacent rural areas and their determinants. Journal of Public Health, 34(2), 261–271. doi: 10.1093/pubmed/fdr108

Piechulek, H., Al-Sabbir, A., & Mendoza-Aldana, J. (2003, June). Diarrhea and ARI in rural areas of Bangladesh. Retrieved March 11, 2020, from https://www.ncbi.nlm.nih.gov/pubmed/1297155

Joarder, T., Chaudhury, T. Z., & Mannan, I. (2019). Universal Health Coverage in Bangladesh: Activities, Challenges, and Suggestions. Advances in Public Health, 2019, 1–12. doi: 10.1155/2019/495409

National Research Council. 2010. Understanding the Changing Planet: Strategic Directions for the Geographical Sciences. Washington, DC: The National Academies Press. https://doi.org/10.17226/12860.

PRIMASYS -Bangladesh Case Study. (2020). Alliance for Health Policy and Research.  Retrieved from https://www.who.int/alliance-hpsr/projects/AHPSR-Bangladesh.pdf

Prince, R. Universal Health Coverage in the Global South: New models of healthcare and their implications for citizenship, solidarity, and the public good. Retrieved from https://www.michaeljournal.no/i/2017/03/Universal-Health-Coverage-in-the-Global-South-New-models-of-healthcare-and-their-implications-for-citizenship-solidarity-and-the-public-good

Prodhan, U. K., Rahman, M. Z., & Jahan, I. (2016). A survey on the telemedicine in Bangladesh. 2016 International Conference on Computing, Communication and Automation (ICCCA). doi: 10.1109/ccaa.2016.7813835                      

Siddiqui, N., & Khandaker, S. A. (2007). Comparison of services of public, private and foreign   hospitals from the perspective of Bangladeshi patients. Journal of health, population, and nutrition, 25(2), 221–230.


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