25 years of NGO dependence: How fragile is our urban primary health care system?
Since its beginning in 1998, the urban health care centres have been operated by multiple stakeholders — local governments, ADB, and NGOs. In these 25 years, the local governments have not been able to take sole responsibility of these clinics
For Dr Olima Mitu, it was a rather busy day at the Urban Primary Healthcare Services Centre in Khilgaon. With regular patients, mostly seeking Antenatal Care (ANC) and Postnatal Care (PNC), as well as children waiting for vaccination, the clinic was quite crowded but also well-maintained.
Nojifa Begum, an RMG factory worker, was waiting outside Dr Olima's chamber with her pregnant sister for a regular check-up.
"We have the red health card, which means we can get free treatment here. And the doctor is also very good," she said.
A red card?
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"Yes. The healthcare centre provides primary health services mainly to the urban lower-income groups. And a red card is provided to those who cannot afford treatment. For that, they have to fill up a form and if they fulfil the criteria, we give them a red health card which gives them healthcare free of cost," Dr Olima explained.
Sundays, Tuesdays, and Thursdays are scheduled for child vaccination under the Expanded Programme on Immunisation (EPI) of the Directorate General of Health Services (DGHS). Hence the hustle and bustle at the healthcare centre.
Khilgaon area has four such Primary Health Care Centres (PHCCs) and a "Matri Sadan" (maternity clinic). Dr Olima is at PHCC-1 — a centre she runs with 16 staff members.
"On an average day, we get 30 to 40 patients. But on days like today, we are a bit busy with child patients," Dr Olima said. "Pregnant women like Nojifa's sister are provided primary checkups and after nine months, I will refer her to our maternity centre for delivery."
The maternity centre has 50 beds where health workers provide postnatal services and give vaccines to children. For an urban poor like a garment worker or a rickshaw puller, these centres provide quality healthcare for minimum or no charge.
On top of that, medicines are available for 10% discount in these centres.
Starting in 1998, the Urban Primary Healthcare Services Project (UPHCSP) is one of the largest health projects in urban areas in the South Asia region. The goal of the project is to provide primary health services, mainly to the urban poor for free or at a low cost.
According to a report by the Asian Development Bank (ADB), this project has more than 160 multistoried healthcare centres and 4,000 employees, including doctors, nurses, midwives, and other staff. About 6,29,288 patients take healthcare services in a month from these centres.
Under the project, there are 45 maternity care centres, 167 urban health centres, and 334 satellite centres around the country. Of these, the capital has 12 maternity centres, 61 urban health centres, and 122 satellite centres, according to data provided by the project officer.
Operating under the motto "Shebar Alo, Shobar Jonnyo", which roughly translates to "Light of care for everyone", the centres use a special rainbow symbol to distinguish themselves. Usually, these urban health centres provide treatment, diagnosis, counselling, and some medicines to patients from 9am to 4pm. Apart from this, full-time maternity homes, offering multifaceted services for mothers and babies, are covered under the project.
Too many cooks
"Funded by ADB, these health centres are mainly run by NGOs and the Local Government Division (LGD). For example, in Dhaka, the north and south city corporations supervise the project. And each region is managed by a separate NGO. The PHCC in Khilgaon is managed by Shimantik, a Bangladeshi NGO," said Dr Sharmin Mizan, deputy project director of the project's service delivery, breaking down the complex organogram of the project.
Of the 45 project areas, 17 NGOs are managing 40 areas and the remaining five are directly managed by the municipalities.
Since its beginning in 1998, the project has been operated by multiple stakeholders — local governments, ADB, and the NGOs. In these 25 years, the local governments have not been able to take sole responsibility for the centres.
So far, the LGD (Local Government Division) has been struggling to develop a primary healthcare system for the increasing urban population. Then there is another question: Why is this project being supervised by the local government division instead of the DGHS?
The country's urban population has more than doubled, from 21.3 million to 53.1 million between 1990 and 2014, according to a 2014 United Nations Population Division report. The ratio of urban to rural populations has increased from 19.8% to 38.9% in 2021. By 2040, the urban population is estimated to be 98.9 million, comprising 50.5% of the total population.
Currently, approximately 20% of the urban population lives in slum areas. The knowledge of slum dwellers about health and health care services, and their ability to access essential basic health services, are inadequate, the report says.
The urban areas are expanding and more and more people are getting into the urban areas. That means there is a growing need for healthcare services. But it seems our city corporations are not ready for this.
"At the beginning of the second phase of the project, the two city corporations [Dhaka North and Dhaka South) said that the urban local government body will manage the health service centres, and there will be no NGOs. But then after some period, the chief health officers (CHOs) informed us that they do not have the capability to run the health centres," Dr Mizan said.
Brig Gen Md. Zobaidur Rahman, chief health officer of DNCC, agreed with the explanation. "We do not have the capability to take care of the centres now. And by capability, I mean we do not have the sufficient budget, manpower, or the infrastructure."
The DNCC budget for 2022-23 shows that the corporation has allocated Tk50 lakh out of Tk532 crores of the development budget for constructing and repairing the healthcare centres. Asked how much budget allocation would be sufficient for them to take over from the NGOs, he could not provide an estimate.
When asked about why, despite having 4,000 people working on the project, he felt they had insufficient manpower, Brig Gen Rahman said, "We are not capable of providing salaries to such a large group of people."
DGHS chief Professor Dr Abul Bashar Mohammad Khurshid Alam told The Business Standard that the directorate had already taken initiatives to bring the entire city health care program under its purview.
"But the LGD did not want to hand us the responsibility. And there is no coordination among us. As a result, people do not seem to be getting effective or expected primary health care from these urban health centres," Dr Alam said.
Dr Sharmin Mizan agrees that it is patients who are suffering because of this, saying that they are not able to provide services to the entire country because of this.
"Dhaka has 120 wards or so and we have health service centres in 47 wards, which means more than 50% of the wards are outside our jurisdiction. We are providing healthcare to 10 municipalities only. These other 50% areas are probably covered by other NGOs."
She also said that apart from this, they are also not getting the land for the construction of the facility centres.
"The city corporations could not provide us with the piece of land that we were promised."
Dr Fazle Shamsul Kabir, chief health officer (additional charge) of DSCC, disagreed with the DGHS director general.
"The LGD is managing the project because it is mandated by the local government act. We cannot just give it to the DGHS," he explained.
According to Article 41 of the Local Government (City Corporation) Act 2009, city corporations, as required, can establish, operate and maintain health centres, maternity homes, and welfare centres for women, children and adolescents, midwifery training, and the development of family planning.
"I do not agree with the fact that we do not have the capability to run the centres. We are developing our capabilities and infrastructure. Although I cannot give you an exact date, I assure you we will take full responsibility for urban primary health care services in the future," he further said.
What other countries are doing
Neighbouring India has a National Urban Health Mission (NUHM), which aims to provide equitable and quality primary health care services to the urban population, with a special focus on slum and vulnerable sections of the society.
According to a report published in LiveMint, India's budget for FY22 allocated Rs5,000 crore for urban primary health through urban local bodies (ULBs), in addition to the Rs1,000 crore NUHM budget.
These allocations come from the 15th Finance Commission (FC) grants for primary health to their third tier of government. Nearly 40% of 15th FC's earmarked health grants — worth Rs70,000 crore over a five-year period (2021-22 to 2025-26) — are for urban areas. Much of this money will be used to build urban health and wellness centres.
Another example could be that of Argentina. Argentina's Plan Nacer, where city governments receive funds from the national health ministry based on population coverage, has had a positive effect. The probability of low birth weight, a key health outcome, fell by 23% in the country.
And the UK's NHS (National Health Service) is an ideal example for a healthcare system as well, where people's taxes are used to provide quality healthcare at an affordable price to all.
From Alma Ata Declaration to ADB's urban primary healthcare project
According to the World Health Organization (WHO), the Alma-Ata Declaration of 1978 first expressed the need for actions by all governments, all health and development workers, and the world community to protect and promote the health of all the people of the world. That is what gave birth to the concept of urban primary health care.
Those who signed the declaration hoped that it would be the first step toward achieving health for all by the year 2000. Although that goal was not achieved, the Declaration of Alma-Ata still stands as an outline for the future of healthcare.
Following the declaration, ADB and LGD started the Urban Primary Healthcare Services project in 1998.
LGD implemented the Urban Primary Health Care Project Phase-I from 1998 to 2005 with financial and technical support from ADB, the Nordic Development Fund, and the United Nations Population Fund (UNFPA). The Second Urban Primary Health Care Project (2005–2012) was funded by the ADB, the government of Sweden, the government of the United Kingdom, UNFPA, and Orbis International.
And the Urban Primary Health Care Services Delivery Project Phase I (2012-2018) was run with support from ADB, the government of Sweden, and UNFPA.
Currently, the second phase of the delivery project is going on, which was supposed to end this year. But Dr Sharmin Mizan informed us that the project duration has been extended.
"The tenure of the second phase was till 31 March 2023. But we already have submitted an RDPP [Revised Development Project Proposal] for extending the project tenure to June 2024. That means we have 15 more months."
In the next phase of the project, 11 new areas will be covered, including one city corporation — Chattogram — and 10 municipalities — Netrakona, Noakhali, Magura, Habiganj, Kurigram, Lalmonirhat, Gaibandha, Nilphamari, Panchagarh, Thakurgaon, and Tarab.
